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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<item>
		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at $10 to $15 per ticket. The European airline industry warned earlier this year that it would have to spend over $65 billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend $65 billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them $690 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
			<content:encoded><![CDATA[]]></content:encoded>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<item>
		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
			<content:encoded><![CDATA[]]></content:encoded>
			<wfw:commentRss>http://www.nolan-law.com/birth-control-pill-injury-report/feed/</wfw:commentRss>
		<slash:comments>0</slash:comments>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<item>
		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Nolan Law Group</title>
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	<link>http://www.nolan-law.com</link>
	<description>Ability, Integrity, Strength: Legal representation that puts YOU first</description>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<item>
		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
			<content:encoded><![CDATA[]]></content:encoded>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
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				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
			<content:encoded><![CDATA[]]></content:encoded>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

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		<title>Nolan Law Group</title>
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	<link>http://www.nolan-law.com</link>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<item>
		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>Nolan Law Group</title>
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	<link>http://www.nolan-law.com</link>
	<description>Ability, Integrity, Strength: Legal representation that puts YOU first</description>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
			<content:encoded><![CDATA[]]></content:encoded>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Nolan Law Group</title>
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	<link>http://www.nolan-law.com</link>
	<description>Ability, Integrity, Strength: Legal representation that puts YOU first</description>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<item>
		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<item>
		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Carbon Trading Hits Airline Industry</title>
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		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
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		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
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		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

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		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<item>
		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		<title>Nolan Law Group</title>
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		<title>Carbon Trading Hits Airline Industry</title>
		<link>http://www.nolan-law.com/carbon-trading-hits-airline-industry/</link>
		<comments>http://www.nolan-law.com/carbon-trading-hits-airline-industry/#comments</comments>
		<pubDate>Thu, 07 Jul 2011 13:13:10 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/carbon-trading-hits-airline-industry/</guid>
		<description><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit [...]]]></description>
			<content:encoded><![CDATA[The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO<sub>2</sub>). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

[caption id="attachment_2418" align="aligncenter" width="144" caption="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share"]<img class="size-full wp-image-2418" title="air pollution aviation" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation.JPG" alt="Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share" width="144" height="168" />[/caption]

The cap for 2012 is set at 212.9 million tons of CO<sub>2</sub> – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% -- to around 208 million tons of CO<sub>2 </sub>– remaining at this level until 2020.

According to the EU, aircraft CO<sub>2</sub> emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

[caption id="attachment_2419" align="aligncenter" width="358" caption="Contrails contribute to the greenhouse effect"]<img class="size-full wp-image-2419 " title="EU carbon tax" src="http://www.nolan-law.com/wp-content/uploads/2011/07/EU-carbon-tax.JPG" alt="Contrails contribute to the greenhouse effect" width="358" height="153" />[/caption]

The EU estimates the cost of the program at  to  per ticket. The European airline industry warned earlier this year that it would have to spend over  billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO<sub>2</sub> emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO<sub>2</sub>. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

[caption id="attachment_2421" align="aligncenter" width="163" caption="International flights represent approximately 62% of global aviation&#39;s fuel consumption"]<img class="size-full wp-image-2421" title="air pollution aviation2" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-aviation2.JPG" alt="International flights represent approximately 62% of global aviation's fuel consumption" width="163" height="195" />[/caption]

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

[caption id="attachment_2422" align="aligncenter" width="275" caption="London&#39;s Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off&#39;s and landings each hour"]<img class="size-full wp-image-2422 " title="air pollution heathrow" src="http://www.nolan-law.com/wp-content/uploads/2011/07/air-pollution-heathrow.JPG" alt="London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour" width="275" height="231" />[/caption]

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:
<blockquote>“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 ... is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO<sub>2</sub> emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”</blockquote>
Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend  billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:

 

“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”

_________________________

 

“It is well known that the impact of CO<sub>2</sub> by airlines is greater than the same amount of CO<sub>2</sub> by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO<sub>2</sub>/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”

_________________________

 

“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”

_________________________

 

“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before ... If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”

_________________________

“A general CO<sub>2</sub> tax would be the first transnational tax in history.”

_________________________

“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”

_________________________

 

“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO<sub>2</sub> efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer ...

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO<sub>2</sub> efficient tech [which] will be employed where the effect is greatest.”

_________________________

 

“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”

_________________________

“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”

_________________________

“It is hardly a development that is hostile to the aircraft design and construction industries.”

_________________________

“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU ...

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network ...

“3-4%. 100%. The difference is huge.”

_________________________

 

“Microsoft took the view that the EU would back down. It looks like costing them 0 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”

_________________________

 

“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”]]></content:encoded>
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		<item>
		<title>2011 &#8216;Most Wanted&#8217; List Still a Pig in Lipstick</title>
		<link>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</link>
		<comments>http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/#comments</comments>
		<pubDate>Fri, 01 Jul 2011 15:04:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/2011-most-wanted-list-still-a-pig-in-lipstick/</guid>
		<description><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its [...]]]></description>
			<content:encoded><![CDATA[The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2405" title="mwl-header" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-header.png" alt="mwl-header" width="515" height="37" /></p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2406" title="mwl-safety-6" src="http://www.nolan-law.com/wp-content/uploads/2011/07/mwl-safety-6.gif" alt="mwl-safety-6" width="174" height="144" /></p>

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

[caption id="attachment_2407" align="aligncenter" width="223" caption="NTSB Chairman Deborah Hersman"]<img class="size-full wp-image-2407 " title="Plane_Into_Home_NTSB_Lea_s640x425" src="http://www.nolan-law.com/wp-content/uploads/2011/07/Plane_Into_Home_NTSB_Lea_s640x425.jpg" alt="NTSB Chairman Deborah Hersman" width="223" height="220" />[/caption]

Regarding the new format, Deborah Hersman, NTSB chairman, said:
<blockquote>“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”</blockquote>
If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:
<blockquote>1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).</blockquote>
The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

<strong>Addressing Human Fatigue</strong>

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2409" title="pilot_nap_091013_mn" src="http://www.nolan-law.com/wp-content/uploads/2011/07/pilot_nap_091013_mn.jpg" alt="pilot_nap_091013_mn" width="224" height="168" /></p>

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation ... Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:</em>
<blockquote><em> </em><em>“We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at <span style="text-decoration: underline;">lower costs</span>.” [Emphasis added]</em></blockquote>
<em> </em><em>In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.</em>

<em> </em><em>Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.</em>

<em> </em><em>The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:</em>
<blockquote><em> </em><em>“The FAA ... believes it is inappropriate to rely on existing requirements ... to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”</em></blockquote>
<em> </em><em>Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.</em>

<em> </em><em>In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)</em>

<strong>General Aviation Safety</strong>

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2411" title="alaska3" src="http://www.nolan-law.com/wp-content/uploads/2011/07/alaska3.JPG" alt="alaska3" width="198" height="248" /></p>

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence. </em>

<em> </em><em>It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.</em>

<em> </em><em>The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be <span style="text-decoration: underline;">used</span>. (See Aviation Safety Journal, “Crash in Alaska &amp; Lack of Probing About Key Safety System”)</em>

<strong>Safety Management Systems</strong>

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries ...

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs ...

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been <span style="text-decoration: underline;">required</span> by the FAA’s equivalent agency, Transport Canada.</em>

<strong>Runway Safety</strong>

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight ... In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2412" title="g650b" src="http://www.nolan-law.com/wp-content/uploads/2011/07/g650b.JPG" alt="g650b" width="279" height="167" /></p>

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers ...

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.</em>

<strong>Pilot and Air Traffic Controller Professionalism</strong>

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust ...
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2414" title="most wanted 2011-4" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-4.JPG" alt="most wanted 2011-4" width="184" height="238" /></p>

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior ... And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

<em><span style="text-decoration: underline;">ASJ comment:</span> The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)</em>

<strong>Recorders</strong>

What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft ... are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.
<p style="text-align: center;"><img class="aligncenter size-full wp-image-2415" title="most wanted 2011-5" src="http://www.nolan-law.com/wp-content/uploads/2011/07/most-wanted-2011-5.JPG" alt="most wanted 2011-5" width="226" height="195" /></p>

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

<em><span style="text-decoration: underline;">ASJ comment:</span> the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”) </em>]]></content:encoded>
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		<title>Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn</title>
		<link>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</link>
		<comments>http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/#comments</comments>
		<pubDate>Fri, 24 Jun 2011 14:06:20 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/beware-the-icing-hazards-masked-by-average-droplet-size-scientists-warn/</guid>
		<description><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O [...]]]></description>
			<content:encoded><![CDATA[Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory &amp; Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:
<blockquote>“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”</blockquote>
The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 &amp; 6; 2 &amp; 5; 3 &amp; 4; 5 &amp; 2; and 6 &amp; 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:
<blockquote>June 21, 2011

 

Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001

 

<em>Re: Supplemental Comments to Docket Number FAA-2010-0636</em>

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) ... published in the Federal Register June 29, 2010 ... We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, <em>we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards</em>. [Emphasis added] We explain the reasons for this assertion below ...

Our main concern is that ... the draft regulations implicitly assumes that the icing hazard is represented adequately by ... liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard ...

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 ... concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set ... The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops ... Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable ...

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity ...

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass ...

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.</blockquote>
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2400" title="sinatures" src="http://www.nolan-law.com/wp-content/uploads/2011/06/sinatures.JPG" alt="sinatures" width="323" height="332" /></p>

The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.]]></content:encoded>
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		<title>Airbus Envisions a New Supersonic Transport Plane With Rocket-Like Performance</title>
		<link>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</link>
		<comments>http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/#comments</comments>
		<pubDate>Wed, 22 Jun 2011 20:35:13 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/airbus-envisions-a-new-supersonic-transport-plane-with-rocket-like-performance/</guid>
		<description><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the [...]]]></description>
			<content:encoded><![CDATA[The notion of supersonic airline flight keeps popping up, like a perennial weed. The latest concept comes from Airbus, which envisions of all things an eco-friendly supersonic jet that will fly 100 passengers at hypersonic speeds. The Airbus concept for such an airplane was revealed at the Paris Air Show, to great excitement among the aerospace cognoscenti. The flying public may take a different, more ho-hum view.

