Aircraft Accidents and UAS Data, Part IX

Beginning in November 2016, with Aircraft Accidents and UAS Data, Parts One and Two; then in October 2018 with Parts Three and Four; March 2019 was Parts Five and Six. In May 2019, Part Seven was written; Part Eight in October. The unmanned aerial system (UAS) and the national airspace system (NAS) continues to need dedicated professionals who both understand the UAS industry and comprehend the need for rules. The fifth Article (study) has been written by principal authors: Ryan Wallace of Embry-Riddle University (ERAU); Jon Loffi, Samuel Vance, Jamey Jacob and Jared Dunlap of Oklahoma State University (OSU). Their study titled: Cleared to Land: Pilot Visual Detection of Small Unmanned Aircraft During Final Approach is a qualified sequel to the four previous studies. This article was printed in the ERAU Scholarly Commons, Volume 6, Issue 5, Article 12.

As with the previous studies, the author team makes use of real-time situations and equipment to simulate as closely as possible the concerns. In the accomplishment of the previous studies, the teams have employed manufacturer-specific equipment to track certain sUASs; they have observed airspace violations around major airports, e.g. Daytona Beach IA, and commercial air routes, e.g. banner-towing. They have made use of the services of volunteer project pilots, with qualifying FAA-certifications.

More importantly, the teams have contributed to the future of unmanned flight safety. All the studies conducted had a unique theme; when taken together, the themes demonstrate a step-by-step story about how the UAS industry should prepare their operators for inclusion in the NAS. The writer for this website has written about these studies, to point out the futility many persons have of trusting to government to solve all the problems with UAS safety.

The article’s Problem statement is: “The threat of a midair collision between a sUAS [small UAS] and manned aircraft is heightened during the final approach phase of flight, as aircraft transition from higher-altitude airspace into the low altitude arena now populated by small unmanned aircraft. Absent benchmarks for electronic detection and sense and avoid systems, pilots rely primarily on visual senses and proper visual scanning techniques to ensure a positive separation and collision avoidance from sUAS platforms during this segment of flight.”

This problem statement demonstrated the correct concern for sUAS that threaten aviation safety; the concern has grown exponentially over the years: “The number of pilot-reported encounters with unmanned aircraft has been on the rise, since 2014 …” The article further stated, “… more concerning is the number of unreported UAS encounters during the final approach phase of flight.”

A Notice of Proposed Rule Making (NPRM) called Safe and Secure Operations of Small Unmanned Aircraft Systems, was introduced in 2019, to combat the intrusion of sUAS vehicles. It gave aviation professionals an opportunity to vent their concerns. However, an NPRM is a feeble argument; it holds no consequences and cannot be acted upon in a timely manner; it is a band-aid.

The article raised three questions:

  • What is the visual detection rate for a small unmanned aircraft system by an aware pilot when transitioning from an instrument approach to visual landing?
  • What is the mean distance at which a small unmanned aircraft system can be detected by an aware pilot when transitioning from an instrument approach to visual landing?
  • What factors affect visual detection of small unmanned aircraft systems by pilots?

The study was conducted under controlled conditions, a safe distance from regular commercial traffic. The place: a modest landing strip in rural Oklahoma. The approach was at 60 to 70 knots. The weather conditions: visual flight rules. Pilots: two per single-engine aircraft. The sUAS: a DJI Phantom (white quadrotor) against a green and brown terrain. Even with the pilots knowing the sUAS was either to port or starboard, the visual detection rate was “… 12 out of 40 possible events, resulting in an overall detection rate of 30.0%”. Moving sUAS were detected during 9 out of 18 possible events, resulting in a detection rate of 50.0%. Static sUAS were detected during only 3 out of possible 22 possible events, yielding a detection rate of 13.6%.”

Question: Given the study pilots’ awareness of an sUAS in his approach vicinity, how much harder would it be to see an sUAS against a background of dense visual ‘noise’? The study employed pilots watching for known targets against contrasting farmland, which easily betrayed the white sUAS in flight. But what about an approach into La Guardia airport at 140 to 150 knots? Would a B737 pilot easily distinguish an sUAS on approach over the mosaic that is Jackson Heights to runway 4 in midday?

