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Episode 40 is about maintenance blunders. Aviation is littered with a long list of these, sometimes it the failure of unofficial parts, sometimes its poor management, sometimes engineers who cut corners - and believe it or not, all three.
Because the topic is vast, I’m going to return to this subject in future podcasts.
In this episode we’re going to focus on ground crews replacing important components with non-certified parts and what happens to aeroplanes when you do that.
Our first nomination - the 1949 Strato-Freight Curtiss C-46A crash into the ocean 10 kilometers west of San Juan-Isla Grande airport in Puerto Rico which killed 53 of the 81 people aboard. The plane was en route to Miami and what happened was not just a story of bad maintenance.
Three days prior to the accident, on 4 June 1949 the Strato Freight C-46 arrived in San Juan from Newark, New Jersey for regular maintenance. Mechanics installed a new flap follow cable, then checked both engines and they noted the right engine was misfiring.
Thirteen new spark plugs were installed, the engines cleared and the Curtiss C-46 D registration NC92857 was sent back to its routes. We’ll come back to the problem with the plugs in a moment.
On 7 June the Curtiss was cleared for a flight to Miami, taxying to the runway at 00:10 a midnight flight. Cheaper flight and strike two was the crew overloaded the plane.
There were 75 passengers aboard, including five infants, babes in arms, and 14 other children aged between 2 and 12. Captain Lee Howard Wakefield was in charge, also on board were Captain Alfred Cockrill — the company chief pilot and vice president of Strato-Freight. Copilots were John Connell and George Cary. Stewardess as they called them back in the day, was Judith Hale.Moving along to example two of flouting maintenance rules A Transat Flight 236 from Toronto to Lisbon scheduled August 24th 2001. Everyone survived this accident as you’ll hear.
The Airbus A330 lost all engine power while flying over the Atlantic Ocean- all because of improper maintenance. This incident became known as the Azores Glider - it was the longest passenger aircraft glide without engines at that point, gliding for nearly 75 miles or 121 km
As you’re going to hear, the flight crew made the situation worse although they apparently appeared to get a bad rap.
Experienced pilot 48 year-old Captain Robert Piché was in command, first officer was 28 year-old Dirk DeJager. Piche had 16 800 hours with 796 on an Airbus, while DeJager had logged 4800 hours - 386 on an Airbus. The aircraft was registered as C-GITS configured with 362 seats and placed in service by Air Transat on April 28, 1999. It was powered by two Rolls-Royce Trent 772B-60 engines.
Leaving the gate in Toronto, the aircraft had 46.9 tonnes of fuel on board, 4.5 tonnes more than required by regulations. So how did it run out of fuel?The third example of poor maintenance involved the British Airways Flight 5390 1990 event which is very well known, when an improperly installed windscreen blew out, causing the Captain Timothy Lancaster to be sucked partially out of the flight deck.
Again, this was a matter of millimetres. First the events of 10th June 1990.
The County of South Glamorgan was a BAC One-Eleven Series 528FL jet airliner, registered as G-BJRT, captained by 42-year-old Timothy Lancaster. He had 11,050 flight hours, including 1,075 hours on the BAC One-Eleven, while the first officer was 39-year-old Alastair Atchison who had logged 7,500 flight hours — 1,100 of them on the BAC One-Eleven.
The aircraft carried four cabin crew and 81 passengers. Atchison flew what was called a routine take-off at 08:20 local time, then handed control to Lancaster as the BAC One-Eleven Series climbed. As was the habit at the time, both pilots released their shoulder harnesses and Lancaster went further, loosening his lap belt. -
This is episode 39 and we’re looking at a horrendous accident, Saudia Airlines Flight 163, a Lockheed TriStar which was gutted in a blaze on the ground on 19th August 1980 - all 301 aboard died.
The plane was registered in Saudi Arabia as HZ-AHK, and made its first first flight on 13 July 1979, and was delivered brand new to Saudia on 21 August 1979.