The grim legacy of the supersonic Anglo-French Concorde jet seems all but forgotten. Recall that Concorde was retired in late 2003, primarily because of the airplane’s range/payload limitations and its high operating cost. An Air France Concorde suffered a spectacular takeoff crash in 2000. The jet struck a piece of metal debris on the runway at Charles de Gaulle airport; the debris strike resulted in cut wires in the landing gear well and a punctured fuel tank. The airplane, on fire, crashed into a nearby hotel.

The accident was the last and grimmest of a long line of landing gear tire failures that punctured holes in fuel tanks. French investigators into the crash identified 57 incidents of Concorde experiencing deflated or blown tires. In 1979, an Air France Concorde on takeoff from Washington’s Dulles airport experienced punctured fuel tanks. The airplane’s magnesium wheels struck the runway, broke apart and hurled metal shards into the wing fuel tanks. With fuel dribbling from the punctured tanks, the airplane returned to Dulles. Passengers could see through the holes in the wing to the ground below.

With longer takeoff runs, higher speeds and stressed tires, the Concorde was 60 times more liable that the subsonic A340 jetliner to a tire burst. The comparison is apt, as both the A340 and the Concorde are four-engine airliners.

The energy from a burst tire is equivalent to approximately 4-5 sticks of dynamite. Yet, to save weight on the Concorde, electrical and hydraulic lines in the main landing gear receptacle were not shielded. Despite easily-punctured metal skin (about the thickness of a piece of cardboard backing a pad of paper), the fuel tanks were not protected with self-sealing rubber.

[caption id="attachment_2395" align="aligncenter" width="430" caption="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?"]<img class="size-full wp-image-2395  " title="concorde" src="http://www.nolan-law.com/wp-content/uploads/2011/06/concorde.JPG" alt="In service from 1976 to 2003, Concorde was built to a lower safety standard than subsonic airliners; will ZEHST repeat this legacy?" width="430" height="197" />[/caption]

Why were such practices tolerated? Because Concorde was not certificated to the same standard as subsonic airliners. Every ounce of weight that could be pared from the airframe was critical if the Concorde was to haul 100 trans-Atlantic passengers and their luggage. Thus, instead of being designed to the 1-in-a-billion standard against catastrophic failure, Concorde was designed to a lesser standard. About 10 times lower, as a matter of fact. The waivers, deviations and special provisions necessary to yield an airplane with acceptable weight meant that passengers were flying in an airplane where the risks of failure were greater. The fatal crash occurred at approximately 75,000 flights – far less than a million, much less a billion flights.

Concorde was never an economic success. The airlines could not afford to buy it, so the Anglo-French consortium that built Concorde basically gave the airplanes to Air France and British Airways. To fly supersonically across the Atlantic, Concorde burned a ton of fuel per passenger. A subsonic airliner consumes about a quarter-ton of fuel for the same distance.

Sometimes, the Concorde’s need for sufficient fuel was so great that the passengers’ luggage made the trip across the Atlantic in a subsonic jet.

Aircraft manufacturers Boeing and Lockheed toyed with supersonic airliner designs, but the operating costs and the environmental and noise challenges proved insurmountable. Their designs never progressed beyond full-scale mockups.

Enter Airbus; at a briefing a day before the 20 June opening of the Paris Air Show the manufacturer’s executives presented their vision. Jean Botti, the manufacturer’s head of technology, said the project’s success depends on cost containment and whether or not buyers for the plane can be found.

On both counts, the effort seems doomed.

The Airbus concept is known by the acronym ZEHST, for Zero Emission High Supersonic Transport. The airplane is envisioned to carry 100 passengers (like Concorde) while cruising at 2,600 mils per hour (faster by 1,000 mph than Concorde) at an altitude of 100,000 feet (twice as high as Concorde).

While Concorde was powered by four turbojet engines, the ZEHST concept features three separate types of power.

[caption id="attachment_2397" align="aligncenter" width="405" caption="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery"]<img class="size-full wp-image-2397" title="airbus sst" src="http://www.nolan-law.com/wp-content/uploads/2011/06/airbus-sst.JPG" alt="The ZEHST concept. Remember, the Space Shuttle was supposed to feature a shirt-sleeves environment for the crew and ended up with the crews wearing bulky pressure suits for launch and recovery" width="405" height="563" />[/caption]

The airplane would climb to approximately 40,000 feet using turbofan engines, whose fuel would be derived from seaweed or algae (thus satisfying the environmental dictates). At 40,000 feet, ramjet engines would take over, powering the airplane to approximately 100,000 feet, where yet another set of engines would propel the airplane at four times the speed of sound (Mach 4).

The airplane would be geared towards business travelers, who supposedly could afford the cost of a ticket. That cost would be first class plus a premium. The question is how many business travelers would be willing to pay two, three, four or more times the cost of a subsonic first-class ticket for the privilege of arriving a few hours earlier.

Given the highly public demise of Concorde, ZEHST will have to be built to a 1-in-a-billion standard, which means no slipping around or sidestepping certification requirements. Those standards are independent of the cruising speed of the airplane.

To borrow a somber nautical term, ZEHST seems dead in the water.]]></content:encoded>
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		<title>Birth Control Pill Injury Report</title>
		<link>http://www.nolan-law.com/birth-control-pill-injury-report/</link>
		<comments>http://www.nolan-law.com/birth-control-pill-injury-report/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:41:44 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/?p=1245</guid>
		<description><![CDATA[]]></description>
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		<title>Suit alleges Baxter&#8217;s heparin killed wife</title>
		<link>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/</link>
		<comments>http://www.nolan-law.com/suit-alleges-baxters-heparin-killed-wife-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=203</guid>
		<description><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower [...]]]></description>
			<content:encoded><![CDATA[Baxter International Inc. faces a growing number of lawsuits from families who blame the company's blood-thinning drug heparin for deaths of loved ones. Heparin was used by millions of people to prevent blood clots during dialysis and other medical procedures.

The latest wrongful death suit was filed Wednesday in Cook County Circuit Court by the widower of an Iowa woman who died at home during kidney dialysis Nov. 30. Mark Scott of Davenport accuses Baxter of selling defective heparin that caused her death.His wife, Melissa Scott, 53, began experiencing nausea and vomiting after treatment began in August, said Tom Ellis, a spokesman of the Nolan Law Group in Chicago

Chicago, which brought the suit on behalf of Mark Scott. On Nov. 30, Ellis said, an allergic reaction to the heparin caused Scott to fall and as a result disconnect from the machine. Mark Scott found his wife on the floor after she called out to him during a treatment. The death certificate said death was caused by an air embolism in the heart, Ellis said. An autopsy was not performed."Mark wants to know for sure what happened to his wife," Ellis said. "His wife was well trained on the dialysis machine."

A Baxter spokeswoman said the company had not yet seen the Scott suit and declined to comment on its specific allegations. But she said the company is aware of at least four other wrongful death suits in the

U.S.
U.S.

"No patient deaths have been confirmed by medical or epidemiological evaluation by Baxter or [the U.S. Food and Drug Administration] to have been caused by the allergic-type reactions associated with the current heparin recall," said Baxter spokeswoman Erin Gardiner. "None of these suits includes any credible medical information to allow the company to medically evaluate these claims."The Deerfield-based company also is defending at least five suits brought by patients who allege they were harmed by tainted heparin.

The FDA is investigating whether heparin is connected to as many as 19 deaths and more than 700 serious illnesses since

Jan. 1, 2007
. Baxter insists that four deaths so far may be connected to adverse reactions to heparin.Baxter recalled the drug in February after a spike in severe allergic reactions in patients. Further investigation revealed a significant amount of an unidentified foreign substance contaminated batches of heparin.

The suspect active ingredient originated at a

Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.
Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis. Last month the FDA disclosed that low-cost animal cartilage made its way into Baxter's heparin but has not determined a specific link to allergic reactions.]]></content:encoded>
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		<title>FDA finds unidentified substance in Baxter&#8217;s blood-thinning drug heparin</title>
		<link>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/</link>
		<comments>http://www.nolan-law.com/fda-finds-unidentified-substance-in-baxters-blood-thinning-drug-heparin-2/#comments</comments>
		<pubDate>Fri, 10 Jun 2011 15:27:18 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Uncategorized]]></category>

		<guid isPermaLink="false">http://74.208.14.2/NolanLaw.com/blog/?p=200</guid>
		<description><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 [...]]]></description>
			<content:encoded><![CDATA[A significant amount of an un-identified foreign substance contaminated Baxter International Inc.'s blood-thinning drug heparin, the U.S. Food and Drug Administration said Wednesday, raising the possibility of intentional tampering in a supply chain that begins with pig farms in China
.The mysterious substance, which has a chemical makeup similar to heparin, comprises as much as 20 percent of the active ingredient in nine suspect lots produced by Baxter since September, the FDA said Wednesday. The suspect lots are connected to at least four deaths reported nationwide since Baxter noted a spike in adverse reactions to the drug in late December.