The authors were very familiar with the effects of sUAS interference on populated airports. ERAU is near Daytona Beach International Airport (IA) and close to Orlando IA. OSU is near Tinker Air Force Base and Will Rogers World Airport. They understood that reaction times for pilots, whether a Cessna 150 or a B737, were extremely limited. From the study, they learned the fact that visually detecting an sUAS was almost impossible when the pilot did not know the sUAS was there and not camouflaged against a multicolor background or below line-of-sight over the nose of the aircraft.

What is required is perspective. This writer is not a pilot; never, outside of a simulator, landed an aircraft. What would happen to a car’s windshield or frame if someone hit a solid object (not a bird) at the approach speed of a Cessna single-engine aircraft: 60 to 70 knots (70 to 80 miles per hour)? The solid object would penetrate the windshield, kill the driver; the object would make the car undriveable and unsafe. The car, driving on a two-dimensional plane (X and Y-axis), could result in the death of the vehicle’s occupants and, perhaps, wiping out anyone else within crashing distance.

What about a car driving at the speed of a B737 on approach, at 140 to 150 knots (161 to 172 miles per hour); what would the effect be on that car if it operated in a three-dimensional plane (X, Y and Z-axis)? All passengers would be at risk; everyone below the approach would be at risk (think American 587); the engine could be destroyed at a critical point of approach (think US Airways 1549); if the driver survived a windscreen impact, he would be trying to safely land the vehicle … somewhere; an impossibility over a major city.

There remains through all these studies one simple question no one has asked: Why would anyone need to violate NAS airspace and endanger lives? This website addressed this concern in last week’s archived article:

An analogy for this activity is: the equivalent of randomly dropping a brick off a highway overpass or shining a laser at an approaching airliner. Are these thoughts speculation? Perhaps, but speculation based on fact is theory and theories are proven by using facts. Unless we continue to shut our eyes to the danger, a midair sUAS impact will prove these theories to catastrophic effect.

For instance, in April 2018, Southwest Airlines flight 1380, validated the dangers of an engine when its blades separate at operating speeds; this would be the scenario should an engine fan, turning at over 1800 rotations per minute, hit a solid object, e.g. sUAS. A windscreen, designed to absorb the impact of semi-solid objects, such as a bird, will not be able to sustain the damage made by an sUAS and will result in the pilot(s) being killed. That is a fact; the windscreen will not survive an impact with a solid object. It was never designed to. This is the fifth installment in the authors’ attempts to educate the aviation community, as a whole, about real dangers. Their intention is to make known possible threats to all aviation-minded people and to provide the facts for the industries to base productive conversations on, work proactively towards safety as opposed to reactively, to challenge the industries to prevent accidents before they happen.

Aircraft Accidents, UAVs and Finding Nero

There is very little proof that Emperor Nero fiddled while Rome burned, especially since the fiddle did not exist at Nero’s time. It’s the expression that matters; it is meant to allow us to envision one who just wants to see the world burn, for selfish reasons. The unmanned aerial system (UAS) industry knows about their Neros and they are hiding in plain sight.

Before this author analyzes the latest unmanned aerial vehicle (UAV) study by Doctors Wallace, Vance, Loffi, Jacob and Dunlap: Cleared to Land: Pilot Visual Detection of Small Unmanned Aircraft During Final Approach, next week, it is probably best to explain why the Neros of the UAS industry are going to destroy any progress the UAS industry has made.

UAVs continue to threaten air commerce, whether airliners, corporate operators, banner towers, crop dusters or aerial fire-fighters; irresponsible children with UAVs are endangering lives and property, both in the air and on the ground. Why would they do this? Why would someone shine a laser at an inbound airliner when they know the light blinds the pilots? The child wants to see the world burn. View a video, FAA investigates drone flying near news choppers:

If we wait for an accident, that would require a year-long National Transportation Safety Board (NTSB) investigation; it would also be futile. Waiting for an accident is reactive and deadly. In addition, the NTSB’s track record is in question. They will punt by blaming the Federal Aviation Administration (FAA) for everything, which does not address the safety issues or fix the problems. Besides, the NTSB fundamentally does not even understand the FAA.

