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Powerpoint Template Why Are We Here? (The Accident Loss of Control Record) ICAO Loss of Control Symposium May 20-22, 2014 Dennis A. Crider Chief Technical Advisor, Vehicle Simulation National Transportation Safety Board 1 LOC Accident / Incident Data Set • NTSB LOC data collection • Dick Newman (Crew Systems) and Tony Lambregts • 2008 paper • Frequently quoted • NASA • Wouldn’t it be nice to work together? • Broader LOC dataset 2 LOC Accident / Incident Data Set • Data Sources • Aircraft Accident Reports on DVD (R. Dorsett, 2006) • Australian Transport Safety Bureau (ATSB) • Aviation Safety Network (ASN) • Canadian Transportation Safety Board (TSB) • Flightglobal (Ascend Database) • French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) • German Bundesstelle für Flugunfalluntersuchung (BFU) • International Civil Aviation Organization (ICAO) • Irish Air Accident Investigation Unit (AAIU) • National Transportation Safety Board (NTSB) • Search Criteria • “loss-of-control” • “upset” • “unusual attitude” • “stall” • “uncontrolled” 3 4 LOC by Flight Regime 80 2500 On-Board Fatalities Events 2000 60 1500 40 Events 1000 20 500 Fatalities On-Board 0 Takeoff Initial Climb Climb Cruise Descent Holding Approach VFR Pattern Circling ApproachFinal Landing Go-around Missed Approach Maneuvering 0 5 LOC by Event Factors 6 Stall Examples • Pinnacle Airlines, Flight 3701 • Bombardier CL-600-2B19 • Aircraft stalled at high altitude • Colgan Air Flight 3407 • Bombardier DHC-8-400 • Stalled on approach to Buffalo 80 Right Right 40 Left Wheel 60 Right Wheel 30 Roll - left system 40 Roll - right system 20 20 10 0 0 -20 -10 Wheel (deg) Bank Angle (deg) -40 -20 -60 -30 Left Left -80 -40 02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20 Time (Hr:Min:Sec) 8 Buffalo Colgan DHC-8-400 110 100 Right Right 100 80 90 Captain's Wheel 80 Roll 60 70 60 40 Upset 50 20 40 30 0 20 10 -20 0 (deg)Wheel Roll (deg) -40 -10 -20 -60 -30 -80 -40 Left Left -50 -100 95520 95530 95540 95550 95560 95570 FDR Time (sec) 9 Nose Up 30 -25 FDR Angle of Attack 25 FDR elevator -20 -15 20 -10 15 -5 10 0 5 5 0 Elevator (deg) 10 Angle of Attack (deg) -5 15 -10 20 Nose down -15 25 02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20 Time (Hr:Min:Sec) 10 15 Left Column 50 Right Column 45 Left Angle of Attack 40 10 Right Angle of Attack 35 Upset 30 5 25 20 15 0 10 Control (deg) Column 5 Angle of Attack (deg) -5 0 95520 95530 95540 95550 95560 95570 FDR Time (sec) 11 Breaking The Accident Chain • Addressing elements in the sequence • Train cue recognition • Account for human nature • Train crews for all cues 12 Precursor Sequence Colgan Air 3407 (2/12/2009) Loss of Energy Normal State Crew Improper / Flight Awareness / Stall / LOC Fatigue / Ineffective Inappropriate Departure Impairment Recovery Energy Management Pinnacle 3701 (10/14/2004) Loss of Energy Normal State Improper / Ground Flight Awareness / Stall / Engine Ineffective Inappropriate Departure failure Recovery Impact Energy Management 13 13 Stall Cues • Stick Shaker • Ignored • Stick Pusher • Fought • Stick pusher dynamics not recognized • Un-commanded Roll • Not recognized 14 Icing and Contaminated Airfoils Upsets from Stalls due to Icing • Saab 340: Eildon Weir, Australia, • November 1998 • 2300-foot altitude loss • Saab 340: Albury, Australia, • June 2004 • 40-foot altitude loss • Saab 340: San Luis Obispo, CA, USA • January 2006 • 5000-foot altitude loss National Transportation Safety Board Saab 340 Icing Event Comparison L Albury Lift Coefficient - C Eildon Weir American Eagle 3008 No ice lift curve 0 5 10 15 20 Angle of Attack - α (deg) 17 CRJ Icing Event Comparison Fredericton no ice (sim sweep) Fredericton Baotou no ice (sim sweep) Fredericton Baotou Baotou L C 0 5 10 15 20 25 Angle of attack 18 Precursor Sequence Ice Contamination Normal Improper / Flight Stall / LOC Icing Ineffective Departure Recovery 19 19 Stall Cues with Ice • Stick Shaker • May be after departure • Stick Pusher • May be after departure • Natural stall cues • Un-commanded