The FDA on Wednesday said heparin is connected to as many as 19 deaths and 785 serious illnesses since

Jan. 1, 2007
Jan. 1, 2007

. But the FDA timeline extends well beyond the period from September to November, when Baxter's Cherry Hill, N.J., plant produced the heparin connected to the recent rash of serious allergic reactions. The suspect active ingredient in heparin originated at a Changzhou, China, plant owned by Scientific Protein Laboratories, a Baxter supplier based in Waunakee, Wis.
"We don't know whether the introduction of the contaminant was accidental, as part of the biological process, or if it was deliberate," said Dr. Janet Woodcock, acting director of the FDA's center for drug evaluation and research.
At least one former top FDA official who helped lead the fight against counterfeit drugs indicated that some Chinese suppliers in the past have introduced foreign substances to boost production when supplies are tight. That's what happened in the early 1990s with an antibiotic known as gentamicin sulphate, which produced adverse reactions and some deaths in the U.S.
"The obvious question is, 'Are these plants back-dooring their supply in order to supplement their capacity?'" asked Benjamin England, who chaired the FDA's Counterfeit Drug Working Group before leaving for a private law practice in

Washington, D.C.
, in 2003.Epidemic in

China
China

Heparin is produced from an enzyme in the mucous lining of pig intestines. The suspect lots of heparin were made beginning in September, just after the peak in an epidemic of an often-fatal disease known as "blue ear" that afflicted more than 250,000 pigs throughout

China
. More than half those pigs died or were exterminated.An FDA official at the press conference said it is possible supplies of the adulterated ingredient came from pig intestines. But FDA officials emphasized they have not pinpointed the source.

Conventional quality and safety testing typically does not discover a foreign substance,

England
England

added, because the tests are not designed for that purpose.The FDA in its press conference Wednesday said conventional tests performed by Baxter and Scientific Protein did not show any variation because the contaminant is so similar to heparin.

"It acts like heparin in this test, so it looks like everything is fine in the test," Woodcock said.

Only after further testing, using nuclear magnetic resonance spectroscopy, did the differences in chemical makeup become apparent, the FDA said.
Scientific Protein's plant obtains heparin from bulk providers of raw material. From its plant in

Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill
Changzhou, Scientific Protein ships raw heparin to the company's headquarters outside Madison, Wis., then on to Baxter's Cherry Hill

plant for final processing, packaging and shipping.Pointing fingers

Baxter, in its own press conference, sought to point the investigative spotlight back to

China
China

. Baxter executives said the active pharmaceutical ingredient sourced from its China-based supplier is the focus of the company's investigation."Either the problem lies further back in the supply chain, somewhere before the material gets to the processing plant, or there's something in the processing before it comes to Baxter," said Peter Arduini, president of Baxter's medication delivery business.

Arduini said the company's

Cherry Hill
Cherry Hill

manufacturing plant, where multidose vials of heparin are finished and filled before shipment to hospitals and dialysis centers, recently passed an FDA inspection.Arduini said Baxter's investigation centers further into the "supply stream" in

China
China

. There could be "process issues" associated with Scientific Protein's Chinese manufacturing plant, he said.Baxter also took issue with the numbers provided by the FDA, which said heparin has played a role in 19 patient deaths since

Jan. 1, 2007
Jan. 1, 2007

. Baxter insists that four deaths so far may be connected to adverse reactions to the suspect heparin.For its part, Scientific Protein disagreed with the FDA's interpretation of test results that seems to focus the investigation on a possible adulterated material being added during Scientific Protein's production process.

"During the call with the media, FDA speculated that the source of the adverse events may be a contaminant," Scientific Protein said in a statement. "It is important to note that this theory is speculation at this point, and [Scientific Protein] is participating actively in working with the FDA to pursue this theory as well as others so that we can understand the cause of the adverse events."
Scientific Protein's

Changzhou
Changzhou

plant, owned in a joint venture with a Chinese partner, is preparing a response to an FDA inspection report last week that criticized the plant's record-keeping, reporting and processes. "It is important to emphasize that the root cause of the heparin adverse events has not been tied to any of the agency's observations," Scientific Protein said in a statement.FDA inspections

Dr. Andrew C. von Eschenbach, commissioner of the FDA, declined to say whether the FDA physically inspects the more than 700 Chinese facilities that ship pharmaceutical ingredients and drug products to the

U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.
U.S. The FDA has deployed a "risk-based" system that seeks to focus inspection on plants that might potentially cause the most harm to U.S.

consumers.Von Eschenbach said the agency is beginning to reallocate resources to better address the problems presented by the huge growth in foreign-made drugs. "We recognize that the number of sites that we must pay attention to that are beyond our borders are going to require us to address this systematically," he said.

The FDA plans to increase the number of inspectors, base inspectors in key foreign cities, and build stronger working relationships with foreign regulators, Von Eschenbach added.]]></content:encoded>
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		<title>Latest Air France Crash Update Bereft of Analysis</title>
		<link>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</link>
		<comments>http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/#comments</comments>
		<pubDate>Tue, 07 Jun 2011 15:26:08 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/latest-air-france-crash-update-bereft-of-analysis/</guid>
		<description><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities [...]]]></description>
			<content:encoded><![CDATA[Even now with the benefit of the flight recorders, French investigators seem quite flummoxed about the circumstances which led to the crash of Air France flight 447 in the South Atlantic on 1 June 2009. The answer to one question seems clear: Is the pilot training to combat automation anomalies and their inherent malfunction complexities adequate enough to prevent further disasters similar to AF 447? The answer appears to be – in a word – no.

The flight recorders were recovered from the wreckage in May of this year, ending repeated and frustrating searches.

[caption id="attachment_2366" align="aligncenter" width="236" caption="A photo released by the BEA showing the plane&#39;s landing gear at a depth of some 12,000 feet"]<img class="size-full wp-image-2366  " title="AF 447 gear" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-gear.JPG" alt="A photo released by the BEA showing the plane's landing gear at a depth of some 12,000 feet" width="236" height="252" />[/caption]

The digital flight data recorder and the cockpit voice recorder (DFDR/CVR) were flown to accident investigators at the Bureau d’Enquêtes et d’Analyses (BEA) in France. From the downloaded recordings and data, BEA produced an update of its investigation. This latest update follows two BEA interim reports of 2 July 2009 and 17 December 2009.

[caption id="attachment_2368" align="aligncenter" width="255" caption="The cockpit voice recorder at the bottom of the Atlantic"]<img class="size-full wp-image-2368   " title="AF 447 CVR-FDR" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF-447-CVR-FDR.JPG" alt="The cockpit voice recorder at the bottom of the Atlantic" width="255" height="148" />[/caption]

 

The interim report of July 2009 clearly focused on the A330-200’s three Thales-manufactured pitot probes and how they feed speed information to the airplane’s computerized engine and flight control systems. It can be credibly argued that the pitot probes on the accident airplane became clogged with ice while flying high over the Atlantic on the journey from Rio de Janeiro to Paris. When the airplane flew into a broad front of clouds, ice crystals – or supercooled water which turns into ice on impact -- rammed into the pitot probes and overpowered their electric heating. (See Aviation Safety Journal, August 2009, “Prompted by Crash, Airworthiness Directive Issued on Pitot Probes” and for replacement of the pitots see February 2011, “Significant Regulatory &amp; Related Activity”)

With ice crystals clogging the pitot tubes, the aircraft computers “sensed” from these duff readings that the airplane was flying slower than it actually was. Auto-thrust quietly added power incrementally as supercooled ice crystals overcame the limited pitot-heating capabilities and ice gradually accumulated as a granular filter inside each pitot – clogging drain and tube equally. The pilots failed to notice the minor power additions or fuel flow increases, as it is common for pilots to manage the fuel management display’s synoptic screen, which focuses on fuel remaining, not on the flow rate.

[caption id="attachment_2370" align="aligncenter" width="283" caption="The three pitots on the A330"]<img class="size-full wp-image-2370 " title="pitot A330" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-A330.JPG" alt="The three pitots on the A330" width="283" height="197" />[/caption]

[caption id="attachment_2371" align="aligncenter" width="284" caption="A simplified schematic of a pitot tube blocked by ice"]<img class="size-full wp-image-2371 " title="pitot blockage" src="http://www.nolan-law.com/wp-content/uploads/2011/06/pitot-blockage.JPG" alt="A simplified schematic of a pitot tube blocked by ice" width="284" height="202" />[/caption]

It is not difficult to imagine the scene in the cockpit if the airplane was being buffeted by a raging storm (although ice crystals can accumulate while cruising in relatively smooth Cirrostratus-type layer cloud, interspersed with a few bumps from embedded Cirrocumulus; it is not necessary to be embroiled in a localized thunderstorm for the pitot probes to be clogged by ice). At the altitude and speed the airplane was flying, it was near “coffin corner” or that top right-hand portion of the flight envelope where the speed-band between controlled and uncontrolled flight is inherently constricted. Long-haul airliners must fly at those heights for best range (e.g. air nautical miles per pound of fuel expended). If, as is suspected, the speed sensors were progressively feeding a false reading of lower than actual airspeed to the automation, the airplane could well have experienced a departure from controlled flight. Equally likely is that the size of the airspeed or trim discrepancy may have triggered an “air data disagree” as the air data inputs fell outside system parameters, causing an auto-pilot disconnect. Whatever the trigger, the unalerted auto-pilot disconnect began the mayhem for AF 447.

From the latest BEA update, this situation appears to be the case.

The captain, Marc DuBois, was on a rest break and not in the cockpit. The first officer, Pierre-Cédric Bonin, and the relief first officer, David Robert, were at the controls. One of them contacted the cabin staff on the intercom and advised that the airplane might experience some turbulence: “In two minutes we should enter an area where it’ll move about a bit more than at the moment...” His reassuring communication did not convey the drama of the situation in the night sky before him. The airplane was using its weather radar to weave a course between the tops of thunderstorms containing black, electrically charged clouds which were roiling up to 41,000 feet at 100 miles per hour – typical seasonal weather for the oceanic InterTropic Convergence Zone (ITCZ).

As the airplane flew into turbulence, the auto-thrust and auto-pilot disengaged. The pilot flying (PF), Bonin, said, “I have the controls.” He applied a nose-up input and the stall warning sounded.