Some say this is a classic case of cockpit resource management gone haywire, with the combination of an autocratic captain, a young and apparently undercooked first officer, and a flight engineer who had his own list of mysteries as you’re going to hear.Saudia Flight 163 was a scheduled passenger flight departing from Karachi, Pakistan, bound for Kandara Airport in Jeddah, Saudi Arabia with a stop planned at Riyadh International Airport. The majority of the passengers were Saudi and Pakistani religious pilgrims on their way to Mecca for a traditional Ramadan holiday, joined by 32 religious pilgrims from Iran. A small number of pax worked in diplomatic missions for various countries.
The question was why the captain had not shut down all engines immediately.He may have prevented the flight attendants from initiating the evacuation by continuing to operate the engines after stopping the aircraft. -
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This episode we’re going to take a look at commercial airliners that have hit obstacles near runways and how three accidents in the small town of Elizabeth New Jersey in 1951 and 1952 led to rules about clear ways and re-zoning.
It’s important though to stress how the rules have changed improving safety particularly with regard to clear ways.
Take one of the the earliest which was the 1933 Imperial Airways Ruysselede incident on 30 December 1933 when an Avro Ten collided with a radio mast at the town of Ruysselede, West Flanders, Belgium and crashed killing all ten people on board.
The Avro Ten's registration was G-ABLU, nickname Apollo, and had entered service with Imperial Airways in May 1931. Apollo the Avro Ten departed Cologne at 12:20 local time - 20 minutes later than scheduled. A thick fog hampered the flight, and the pilots headed out on a track to the north of the normal route. They appeared to be blissfully unaware of the threat that awaited. Less than an hour later at 13h15 the aircraft was cruising at 250 feet when it hit a guy wire of the 870 foot tall Ruysselede radio mast.
The force of the strike demolished the top section of the mast and the Avro Ten lost a wing and crashed. Four workers at the radio station rushed to help those on board the aircraft, joined by local villagers from Ruysselede.
At least one passenger survived the crash, but in a horrible moment, before they could save him, then there was an explosion and the aircraft burnt up despite valiant attempts by the rescuers to get to those on board all perished.
Thirteen of the rescuers suffered serious burns they were so committed. It’s time now to take a closer look at three accidents in a small town called Elizabeth located close to New Jersey’s Newark International Airport that were going to change aviation regulations regarding zoning and clear ways amongst other rules.
The first crash took place on December 16 1951, when a Miami Airlines flight from Newark to Tampa hit a warehouse in an industrial stretch of the Elizabeth River.
All 56 passengers and crew died. Witnesses described seeing the Curtiss C-46 Commando plane belching smoke after take off. The plane lost altitude, swept low over Elizabeth CBD, stalled, and crashing into the warehouse — parts of the plane skidded through the building into the river Elizabeth. This second crash led Elizabeth Mayor James T. Kirk to demand that Newark Airport be closed, a move opposed by the Port Authority because of those two terminal illnesses called stupid politics and greed. But there was a third crash that was imminent - and strike three would change everyone's minds. -
This is episode 37 and we’re dealing with bird strikes. The most famous of these was US Airways flight 1549 from New York City's LaGuardia Airport to Charlotte.
Pilot Sully Sullenberger and first officer Jeffrey Skiles ditched the Airbus A320 in the Hudson River off Midtown Manhattan after a bird strike led to both engines failing - All 155 on board were rescued.
This was known as the Miracle on the Hudson — but this episode is not going to focus on that miracle. What we’re going to do is cover some of the history of bird strikes and how there’s been a consistent attempt to deal with this challenge.
Bird Strikes on aircraft go back to the earliest recorded heavy than air flights, as noted by Orville Wright in his diary in 1905 after a day on board the Wright Flyer over a cornfield in Ohio —
" flew 4,751 meters in 4 minutes 45 seconds, four complete circles. Twice passed over the fence into Beard's cornfield. Chased flock of birds for two rounds and killed one which fell on top of the upper surface and after a time fell off when swinging a sharp curve.”