Roll • Buffet • Stall break 20 Summary • Elements of LOC sequences have been identified • Stall leading element • Need to address multiple points in accident chain for best affect. • New training we are outlining this week addresses most LOC factors • Some elements may be better addressed by technologies 21 Spatial Distortion • In pitch • Typical go-around in IMC • Acceleration produces illusion of pitch up • Pilot pitches down flies into ground • In Roll • Slow roll develops pilot doesn’t feel • Then confused when bank angle warning or g’s alert to roll but feel level Atmospheric Disturbance 25 LOC by Operation 150 6000 140 5500 130 On-Board Fatalities 5000 120 Events 110 4500 100 4000 90 3500 80 3000 70 2500 Events 60 50 2000 40 1500 30 Fatalities On-Board 1000 20 10 500 0 Airlines Scheduled Non-Scheduled Operations Non-Revenue Transportation Executive 0 26 Recommendation A-10-22 Require 14 Code of Federal Regulations Part 121, 135 and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features such as a reference speeds switch Recommendation A-10-23 • Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher- equipped aircraft to provide their pilots with pusher familiarization simulator training. Recommendation A-10-24 Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded. Public Law 11-216 (sec 208) The Administrator of the Federal Aviation Administration shall conduct a rulemaking proceeding to require part 121 air carriers to provide flight crewmembers with ground training and flight training or flight simulator training – A. To recognize and avoid a stall upset of an aircraft or, if not avoided, to recover from the stall; Recommendation A-11-46 Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents. Recommendation A-11-47 Once the simulator model fidelity requirements requested in Safety Recommendation A-11-46 are implemented, require that flight crews of all aircraft certificated for flight in icing conditions be trained in flight training simulators that meet these fidelity requirements. Such simulation training should emphasize the following: (1) cues for recognizing changes in the aircraft’s flight characteristics as airframe icing develops; (2) procedures for monitoring and maintaining appropriate airspeeds in icing conditions, including the use of icing airspeed reference indices; and (3) procedures for responding to decaying airspeed situations, stall protection system activation, and early stalls that can occur without stall protection system activation. Stall Upsets (no icing) Shaker Pusher Break Accident Airborne Express DC-8-63 December 22, 1996 IO IO NR China Airlines Flight 676, A300-622, February 16, 1998 UK UK UK Thai Airways Flight 261, Airbus A310-300, December 11, 1998 UK UK UK Pinnacle Airlines Flight 3701 Bombardier CL-600-2B19, NR NR NR October 14, 2004 United Express Flight 6291 Jetstream 4101, January 7, 1994 NR NR UK Pulkova Flight 612, TU-154M, August 22, 2006 UK UK UK West Caribbean airlines MD-82 near Machiques, Venezuela, NR UK NR August 16, 2005 Continental Connection Flight 3407 Bombardier DHC-8-400, NR NR NR February 12, 2009 IO = Inoperative UK = Unknown NR = Not responded to Stall Upsets (icing) Shaker Pusher Break Accident/Incident Saab 340A, VH-LPI, Eilden Weir, Victoria, November 11, 1998 ES ES NR Saab 340A, VH-KEQ, Albury, New South Wales Australia, ES ES PR June 18, 2004 Saab 340B, VH-OLM, Bathurst, New South Wales Australia, ES ES NR June 28 2002 American Eagle Flight 3008, Saab 340B+, San Luis Obispo, ES ES NR January 2, 2006 Air Canada Flight 646, Canadair CL-600-2B219, December 16, 1997 -- -- -- Cessna Citation 560, Pueblo, Colorado, February 16, 2005 UK UK UK Comair Flight 3272, Embraer EMB-120RT, January 9, 1997 ES -- NR Skywest Flight 3855, Bombardier CL-600-2B19, January 17, 2004 -- -- -- ComAir Flight 5054, EMB-120, March 19, 2001 NR NR NR Empire Airlines Flight 8284, ATR-42, Lubbock TX, January27, 2009 NR ES NR IO = Inoperative UK = Unknown PR = Proper response NR = Not responded to ES = Early stall .
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