The pilot not flying (PNF), Robert, said, “So, we’ve lost the speeds” and then remarked “alternate law”. [In alternate or direct law, the computerized angle-of-attack protections are no longer available; thus, whatever pitch, yaw and roll inputs the pilot commands will be executed by the fly-by-wire system.]

Pitch attitude increased beyond 10º, and the pilot flying made nose-down and left/right roll inputs. The airplane climbed from its planned cruising altitude of 35,000 feet to 38,000 feet; pitch attitude increased to 16º.

The captain re-entered the cockpit to help trouble shoot the situation. The BEA update report stated, “During the following seconds, all of the recorded speeds became invalid and the stall warning stopped.”

With a nose-up pitch, the airplane began a plummet of 10,000 feet per minute to the inky dark ocean below. The airplane rolled left and right up to 40º and engine power was reduced to idle.

The BEA put a positive spin on the frightening scenario: “The engines were operating and always responded to crew commands.”

All 228 people aboard were killed when the jet pancaked into the water at an unsurvivable high rate of descent but, quite extraordinarily, with a forward speed of only 107 knots.

[caption id="attachment_2372" align="aligncenter" width="318" caption="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit"]<img class="size-full wp-image-2372 " title="AF447plot" src="http://www.nolan-law.com/wp-content/uploads/2011/06/AF447plot.JPG" alt="3: The airplane made a slight turn to the left to avoid clouds and turbulence; 4: Auto-pilot and auto-thrust disengaged; 5: Stall warning was triggered again; 6: Captain entered the cockpit" width="318" height="582" />[/caption]

Despite the benefit of the DFDR/CVR data, the 4-page BEA update is scant on analysis.

Presented below are the thoughts of John Sampson, a retired Royal Australian Air Force pilot. His thoughts are easily the most profound on this accident:

<strong><em>BEA report:</em></strong><em> “The stall warning sounded twice in a row. The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS)”.</em>

<strong>Sampson:</strong> The fall off in speed is to be expected in a total pitot clog. The DFDR was of course recording exactly what the pilots were seeing but meanwhile the aircraft’s auto-thrust had actually been increasing power to maintain the programmed speed. The programmed speed was actually exceeded by a considerable margin, as a result of the gradual ice-crystal blockage in the pitot tubes. Speed was headed towards critical Mach [airliners are not designed to fly near critical Mach; at this speed shock waves are sufficient to stall the wing and massively increase drag; from the location of the shock wave on the airfoil, there is laminar flow forward and boundary layer separation aft].

What triggered the auto-pilot disconnect? Was it the critical Mach encounter or was it that the auto-pilot could not hold the increasing elevator force of a system-driven (by an invalid low indicated airspeed) trimmable horizontal stabilizer (THS)? Or, was the auto-pilot disconnect caused by the sudden clog of the pitots and the erroneous speed readings causing an “air data disagree”?

 

<strong><em>BEA report:</em></strong><em> “At 2 hr 10 min 51 sec the stall warning was triggered again. The thrust levers were positioned in the TO/GA [take off/go around] detent and the PF maintained nose-up inputs. The recorded angle-of-attack, of around 6º at the triggering of the stall warning, continued to increase. The [THS] passed from 3 to 13º nose-up in about 1 minute and remained in the latter position until the end of the flight.”</em>

<strong>Sampson:</strong> Over time, as the pilots cruised in the cloud’s ice crystals, the pitot heating was overpowered – a known anomaly for that particular model of pitot. The gradually clogging pitot system resulted in the auto-thrust incrementally applying power to stop the “apparent” speed decay. Similarly, the auto-trim maintained the nose-up trim for that programmed speed – and the auto-pilot offset the elevator trim to hold height – as the aircraft was actually flying faster than shown. When the design pitch-holding limit was reached (i.e. the maximum nose-down force gradient the auto-pilot could hold), the auto-pilot gave up, and the handling pilot had an instant unalerted surprise handful of an aircraft in Alternate Law (or perhaps Direct Law) with nearly full nose-up trim and near to full power. It is not clear from the BEA update if the DFDR faithfully recorded the precise dangerous sequence of arcane events that resulted in a surprised pilot (and the inevitable “startle” reflex). Or did the BEA just conveniently conclude the aircraft’s pitch-up Direct Law behavior had resulted from an aberrant aft side-stick input by the pilot?

When it comes to high speed protection, under the Airbus philosophy, should a flight crew attain an attitude likely to exceed (or undershoot) a design flight envelope speed, they will attract an automatic pitch to a “safe” altitude, and the airplane will try to maintain minimum maneuvering speed plus a few knots. It should be noted that the pilots decided to reduce speed – due to expected turbulence – only two minutes earlier.

Therefore, it is not unusual, following the auto-pilot and auto-thrust disconnect, for the PF to instinctively add TOGA power (a standardized response known as a Standard Operating Procedure). That power addition induced pitch-up, reinforced by the nose-up trim, initiating the unintentional “zoom” of 3,000 feet. It should be noted that the true airspeed (TAS) at cruise height is twice that at sea-level. The effect of this “doubling” is an apparent increase in aircraft inertia and a seemingly quite disproportionate response to a minor pitch attitude change.

RVSM (Reduced Vertical Separation Minima) only became possible a few years ago with the same sort of precision in avionics and barometric altitude maintenance that permitted a business jet and a B737 on the same airway to collide head-on over the Brazilian jungle in September 2006. (See Aviation Safety Journal, January 2009, “Complacency &amp; Computer Perversity Lead to Brazilian Mid-Air Collision”) Until RVSM became technically (although not <em>humanly</em>) possible, the likelihood of large altitude “excursions” (even on auto-pilot) was high enough to predicate a 2,000 foot height separation between cruising aircraft (i.e. a prior separation standard of twice that now allowed under RVSM).

To a pilot not used to hand-flying at high altitude, it would be quite easy to be caught out by this TAS and pitch-up phenomenon and inadvertently gain a few thousand feet while distracted. Additionally, there is the “handling novelty” stemming from nil exposure in training to manual flight at high altitude. Moreover, the non-moving (detented) Airbus throttles mean that <em>urgent</em> power is more easily attained by selecting TOGA. Therefore, the combination of too much power, a nose-up trim at disconnect and the TAS/inertia phenomenon took them up to a ballistic stall at an attitude and height they should <em>never</em> have reached at their weight – let alone at stall speed. A much safer SOP would dictate a deliberate Flight Idle unpowered descent entry at a mild 10º of nose-down pitch (i.e. a safe instant “departure” from coffin corner).

 

These may only be speculative considerations, based upon a knowledge of the factors involved, but they are likely to be supported by analysis. One cannot fill a cockpit suddenly with failed instruments, alerts and alarms, and expect relatively inexperienced and bewildered pilots to confidently assume precise manual flight at high altitude. The Federal Aviation Agency (FAA) has ongoing concerns about pilot proficiency at high altitude, as evidenced by an advisory circular (AC 61-107A) about this very subject; a PowerPoint slide presentation in an appendix to the AC provides information relevant to the case of AF 447.

[caption id="attachment_2373" align="aligncenter" width="323" caption="From the FAA&#39;s high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346"]<img class="size-full wp-image-2373" title="hi alt basics" src="http://www.nolan-law.com/wp-content/uploads/2011/06/hi-alt-basics.JPG" alt="From the FAA's high altitude upset recovery, guidance for pilots; for the full PowerPoint, go to www.tinyurl.com/64bc346" width="323" height="144" />[/caption]

We can theorize that they were actually at an initially higher airspeed than indicated – although this would not have been recorded by the DFDR. However, the engines’ parameters were recorded and the aircraft’s weight is known, so an interpolation of the speed to within a few knots of actual speed should be possible. After the pilots’ involuntary zoom climb (perhaps due to the trim state at auto-pilot disconnect), the static pressure changes in the pitots would have had a considerable additive effect on the blocked pitots’ trapped pressure and thus the displayed airspeed. This further confusing effect is intimated by the BEA report: <em>“The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle-of-attack was around 4º”</em>.

 

<strong><em>BEA report:</em></strong><em> “The angle-of-attack exceeded 40º”.</em>

<strong>Sampson:</strong> The pilots would not have known the angle-of-attack, as there is no such display to them of it. The angle-of-attack vane sits in the relative airflow and directly advises stick-shaker, stall warning, and fly-by-wire protective systems of any incipient exceedance. However, like a wind vane atop a chimney, once the relative wind-speed drops off, the angle-of-attack vane can weathercock uselessly. In the A330, its contribution cuts out at 60 knots. It has been argued that this is necessary to cover the takeoff case; however, a weight on wheels switch would normally inhibit false low speed warnings in such systems. The fact that the angle-of-attack system is not “there” at very low speeds and very high (&gt;30º) angles of attack would be fatally pertinent to what happened later as AF 447 passed 10,000 feet in its deep-stall condition.

By the time the airplane reached the apex of the ensuing pitch up and following the auto-thrust/auto-pilot disconnect, it was actually on a ballistic trajectory and entering into a deep stall with a forward speed of approximately 60 kt and a high angle-of-attack –ultimately resulting in the 10,000 ft per minute rate of descent at a sustained high angle-of-attack – reportedly an astounding 40º (most airfoils stall at just over 16º angle-of-attack). The pilots had initially responded correctly to the stall warning with TOGA power. But, because of the underslung engines, did that coupling also contribute to their pitch-up moment? Sometimes, if you don’t concentrate solely upon flying the airplane in such dynamic situations, it will just “fly you”.

However, the validity of that initial pilot response was soon to change. Why? This is where the startle factor and the understandable inability to identify and interpret Airbus flight control mode changes cuts in.