Since it was determined that the FAA will have sole jurisdiction over the oversight of the UAS industry, no one has taken time to establish just what that means or how successful that mission will be. There are many consequences to not exploring this assignment proactively, to conveying responsibilities based on the sole logic that the FAA has the word ‘Aviation’ in its title.

To be fair, let us discuss the facts of the situation; let us look at the FAA’s Operations side of UAS oversight, since it is the Operations aviation safety inspector (ASI) who works with UAS operations. Airworthiness handles the maintenance side, but it would be the Operations side that would oversee all UAS pilots and operators, such as pilot certification, testing, enforcement and giving the UAS operator his/her operator certification. They would also be responsible for safety violations with UAVs that fly too low, too high, within restricted airspace, etc. To be clear, these ASIs occupy one third of a flight standards district office (FSDO), the office that would oversee UAS issues in a specific area.

What does that mean? Let us look at an average FAA FSDO: the Portland, Maine FSDO. There are only twenty operations ASIs working 8:00 AM to 5:00 PM, Monday through Friday. They oversee three states: Vermont (17 usable airports), New Hampshire (29 usable airports) and Maine (40 usable airports), whose combined area is 54,358 square miles; that’s 2718 square miles per operations ASI. Each operations ASI normally oversees ten to twenty air operators; then there are flight schools, designated examiners, hundreds of helicopter and fixed-wing pilots. Incidentally, less than half of these ASIs have been trained on, or are familiar with, UAVs.

UAV operators can number in the thousands in those states. That means there is one ASI to oversee thousands of certificate holders each, across three states. Major airports like Manchester, Burlington and Portland are under these twenty ASIs’ jurisdiction; that does not include the 83 other airports that regularly report UAV infractions, e.g. trespassing over airport airspace, busted altitudes or flying within an airport’s approach pattern. If a UAV violates the airspace in Burlington, the FSDO is not situated nearby to respond; in fact, the operations ASI is ten hours away, depending on flight availability and/or highway traffic.

During this recent upturn in the economy, the aviation industry has experienced a rise in employment opportunities, pilot jobs particularly. It is financially beneficial for pilots to seek out jobs in the industry; those jobs pay far better than the government does. This affects the number of operations ASIs leaving government positions, as well as those who are no longer looking at government as a viable job opportunity to apply for. Then there are those operations ASIs retiring, which is on the rise. What the FAA ends up with is a shortage of qualified operations ASIs, many of whom have no UAS experience.

Many UAS social media commenters are short-sided critics; they speak from emotion, not common sense. “If anything happens, it’s the FAA’s fault. They’ve been dragging their feet.” Just like the NTSB, these critics do not understand how things work. It is far easier to blame everyone else. If you don’t believe that, turn on the news and see how much government is addressing problems in their own states. In short, government is not the answer.

What happens, then, if the UAV problem continues to get worse? For those who need a history lesson on just how businesses can be devastated by consequences, in 1978, American Flight 191 crashed in Chicago. American Airlines, it was learned, cheated on the engine installation and caused the accident. However, the DC-10 was grounded for over a month; many airlines, e.g. Laker Airways, were hit hard by American Airlines’ incompetence. There are other examples: The Boeing B737-MAX, which has been grounded for months and which the investigatory groups still have not gotten right. It does not matter if the investigatory groups got it wrong, the airlines suffer financially.

The shuttle Challenger caused a two-and-a-half-year grounding; the shuttle Columbia, two years. Each shuttle disaster resulted in millions of dollars lost by companies whose businesses depended on satellite launches; they had to wait in line for years for future shuttle opportunities or invested in more expensive launch vehicles.

At no time during these groundings did anyone from the National Aeronautics and Space Administration or the FAA get their pay interrupted. However, with American 191 many domestic airlines were hurt due to the grounding of a wide-body aircraft; many international airlines could not fly into the United States; their businesses were hit hard. Thousands of flights were cancelled, jobs were liquidated and profits from restructuring delays were lost.