In Direct (or plausibly even Abnormal) Law, which they should now have been in, holding the side-stick back will maintain the stall. The PF might have persisted in holding back-stick to attain/maintain level flight – in the confusion of the situation (with its alerts and alarms), perhaps quite unaware of the airplane’s height gain into even more rarified air. If the fly-by-wire software was now in Direct Law, “kid gloves” for control inputs would have been required.

Why shift the throttles from TOGA thrust to idle? There is a possible clue; in the subsequent descent with static pressure increasing and the pitots still blocked, even though the airplane was actually stalled (complete with stick-shaker) the indicated airspeed could be rising alarmingly – courtesy of increasing static pressure. I have personally experienced this with frozen trapped water in the static lines (i.e. the opposite effect of trapped dynamic pressure). There is a report from the Irish Accident Board about a B747 on a test flight with uncapped static lines due to a maintenance error. It is an elucidating gaelic tale that shows just how confusing the compromised pitot-static scenario can be. Ask any instrument technician how much a 1,000 feet of altitude change is worth in terms of “displayed knots”. He’ll demonstrate this for you on his test bench. An airspeed indicator will wind down from 250 knots to zero over a 3,400-foot climb band – and do the opposite on descent. This phenomenon all depends upon whether the pitot ports were blocked and the pitot drain holes were not.

The other possibility is that the captain, upon re-entering the cockpit, saw a high descent rate, inappropriate airspeed and TOGA power and misinterpreted what he saw as a gyrating loss of control and selected idle thrust (after all, there was no stall warning or stickshaker at this point, because they were, angle-of-attack wise, well above the regime where the angle-of-attack vane functioned). How could the captain know at night that they were stalled? The only clue, of a nose-high attitude, was missing. The captain might not have been able to see what the PF was doing with his side-stick control. Courtesy of the trimmable tailplane, stuck at 13º nose-up (but not advertising its status), AF 447 was now descending rapidly, but in a quite <em>normal</em> flight attitude.

As somebody said, “All this will probably come down to crew composition, very high workload, in adverse weather conditions, having to manually hand-fly an aircraft which suddenly found itself in alternate law at high altitude due to spurious information being fed to not only the flight displays, but also to the flight control guidance computers simultaneously”.

<em>Suddenly?</em> Do not underestimate the power of surprise.

<em>Spurious information?</em> When you are taught to believe your instruments, that is what you react and respond to. You see a high and increasing airspeed and you apply back-stick in an attempt to control it. You idle the throttles for the same reason.

The effect, unbeknownst to the pilots, was to embed themselves in a deep-stall condition. Will the stall warning simply <em>cease</em> once the airplane is embedded in a deep stall at 40º angle-of-attack? That is my guess. From the limited dialogue on the CVR, it is evident they were nonplussed by developments. Even the captain was struck dumb by what he saw. No solution was apparent in the time available. The airspeed could have been seen to be much more than just “adequate” (perhaps even high, and higher as static pressure increased inexorably on descent), so how could they be stalled? Unthinkable, so it wasn’t even considered? They just ran out of ideas in a very distracting and dynamic circumstance for which they had never been trained.

Someone also said, “You are not only dealing with conflicting airspeed information. You are also presented with multiple spurious ECAM [Electronic Caution Alert Module, or the Master Warning Display] warnings and cautions – many of which are irrelevant, yet are persistent and therefore impossible to ignore; also depending on the Alternate Law protection loss, which would mean direct side-stick to flight control input without any load protection, leading to control overload.” Isn’t automation wonderful? Only when it works.

A pitot-static system’s pneumatic airspeed data output relies wholly upon very accurate dynamic pressure and static (i.e. ambient atmospheric) pressure inputs – and the latter changes rapidly during a descent at 10,000 feet per minute. No digitizing the source of that information; it is all air pressure analogue. Falsify either one (via blockage or leak) and zoom up or descend and the story will be ever more confusing to the pilots. The totally bewildered pilots in the fatal crashes of the Birgenair and Air Peru B757s found that to be the case.

In the case of AF 447, a frozen static pressure can mean the airspeed will wind back from 250 knots to zero over as little as 3,400 ft of climb at 250 knots indicated airspeed. BEA investigators may be assuming that the zoom was the result of pilot input and not an aerodynamic pitch-up as a result of possibly hitting critical Mach with auto-pilot disconnect and a very nose-down trimmed horizontal stabilizer (3º nose-up, increasing to 13º nose-up due to the pilot’s aft side-stick inputs after the top of zoom climb). Do I think they hit critical Mach? No; more likely was the excessive elevator force gradient that kicked out the auto-pilot and kick-started the fatal zoom sequence. Perhaps the answer will be evident from the DFDR, but maybe not, as the DFDR was being fed erroneous speed information.

A pilot said of the AF 447 crash, “Direct Law is there to give the pilot more direct control of the aircraft but it still has some protection to offer. BUT the protection on offer is only as good and accurate as the information provided to the computers involved. Much more information is needed before one can create a valid picture of what went wrong when it comes to the decisions the pilots made in the last few minutes of the flight.” However, the change in static pressure resulting from the zoom into ever more rarified air and the instinctive attempt to maintain level flight and use backstick to reduce the possibly ever higher displayed airspeed indicated during the ensuing descent after zoom climb are <em>key factors </em>dictating an inevitable entry into the unrecognized deep-stall condition. Add the dearth of information the pilots had to work with, little prior exposure to degraded flight control laws, at night and hurtling into the turbulent clouds below, and the makings of disaster are evident.

 

<strong><em>BEA report:</em></strong><em> “The airplane’s pitch attitude increased progressively beyond 10º and the plane started to climb. The PF made nose-down control inputs and alternately left and right roll inputs.”</em>

<strong>Sampson:</strong> Perhaps the left and right roll inputs were the PF’s insufficient attempts to get the nose to drop. When you’ve got a stuck elevator, or an aircraft pitching up of its own volition due to a runaway elevator pitch-trim, roll the beast onto its wingtip to get the nose to drop. Pity the pilots didn’t think of that, or were trained to think of that, during the January 2003 Beech 1900 stuck elevator take-off accident at Charlotte, NC (52º nose-up at 1,200 feet above the ground). The PF’s nose-down control inputs? They would have been his opposition to the pitch-up of trim and power.

According to the BEA’s interim report, the horizontal stabilizer moved from 3º to 13º, almost the maximum. In doing so, it forced the airplane into an increasingly steep climb. The airplane “remained in the latter position [i.e. 13º nose-up] until the end of the flight,” the report notes.

As pointed out earlier, with underslung engines, maximum thrust can result in an aircraft’s nose rising on its own, exacerbating any incipient control difficulty. Manufacturers have recognized this pitch-up phenomenon. In a 12 May 2010 post-crash Flight Operations Telex, Airbus quietly removed the maximum thrust instruction from its flight manuals (for loss of control and stall scenarios).

An explanation for the A330’s rising nose could also be provided by that innocuous line in the BEA report referring to the trimmable horizontal stabilizer (THS). If the THS had trimmed itself to 13º nose-up prior to the auto-pilot disconnect, as a result of perceived slowing, it would have boosted the pitch-up effect of the pilot’s TOGA power input. The timing of this THS change should be clearer on the DFDR readout.

Gerhard Hüttig, a professor at the Institute of Aeronautics and Astronautics at the Technical University in Berlin, considers the high angle of the THS to be a failure of the Airbus’ electronic flight control system. Hüttig, a former Airbus pilot himself, calls it “a programming error with fatal consequences.” The THS, and not the side-stick controlled elevators, has the <em>real pitch authority</em> at low speeds.

“No matter how hard the crew tried to push down the nose of the aircraft, they would have had no chance,” Hüttig maintains. He is demanding that the entire fleet of Airbus A330’s be grounded until the phenomenon is adequately explained. The PF was never aware of that 13º nose-up THS (or he might have manually trimmed it out – yet another completely unnatural input for a fly-by-wire Airbus pilot). There was nothing to stimulate any awareness of the extreme position of the THS. Hüttig pointed out that Airbus published a detailed explanation of the correct pilot behavior in the event of a stall in the January 2010 issue of its internal safety magazine. “And there, all of a sudden, they mention manually trimming the stabilizers,” he recounts. A November 2008 crash of an XL Airways A320 had served to alert Airbus to the hazards of a “stuck” (i.e. non auto-trimming) THS in preventing stall recovery.

In the stall, would there have been any tell-tale buffeting? In a word, no. The buffet in a level entry 1G stall is provided by the disturbed airflow over the wing hitting the tailplane. At the BEA’s stated 40º angle-of-attack, the disturbed airflow would not have impinged on the tailplane. Everybody aboard was going down in an express elevator at around that self-same 40º angle that was being presented to the relative airflow. Thus, airflow and airframe buffet would not have been a player, alerting the pilots to their airplane’s stalled condition. Indeed, the interior was probably quieter than the ambient noise in cruise, even with the engines at TOGA power.

By design, in Direct or Abnormal Law, there is no auto-trim (it disconnected after reaching 30º angle-of-attack, leaving the THS stuck at 13º nose-up), no ALPHA FLOOR PROT or ALPHA max (i.e. no maximum selectable angle-of-attack), so the aircraft can be stalled in extremis. I daresay this is a consideration that is alien – even bogus, anathema or heretic – to most Airbus pilots.

AF447’s stall occurred probably in a regime beyond the imagination of Airbus designers or test pilots, at the apex of a ballistic zoom climb with a lot of power set on the throttles, at or above the ceiling for the airplane’s weight. A design in which blockage of the pitots not only loses airspeed data but also (because the system believes speed is less than 60 knots, regardless of the truth of the matter) disables the stall warning? Well, prima facie, it seems at least “unwise” – and may have been conclusive.<span style="text-decoration: underline;"> </span>

Much is inconclusive, but one fact ultimately killed the pilots’ last chance of recovering the aircraft. It is very ironic that it was likely due to one of the systems meant to have saved them. The BEA report states, <em>“At 2 h 12 min 02, the PF said, ‘we have no valid indications’. At that moment, the thrust levers were in the IDLE detent and the engines’ fan speed was at approximately 55%. Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and <span style="text-decoration: underline;">the stall warning sounded again</span>.”</em>

At the sudden sound of the stall warning, the PF was likely deterred from any further initiatives, even though he was on the right track with his pitch-down inputs. Instead, he promptly handed over the controls to his more senior PNF. A stall warning that sounds off as the airplane <em>exits</em> a deep-stall condition? Not a great idea at all; it is likely to have the opposite of the desired effect. The overwrought pilot might easily assume that his action is <em>initiating</em> a stall. A much safer, and saner, proposition would be a Doppler-based stall warning whose pitch and volume varies, dependent upon the degree to which the airplane is embedded in the stall. Military fighter aircraft have had such aural calibrated stall warnings for years.

 

Having read through all of the above, whether it is precisely accurate or just roughly right, one has to ask, “Is the training to combat automation anomalies and their inherent malfunction complexities adequate?” Note how quickly the situation described above can become completely and incomprehensibly unglued. The AF 447 crew was caught out by a little known pneumatics phenomenon and reacted understandably to what they saw. They died clueless as to their actual predicament. The pilots are blameless. As one of them said, “We have no valid indications”.

His futile statement was correct. Man can easily be defeated by automation unwinding haphazardly, and it is a burgeoning problem, especially in this era of decreasing pilot experience and economically abbreviated training.

The captain of an A330-200 endorsed Sampson’s analysis:
<blockquote>“That scenario is horribly plausible. That it was erudite and technically accurate certainly add validity. As a current A330-200 pilot, I can envisage just such a sequence and can now perhaps understand the confusion and fear that must have reigned.”</blockquote>
This encomium notwithstanding, it seems that pilots need to be trained in scenarios where automation failures combine to yield an instant crop of false instrument displays and alerts sprinkled with few clues – and they must cope successfully. To be sure, this will cost the industry in pilot down time, classroom and simulator sessions, flight manual upgrades, and so forth. Adjustments must be made when automation confuses rather than enlightens the pilots’ attempts to resolve deviant and seemingly irrational aircraft behavior.

 

<strong>A post script:</strong>

As early as 2005, the pitot tube manufacturer, Thales, was well aware of the catastrophic consequences of the speed sensors. At the time, the French company concluded that such a failure could “cause plane crashes.”

A total of 32 cases is known in which A330/A340 aircrews got into difficulties because the speed sensors failed. In all 32 cases, Thales pitot sensors were involved. These particular sensors were significantly more prone to failure than a more sophisticated later model produced by American manufacturer B.F. Goodrich.

Yet none of the responsible parties saw any urgency in the dilemma. In 2007, Airbus “recommended” that the Thales sensors be replaced. Air France relied upon that underwhelming recommendation as a justification for not carrying out the modification – and had this course signed off as approved by the regulator. The regulator, the European Aviation Safety Agency (EASA), wrote back to Air France that it identified “no unsafe condition that warrants a mandatory modification of the Thales pitot tubes.”

This indemnifying letter was sent on 30 March 2009, almost two months to the day before AF 447’s demise ushered in a new level of distrust in airliner automation. “Mistrust” would suggest vague doubts. “Distrust” is rather more emphatic, suggesting positive suspicions and even a complete lack of trust. Mistrust was the status quo ante. As evidenced by <em>numerous</em> pilot comments, distrust is now in force.]]></content:encoded>
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		<title>Crash in Alaska and Lack of Probing About Key Safety System</title>
		<link>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</link>
		<comments>http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/#comments</comments>
		<pubDate>Wed, 01 Jun 2011 21:06:15 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/crash-in-alaska-and-lack-of-probing-about-key-safety-system/</guid>
		<description><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could [...]]]></description>
			<content:encoded><![CDATA[It is not good when crash investigators reveal a distinct lack of curiosity. Case in point: the investigation into the crash in Alaska which killed the pilot, Sen. Ted Stevens and three other passengers. Four other passengers survived, although injured. (See Aviation Safety Journal, January 2011, “For Lack of a Locking Screw, a Crashed Airplane Could Not be Found Quickly”)

[caption id="attachment_2351" align="aligncenter" width="378" caption="The DHC-3T"]<img class="size-full wp-image-2351 " title="alaska2" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska2.JPG" alt="The DHC-3T" width="378" height="170" />[/caption]

The National Transportation Safety Board (NTSB) just recently wrapped up its investigation into the August 2010 crash. The NTSB determined that the pilot, who had a history of stroke but had been granted a first class medical certificate after the event by the Federal Aviation Administration (FAA), was “temporarily unresponsive” as the airplane veered left into the path of high terrain.

[caption id="attachment_2353" align="aligncenter" width="390" caption="The accident flight compared to the route that should have been taken"]<img class="size-full wp-image-2353 " title="alaska10" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska10.JPG" alt="The accident flight compared to the route that should have been taken" width="390" height="260" />[/caption]

The radar altimeter sounded a warning about 5 seconds before impact, and the airplane struck the tree tops in a climbing, left bank attitude indicating that the pilot was reacting at the last moment to avoid the terrain.

[caption id="attachment_2355" align="aligncenter" width="308" caption="Left float, showing crush from the front"]<img class="size-full wp-image-2355  " title="alaska15" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska15.JPG" alt="Left float, showing crush from the front" width="308" height="243" />[/caption]

The airplane was equipped with a Terrain Awareness and Warning System (TAWS). This piece of avionics equipment could have alerted the pilot to dangerous terrain ahead. TAWS features a “look ahead” function that provides both aural and visual warning of looming terrain which is as high or higher than the airplane. This safety technology has saved many a pilot and his passengers from driving a perfectly good airplane into the ground.

[caption id="attachment_2356" align="aligncenter" width="488" caption="Terrain altitude/color correlation on the TAWS display"]<img class="size-full wp-image-2356 " title="alaska16" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska16.JPG" alt="Terrain altitude/color correlation on the TAWS display" width="488" height="166" />[/caption]

But in this case, the TAWS was inhibited. In this mode, the aural and visual alerts of terrain ahead are deactivated. The pilot deactivates the system by pushing a button on the control panel. Investigators dug through the wreckage and found the TAWS control panel caked in mud. When the dirt was scraped away, the TAWS inhibit button was found in the depressed position – meaning TAWS essentially had been disabled by the pilot.

[caption id="attachment_2357" align="aligncenter" width="317" caption="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away"]<img class="size-full wp-image-2357 " title="alaska7" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska7.JPG" alt="TAWS pushbutton found in the depressed (inhibited) position after the mud was cleared away" width="317" height="195" />[/caption]

Investigators intimated that inhibiting TAWS is standard practice among many pilots in Alaska because of the system’s tendency to issue distracting nuisance alerts. These are not false alarms, but bona fide alerts based on the airplane’s height above terrain.

As NTSB Chairman Deborah Hersman stated:
<blockquote>“While aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain – 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there’s the challenging and rapidly changing weather conditions. Lastly, there are uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.”</blockquote>
One Board Member, Robert Sumwalt, was even more direct: “It makes no sense to me that to fly in Alaska you have to inhibit TAWS” [to reduce nuisance alerts].

The accident airplane was a de Havilland DHC-3T equipped with floats for take-offs and landings in the myriad lakes in the region. Lakes are not officially designated airports in the TAWS data base, so the system will alert the pilot when he is about to land on a lake, as he intends.

To suppress such an alert, TAWS can be inhibited. However, that can be done moments before landing. On the accident airplane, TAWS was inhibited during the cruise portion of flight.

Contrary to flights the previous days from the fishing camp on Lake Nerka southeast 52 miles to a remote fishing camp on the Nushagak River, the accident flight veered left to an east-northeast direction. The course change took the aircraft into mountainous terrain.

[caption id="attachment_2358" align="aligncenter" width="388" caption="Accident flight path in red compared to flight paths with the same pilot on three previous days"]<img class="size-full wp-image-2358 " title="alaska11" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska11.JPG" alt="Accident flight path in red compared to flight paths with the same pilot on three previous days" width="388" height="252" />[/caption]

Had TAWS not been inhibited, the system would have issued an alert, “Caution, Terrain” about 30 seconds before impact. About 15 seconds before striking terrain the system would have sounded, “Terrain, Terrain, Pull Up, Pull Up.” The electronic map display associated with TAWS would have shown terrain 100 feet to 1,000 feet below the aircraft in yellow; terrain within 100 feet of the airplane’s altitude or higher would have been depicted in red.

[caption id="attachment_2360" align="aligncenter" width="297" caption="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red"]<img class="size-full wp-image-2360 " title="alaska18" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska18.JPG" alt="What the pilot would have seen on the terrain display, had it not been inhibited -- no ground in black (a safe 1,000 feet below); rather, all yellow or red" width="297" height="284" />[/caption]

With 30 seconds notice, a pilot should have had ample time to maneuver his airplane and avoid impact with the ground. That is, if TAWS is not inhibited.

[caption id="attachment_2361" align="aligncenter" width="260" caption="A warning pop-up message, which would have been accompanied by a voice alert"]<img class="size-full wp-image-2361 " title="alaska6" src="http://www.nolan-law.com/wp-content/uploads/2011/06/alaska6.JPG" alt="A warning pop-up message, which would have been accompanied by a voice alert" width="260" height="186" />[/caption]

Investigators were unable to determine why the pilot deviated from his previous routes and turned east-northeast. Did he have another stroke? Three autopsies were unable to find such evidence.