How many UAS businesses are willing to lose it all because of a few irresponsible children? Whether your business is real estate, mapping or website building, if a UAV causes a major accident, the UAS industry will be hard-down grounded – not might be, will be! UAS businesses will be financially devastated by these children who continue to threaten aviation safety. And when the grounding is over, how long will the aviation industry make you suffer for what had happened? How long will they work to block UAVs from re-entering the national airspace? Their lobbyists are more vocal and well-funded.

Many may argue that the FAA authorizes some uncertificated pilots to fly ultralight aircraft, with nothing more than a driver’s license. Argue all you want; nobody cares about these arguments because these ultralight pilots only endanger themselves. They won’t get sucked into an aircraft engine or crash through a windscreen at 130 knots. If the ultralight pilot defies the regulations or laws of physics, they are the casualties – not strangers, not families killed in the crash.

Doctors Wallace and his co-authors have been putting these series of studies out for years; they are invaluable. They are trying to open the eyes of the UAS industry to police yourselves, create the tracking technologies and educate the children. Find these Neros and get in front of their irresponsible behaviors; prevent them from watching the world burn. The consequences will not just be your short-term industry plans. The consequences will be that your businesses will go up in smoke.

Aircraft Accidents and Lessons Unlearned XXXI: Lion Air 610

Unknown photographer – B737 Angle of Attack Vane

On October 29, 2018, thirteen minutes after departing Jakarta, Indonesia, Lion Air flight 610, a new Boeing B737-MAX, registration PK-LQP, suddenly plunged into the Java Sea. The Komite Nasional Keselamatan Transportasi (KNKT) final accident report, KNKT., was released on Friday, October 25, 2019. The report revealed multiple cultural issues in Lion Air’s Operations division. What the report also demonstrated was KNKT’s fundamental inexperience with aircraft maintenance (AC-MX) issues that directly contributed to the accident. However, the KNKT was not alone; the National Transportation Safety Board (NTSB), who assisted in the investigation, was just as naïve in AC-MX issues as the KNKT.

The major contributing factor centered around the left-hand angle of attack (AOA) vane on the B737-MAX. Whether it was improperly overhauled or not correctly installed, the two investigatory groups focused on the easy culprit of new technologies and downplayed a simple fact: the AOA vane caused the accident … period. The KNKT failed to distinguish the difference between probable cause and root cause. That AOA vane caused a malfunction in the B737-MAX’s system (probable cause), but why that AOA vane was on the airplane (root cause) was ignored. Probable cause tells how accidents occur; root cause tells why accidents occur. If one removes root cause, probable cause goes away.

Out of 89 findings in the KNKT report, only ten findings were dedicated to AC-MX and even those were thinned by other problems. The report had scores of recommendations which never addressed the AC-MX issues that contributed directly to the accident. Instead they focused on the minutiae, such as pilot actions in the emergency or second-guessing decisions. These were safety issues for training or design flaws to be fixed, but they did not cause the series of events that led Lion Air 610 to crash.

Per the KNKT report, on page 131, “The investigation received AFML [aircraft flight maintenance log] record on October 2018 of PK-LQP.” The report then stated, “The investigation found 31 pages not included in the package.” Were the missing pages ever found? How did the KNKT investigate an accident for one year and never find any or all of the 31 missing pages? What did those missing pages say about Lion Air’s AC-MX culture? Did they agree with digital AFML copies? Why did AC-MX keep resetting circuit breakers on the accident aircraft during the last weeks?

The left-hand AOA vane was replaced with a defective part. This happens; a defective part is called ‘bad-from-stock’. It just should not be left on the plane. In the KNKT report, page 36, the left AOA vane was operationally tested using an alternative – yet approved – method, which required deflecting the AOA vane to different positions and then verifying each AOA position on the stall management yaw damper (SMYD) computer. However, “The [mechanic] did not record the indication on the SMYD computer during the installation test.” Why? Why were operational check parameters not recorded as directed? Why did no one question the unusual maintenance steps taken to clear computer faults?