Investigators interviewed the senior pilot and fellow pilots at General Communications, Inc. (GCI), the owner/operator of the de Havilland float plane. NTSB investigators did not ask a single one of them about any habits on their part or the accident pilot to inhibit TAWS. Nor were other pilots in the region, flying for different companies, asked about any tendency to inhibit TAWS.

If pilots are inhibiting TAWS to suppress alerts of threatening terrain, maybe they are flying too low. After all, the accident pilot was flying about 100 feet higher than on previous flights through the mountain pass (where he suddenly turned left towards what a fellow pilot described as “smack in the biggest portion of the Muklung hills”). But the accident pilot was still flying lower than the tops of the hills.

Are there other cases in which pilots in Alaska are flying lower than the conditions warrant, with TAWS inhibited? Who knows? The records of interviews with other GCI pilots reveal no curiosity whatsoever on the part of NTSB investigators about these critical questions.

There were no recommendations from the NTSB to the FAA to find out if there is a widespread habit in Alaska for pilots to fly with TAWS inhibited – which is like flying without TAWS at all.

Any accident which occurs because a key safety system is inhibited or shut off goes beyond ironic tragedy. It is the very essence of a useless crash. There will likely be another because the NTSB did not inquire further.]]></content:encoded>
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		</item>
		<item>
		<title>Taking Credit For Scant Accomplishments</title>
		<link>http://www.nolan-law.com/taking-credit-for-scant-accomplishments/</link>
		<comments>http://www.nolan-law.com/taking-credit-for-scant-accomplishments/#comments</comments>
		<pubDate>Fri, 20 May 2011 01:30:06 +0000</pubDate>
		<dc:creator>David Evans</dc:creator>
				<category><![CDATA[Comment on Air Safety]]></category>

		<guid isPermaLink="false">http://www.nolan-law.com/taking-credit-for-scant-accomplishments/</guid>
		<description><![CDATA[Some bureaucrats at the Federal Aviation Administration (FAA) are good at tooting their own horns in the face of overwhelming and continuing vulnerability. A case in point is an FAA Technical Center document dated May 2011.

[caption id="attachment_2341" align="aligncenter" width="133" caption="Technical Center logo"][/caption]

This technical note (DOT/FAA/AR-TN11/8) is grandly titled, “Improvements in Aircraft Fire Safety Derived From [...]]]></description>
			<content:encoded><![CDATA[Some bureaucrats at the Federal Aviation Administration (FAA) are good at tooting their own horns in the face of overwhelming and continuing vulnerability. A case in point is an FAA Technical Center document dated May 2011.

[caption id="attachment_2341" align="aligncenter" width="133" caption="Technical Center logo"]<img class="size-full wp-image-2341" title="logo" src="http://www.nolan-law.com/wp-content/uploads/2011/05/logo.JPG" alt="Technical Center logo" width="133" height="143" />[/caption]

This technical note (DOT/FAA/AR-TN11/8) is grandly titled, “Improvements in Aircraft Fire Safety Derived From FAA Research Over the Last Decade”. The reality is that the research has been selective and has not as of yet resulted in a whole scale improvement in the nation’s fleet of airliners. Passenger and cargo-carrying aircraft remain flying firetraps. Unlike public buildings, such as offices, schools, hospitals, nursing homes and the like, which are required by building codes to be 100% covered by fire detection and suppression, an airliner has entire areas bereft of fire detection and suppression, despite the fact that airplane occupants are stuck in their seats until an on-fire airplane lands. In this respect, passengers are analogous to nursing home occupants – aged patients with limited mobility, often confined to wheelchairs. The inability of nursing home occupants to quickly evacuate a burning building is a major reason for full detection and suppression of fires. Passengers do not benefit from similar protection, despite the fact that the aircraft is a mobile life support system from which immediate escape is not possible.

One could argue that the results of the Technical Center’s efforts are paltry. The TechCenter asserts that its fire safety research during the period from 2000 to 2010 has:
<blockquote>“[Resulted] in the adoption/issuance of five final regulations, two Airworthiness Directives, two Advisory Circulars, and two Safety Alerts for Operators, which are expected to significantly improve aircraft fire safety.”</blockquote>
This assertion may sound like a very productive effort. However, only regulations and Airworthiness Directives (ADs) are mandatory. Everything else is advisory, for information, and definitely not required.

If one looks only at the seven mandatory actions, these actions are the equivalent of  approximately one regulatory action or required corrective action every 1.5 years. Regarding these various mandated initiatives, some of the most important have had no effect on the fleet of aircraft because of their generous implementation time. For example, one of the touted mandatory actions concerns fuel tank inerting – or the provision of explosion-suppressing gas into the void spaces of fuel tanks. This inerting program is intended to prevent a recurrence of a TWA Flight 800 disaster, in which the flammable ullage (vapors) in the center wing tank of an older B747-100 was ignited by electrical arcing of fuel quantity indication system (FQIS) wires inside the tank. The resulting catastrophic explosion shortly after takeoff from New York’s Kennedy International Airport blew apart the airplane and killed all 230 persons aboard.

In the July 2008 <em>Federal Register</em>, the FAA published a final rule requiring new and existing airliners to be fitted with either a Flammability Reduction Means (FRM), which is generally understood to mean an inerting gas inside the fuel tank, or an Ignition Mitigation Means (IMM). An IMM can be foam block in the tank to reduce or contain an ignition source, preventing an explosion and thereby accomplishing the same end as inerting.

Either FRM or IMM must be installed on new aircraft within two years, placing the deadline in July 2010. The number of new airliners entering service is paltry compared to the size of the existing fleet: approximately 100 new aircraft compared to an existing fleet of some 4,000 jets.

For the existing fleet, the FAA has allowed planes to operate without retrofit until 2018 – fully 22 years after TWA 800 exploded.

The TechCenter takes credit for a rule that should have been published years ago and, in fact, published well before TWA 800 blew up, as the hazard has long been recognized and systems have been developed to mitigate it. The record demonstrates that at least three generations of inerting technology were not deployed on airliners because of the absence of an FAA requirement to do so:
<blockquote><strong>1st generation:</strong> 1950, an inerting system was fitted to the first jet bomber, the B-47, based on filling canisters in the wheel wells with dry ice (CO2). The ice was heated, and the resulting CO2 gas was piped to the fuel tanks.

<strong>2nd generation:</strong> 1970, the FAA successfully demonstrated a liquid nitrogen (LN) based inerting system in a DC-9 aircraft.

<strong>3rd generation:</strong> 1983, Boeing patented a membrane-based technology to produce nitrogen-enriched air (NEA) to inert fuel tanks.</blockquote>
The technology mandated by the FAA is a pared down version of the 3rd generation system. A vacuum bottle, used originally, to store NEA for the descent phase of flight has been eliminated. The bottle was used to store surplus NEA produced during cruise, which would then be metered to the fuel tanks during descent. With the vacuum bottle removed (as a weight saving measure), the new system will not provide inerting during descent.

[caption id="attachment_2342" align="aligncenter" width="429" caption="The inerting system developed by the TechCenter, which basically is a stripped down version of Boeing&#39;s patented system. The arrangement shown here lacks an oxygen sensor to ensure that the fuel tank is in fact inerted."]<img class="size-full wp-image-2342" title="techctr2" src="http://www.nolan-law.com/wp-content/uploads/2011/05/techctr2.JPG" alt="The inerting system developed by the TechCenter, which basically is a stripped down version of Boeing's patented system. The arrangement shown here lacks an oxygen sensor to ensure that the fuel tank is in fact inerted." width="429" height="304" />[/caption]

This rule addresses only heated center wing tanks, the type which exploded on TWA 800. Airplanes with unheated center wing tanks or no center tanks are not affected. A heated center wing (e.g., fuselage) tank is one in which nearby equipment generates heat which, in turn, can migrate into the center wing tank, thereby elevating the temperature of the ullage into the flammable range. A spark from fuel pumps, fuel quantity, or other electrical systems internal to the tank can ignite flammable vapors.

The National Transportation Safety Board (NTSB) did not make a distinction between unheated and heated, or between center or other tanks. The NTSB recommended that <em>all</em> fuel tanks be inerted.

The NTSB complained to the FAA about the unavailability of inerting on all aircraft regardless of whether or not they have heated center wing tanks. For example, in its 2004 protest over the intended Airbus A380 super-jumbo jet design, the NTSB said:
<blockquote>“The draft SC [Special Condition] is ... based on a philosophy that accepts fuel tank flammability, proposes that safety assessments be performed to demonstrate that the presence of an ignition source within the fuel system is ‘extremely improbable’, and describes the operation of a new transport airplane with a flammable fuel/air mixture in the fuel tanks.”</blockquote>
Despite this complaint, the European Aviation Safety Agency (EASA) certified the A380, as did the FAA.

It gets worse. The inerting rule completely ignores safety margins. For example, the FAA considers the fuel tank to be explosive only after the fuel vapor concentration exceeds 100% of the Lower Flammability Limit (LFL), as opposed to the 25% limit adopted by the National Fire Protection Association.

The FAA assumed that if the ullage had an oxygen concentration restricted to 12% then the tank would effectively be inerted. Traditionally, an oxygen content of 9% has been used, which provides a safety margin. The FAA determined that an inerting system capable of reducing the oxygen content of the ullage to less than 12% is “impractical for commercial airplanes” since a more capable inerting system would be needed.

There are other deficiencies in the final rule on inerting. Suffice it to say, the FAA has opted for a minimalist approach to inerting which eliminates all safety margins.

The TechCenter takes credit for having influenced this travesty of a rule.

 What did the TechCenter <em>not</em> do? It failed to address why fuel tanks were, and are, designed with all sorts of electrical components inside the tanks, such as electric fuel pumps, electric fuel quantity measuring systems, and the routing of wires for other systems inside fuel tanks. The density of electrical systems inside fuel tanks invites the probability of failure (e.g., chafing) and the likelihood of an errant spark.

It would have been more fruitful for the TechCenter to explore alternate designs in which fuel tanks did not contain any electrical components, thereby providing a design template for aircraft manufacturers to emulate.

To be noted, the TechCenter did perform useful work by demonstrating the flammability of insulation blankets covered in metalized Mylar.

[caption id="attachment_2343" align="aligncenter" width="278" caption="Photographs compiled by the TechCenter showing damage resulting from a hidden in-flight fire involving insulation blankets."]<img class="size-full wp-image-2343" title="techctr1" src="http://www.nolan-law.com/wp-content/uploads/2011/05/techctr1.JPG" alt="Photographs compiled by the TechCenter showing damage resulting from a hidden in-flight fire involving insulation blankets." width="278" height="149" />[/caption]

All such insulation material was removed from about 800 airliners as a result of the TechCenter’s research. Again, consider what the center has <em>not</em> done -- it has not tested new, absolutely flameproof insulation material. Called Starlite by its manufacturer, it is superior to even the most dramatic insulation on the Space Shuttle. A Boeing official said:
<blockquote>“We coated an egg with a layer of [the] material about the thickness of peanut butter you’d put on a sandwich, then we put a blowtorch to it for a couple minutes until it glowed red. Immediately after the flame was removed, you could hold the egg in your hand, and when we broke the egg open it was still raw. We see the possibility of preventing injuries and death during aircraft ground fires with this material.”</blockquote>
Not to mention that the material, substituted for existing insulation blankets on an airplane, would enhance safety during in-flight fires as well.

Maybe the fact that this the material is the invention of a former hairdresser, not of an aerospace scientist, is part of the reluctance to accord Starlite due deference for its flame proof properties. That, and the reluctance of the inventor to divulge the exact chemical make-up of Starlite. In any event, it has not been subjected to high profile tests by the TechCenter.

The TechCenter did test a device in which a hand-held fire extinguisher could have its chemicals get behind a cabin ceiling. The Swissair Flight 111 aircraft, an MD-11, which crashed in Halifax, Canada, in 1998, was downed by a fire in the so-called attic space above the cabin ceiling panels. One company has developed a port, affixed to interior cabin panels, in which an extinguishing agent could be squirted into the area behind. The TechCenter gave the device lukewarm marks:
<blockquote>“A preliminary series of tests were conducted to examine the use of ports, opening in the cabin ceiling, to allow the discharge of Halon 1211 hand-held extinguishers into the attic area. Not surprisingly, it was shown that the ports could be effective in the relatively small volume that exists in a standard-body aircraft (e.g., a B737 or A320); but in a wide-body aircraft (e.g., a B747), this approach would not be effective because the agent is diluted by the large volume of the attic area. Additionally, to make the ports practical and effective in a standard-body aircraft, a detection system would be needed to locate the fire, and the ports would have to be spaced to optimize the effectiveness of the available extinguisher.”</blockquote>
What is not mentioned is that after the crash in Canada, Swissair installed infrared cameras in the attic space of its remaining MD-11s, with the pictures piped to a display in the cockpit. The problem of locating a hidden fire was effectively solved.

The problem of attic space conflagrations is only a part of the hidden fire problem in which access ports would be useful. The TechCenter report does not mention that behind cabin sidewalls electrical components proliferate. A series of ports along the cabin would facilitate the application of fire suppressant chemicals in a confined area where the chemicals would not be diluted by space.

The TechCenter report also fails to address the problem of smoke in the cabin and cockpit. Regarding smoke in the cabin, one manufacturer has developed a combination oxygen mask/smoke hood which would drop from the overhead instead of the “little yellow cups” which constitute the current passenger emergency oxygen mask.

The combination mask/hood would not only provide exygen, but would also protect the passenger from heat and the noxious effects of smoke. When it would be time to evacuate the airplane, the hood would break away from its oxygen umbilical and the passenger would have sufficient breathable air to evacuate the airplane.

With nil interest from the aviation industry, the manufacturer has suspended further development and marketing of the combination mask/hood. The U.S. military has not accepted this state of affairs. All military transports are equipped with portable breathing equipment (PBE) for passengers and crew. The PBE weights about 1 lb and can keep the wearer alive for up to an hour. This safety device is also used on many civil passenger planes, but is only available for the crew.

Smoke in the cockpit can be countered by oxygen masks and goggles worn in emergencies by the pilots. However, the presence of thick, blinding smoke can obscure instruments and the view out of the windscreen. In the Canadian report of the Swissair disaster, it was surmised the pilots had trouble seeing their instruments and therefore standby gauges and displays should be larger. In the presence of pervasive smoke, goggles are of no use beyond the short distance from eyeball to faceplate, and the size of the instruments is of no help. If the pilots cannot see out the windscreen, how are they supposed to land the airplane? A device known as EVAS (Emergency Vision Assurance System) features an inflatable, clear plastic bubble which physically displaces the smoke, giving the pilot a reduced view of instruments and a forward view out of the windscreen.

[caption id="attachment_2344" align="aligncenter" width="264" caption="EVAS deployed from its briefcase-size box and in action."]<img class="size-full wp-image-2344   " title="evas in use" src="http://www.nolan-law.com/wp-content/uploads/2011/05/evas-in-use.JPG" alt="EVAS deployed from its briefcase-size box and in action." width="264" height="233" />[/caption]
<p style="text-align: center;"> <img class="aligncenter size-full wp-image-2346" title="evas schematic" src="http://www.nolan-law.com/wp-content/uploads/2011/05/evas-schematic.JPG" alt="evas schematic" width="483" height="118" /></p>

This technology has not been tested or endorsed by the TechCenter. However, the FAA has equipped its own airplanes with this safety device, and it has approved installation on airplanes when applicants have asked for it. So now we have the FAA preaching “one level of safety”, with a higher standard for its own airplanes than for those of the flying public.

An example of the cockpit visibility problem comes from the September 2010 crash in the United Arab Emirates (UAE) of a United Parcel ervice (UPS) B747-400 freighter.

[caption id="attachment_2347" align="aligncenter" width="222" caption="Crash scene of a UPS B747 freighter near Dubai"]<img class="size-full wp-image-2347" title="ups 747 crash" src="http://www.nolan-law.com/wp-content/uploads/2011/05/ups-747-crash.JPG" alt="Crash scene of a UPS B747 freighter near Dubai" width="222" height="175" />[/caption]

With a fire on the main cargo deck, the cockpit quickly filled with smoke. According to the preliminary report by the UAE's General Civil Aviation Authority (GCAA):
<blockquote>"The crew informed BAH-C [Bahrain Air Traffic Control] that there was smoke in the cockpit and that the ability of the crew to view the primary flight instruments and radio frequency selection controls had become degraded ...</blockquote>
<blockquote>"Based on the information available to date, it is likely that less than 5 minutes after the fire indication on the main deck, smoke had entered the flight deck and intermittently degraded the visibility to the extent that the flight instruments could not be effectively monitored by the crew."

[caption id="attachment_2348" align="aligncenter" width="424" caption="From the GCAA preliminary report"]<img class="size-full wp-image-2348 " title="ups 3" src="http://www.nolan-law.com/wp-content/uploads/2011/05/ups-3.JPG" alt="From the GCAA preliminary report" width="424" height="221" />[/caption]</blockquote>
The crew was killed while attempting an emergency landing. Since the accident, UPS has ordered EVAS for its entire fleet.

A tantalizing -- and chilling -- statistic is contained in the TechCenter report: in 2006 there were more than 800 incidents of smoke or odor in the cabin or cockpit. In 34% of cases, the severity was such that the pilots diverted the aircraft to a quick landing or returned hastily to the departure airport. This works out to one incident every day for nine months. Yet smoke hoods and emergency vision for the pilots remain unexplored territory at the TechCenter.

Above all, the TechCenter has not undertaken a vigorous research program into one of the fundamental recommendations coming out of the Swissair 111 disaster. The Transportation Safety Board (TSB) of Canada, who investigated the crash, stated that if there were no flammable materials used in the construction and equipping of airliners, the danger of airborne fire would be greatly reduced.

A technical inquiry into such feasibility has not been undertaken.

Rather, research remains focused on various tactical problems, such as the vulnerability of certain types of insulation blankets to ignition from adjacent fire, or reducing fuel tank vulnerability to explosion. Promising technologies seem to be ignored and basic issues – such as electrical components routed inside fuel tanks – are not questioned.

As the TechCenter report freely notes, three crashes were major stimulants of its work:

1. The 1996 loss of a ValuJet DC-9 due to an uncontrolled fire in its foward belly hold, with the loss of 110 lives when the airplane plummeted into the muck of the Florida Everglades. Before the crash, there was smoke in the cockpit.

2. The 1996 destruction of the TWA B747 due to the explosion of flammable vapors in a fuel tank, with 230 fatalities resulting.

3. The 1998 loss of a Swissair MD-11 due to an uncontrolled fire in the attac space, with 229 fatalities. Before the crash, there was smoke in the cockpit.

Without these crashes, it is doubtful that the TechCenter would have undertaken the modest research program it did perform, looking into fire aboard airplanes. In other words, without the grim stimulus of three crashed airplanes and 569 lives lost, the belated and weak research program which was undertaken might not have been conducted.

The FAA is often accused of taking a “tombstone” approach to air safety, which means the agency is only galvanized by disaster to take action. The TechCenter report provides further evidence of this approach; and the report, with all of its self-proclaimed accomplishments, still evades basic issues, such as electrical system routing, flammable materials, and new technologies.

Indeed, the TechCenter report could be compared to one completing his/her own report card. The center gives itself an "A" for contributing effort -- one required action every 1.5 years.

A knowledgeable third party might be less generous – maybe a gentleman’s “C” for doing just the basics – after hundreds of lives were unnecessarily lost.]]></content:encoded>
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