Shouldn’t the NTSB have caught these issues? The NTSB’s September 19, 2019, report failed to direct attention to AC-MX. No finding or recommendation about the missing paperwork or the questionable testing performed on the accident aircraft prior to the accident. Did the NTSB understand the culture of Lion Air’s AC-MX division and/or its repair station personnel? Did the NTSB have AC-MX investigators with AC-MX experience? Has the NTSB started hiring seasoned AC-MX investigators or are they still using inexperienced engineers?

The NTSB and KNKT’s lack of AC-MX experience was shared by the Joint Authorities Technical Review (JATR), led by former NTSB Member, Christopher Hart. The JATR team of technical representatives was chartered by the Federal Aviation Administration (FAA) to review the FAA’s certification process. On October 11, 2019, the JATR report to the FAA was published. On page XII, paragraph 11, Impact of Product Design Changes on Maintenance Training, the JATR team stated, “The JATR team was tasked to consider maintenance suitability of the design. Due to lack of maintenance expertise on the JATR, the team was unable to make a determination of such adequacy.”

Amazing! Did the FAA cancel the JATR’s check? How can a team of technical representatives, employed by the FAA to provide unbiased, rounded views into the FAA’s certification process, fail to have AC-MX expertise? Certification relies heavily on AC-MX and inspection personnel to follow the procedures and instructions for continued airworthiness (ICA) for maintaining the aircraft. The ICAs, which appear to not have been followed, directly contributed to the Lion Air 610 accident. The JATR should have employed somebody … ANYBODY … who could address AC-MX issues. This was unacceptable.

The JATR was hired to help the FAA find problems.  Instead, the JATR ignored the basic needs of the AC-MX workforce using the ICAs. How could the NTSB expect the B737-MAX to be safe if they ignore fundamental problems that led to the accident? How did the KNKT expect Lion Air to learn from a catastrophic mistake if the KNKT cannot even understand why, e.g. missing AFML log pages and unknown test procedures were important? Did the KNKT, NTSB or JATR take AC-MX or Systems training on the B737-MAX? Did they take Lion Air’s approved B737-MAX Systems training to check for quality? Anybody?

The FAA and all oversight agencies across the world divide certificate holder oversight responsibilities into two groups: Operations and Airworthiness. Operations oversees the operator’s pilots, ramps, flight attendants, training and operations control; just because engineers designed the aircraft does not mean engineers can tell pilots how to fly it. Airworthiness oversees the operator’s maintenance, inspection, training, engineering and contract outsource maintenance; just because an engineer designed a single aircraft’s system does not mean that engineer understands all the systems and how to repair them.

The FAA has used these methods to capture all manufacturers, contractors, air carriers and outsourced maintenance for decades. The FAA, unlike the NTSB and the KNKT, does not hire engineers for investigations, performing surveillance or oversight. Why? Because engineers are not certificated; engineers do not receive systems training; engineers don’t understand how an operator works; they lack experience and basic troubleshooting skills to recognize problems, just like in Lion Air 610.

Lion Air 610 is the latest example of the NTSB’s failure to determine root cause. In this accident, the KNKT and the NTSB, by trivializing Lion Air’s AC-MX, ignored a major contributor to the future of Lion Air’s safety, not just of the B737-MAX, but its entire fleet. The evidence pointed to an inherent problem at Lion Air and/or its AC-MX provider that the KNKT and NTSB missed. Did Lion Air call Boeing technical support to ask about the AOA problems between October 9 and October 29, 2018? If not, why not? Did the KNKT interview the accident aircraft’s mechanics? The KNKT report does not say. AC-MX professionals would know that the manufacturer’s technical support always answers the phone.

Could the KNKT and NTSB’s AC-MX lapses have prevented Ethiopian Airlines 302’s crash five months later? That falls within the area of speculation. However, the omission of AC-MX issues in both the KNKT and NTSB reports demonstrated that they focused on what resulted from the series of events that led to the accident and ignored what caused the series of events that led to the accident. They obsessed on certification failures on a grounded aircraft – old news, all too easy. They failed to solve the root cause of the accident.

What does it mean that the root cause was never discovered by three respected organizations: the KNKT, the NTSB and the JATR? It means that the root cause still exists, that the ignored problems with Lion Air’s maintenance program have not been identified and fixed. It means, once again, that airplanes will continue to be unsafe from a root cause of ignorance.