Interesting to see that the earliest aviators were chasing birds instead of trying to avoid them, not a bird strike so much as a strike on the bird.
In 1911 French Pilot Eugene Gilbert was flying his open-cockpit Bleriot XI in the Paris to Madrid Air Race over the Pyrenees when he was attacked by an angry mother eagle. I’m not sure about Standard Operating Procedure, but Gilbert was armed and opened fire on the eagle with his trusty pistol, but missed.The greatest loss of life directly linked to a bird strike took place on October 4, 1960, when an Eastern Air Lines Flight 375, Lockheed L-188 Electra, flying from Boston hit a flock of starlings during take-off, damaging all four engines.
The aircraft crashed into Boston harbour killing 62 out of 72 passengers. This focused authorities on the dangers of bird strikes. This crash wasn’t only about avians, but poor maintenance because a pilots seat that slid backwards was cited as part of the litany of events that caused the plane to stall.Another bird-strike incident that was critical in the development of improved standards was the United Air Lines Flight 297 crash.
It was a scheduled flight from Newark International Airport to Atlanta which plunged to the ground 10 miles southwest of Baltimore on November 23, 1962, killing all 17 people on board.
Most accidents occur when a bird collides with the windscreen or is sucked into the engine of jet aircraft, annual damage estimated to be $400 million within the United States alone and up to $1.2 billion to commercial aircraft worldwide. -
This is episode 36 and its icy cold out there - it’s time to check out the incidents involving icing - starting with a short list and general description of the causes, then focusing on the two Aeroflot Atonovs accidents in 1971 and a design fault in the ATR-72.
There’s an unfortunately long list of commercial airliners lost due to icing, more than 540 accidents and events caused by aircraft icing by the late 1980s in the United States alone and most of these were fatal.
Anti-icing and de-icing research can be traced back to the early 1930s and in 1948, two scientists, AG Preston and Calvin Blackman conducted the first successful iced flight experiment in which the drag coefficient increased by 81% when the wing was covered and the pilot reported the plane was almost beyond control. I’m not sure of what aircraft they used but the results were extraordinary.
Other research by NASA on the DHC-6 Twin Otter aircraft measured various conditions and ice shapes and their effect on aircraft thrust, landing flaps, and angle of attack.
It’s thought that the first recorded case of a commercial airplane accident caused by icing occurred on December 15, 1920 when a de Havilland DH.4 mail plane operated by the United States Post Office Department crashed near Belleville, Pennsylvania, in the USA due to ice accumulation on the wings and control surfaces.There was a happier end to another on 19th December 1946 where a Railway Air Service Douglas Dakota 3 stalled on take-off 1 km north-east of Northolt Airport in London.
This was the case of the scheduled service to Glasgow Airport from London. Four crew and one passenger were on board .. Yes, you heard correctly, one passenger.So to matters more terminal if you excuse the extremely cheesy aviation pun.
That be the highly unusual twin crashes of the Antonovs in 1971 both caused by ice accretion. ot Antonov An-12s crashed on approach to Surgut International Airport, just nine days apart. The crashes occurred under near-identical circumstances due to the aircraft type’s lack of preparedness for flying in severe icing conditions.
It’s the formation of an ice ridge by water droplets beyond the ice protection system and one side anti-icing system that is likely to cause rolling and overturn according to research documents.
A case in point of the ridge cause was an ATR-72 crash in 1994. At that time, the airplane was at a severe level of icing condition, and the co-effect of the electric heating de-icing system at the wing leading edge and the natural conditions formed an ice ridge on the second half of the wing, resulting in a negative pressure zone on the one side's aileron. -
Episode 35 - The 1986 Aeromexico collision over L.A. that changed aviation by Desmond Latham
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The British government was focused on making dirigibles the transport of choice in the 1930s - competing with the Germans to produce the largest, most luxurious and most convenient way to travel across its empire. In the summer of 1930 two variants were created, one designed by a government team known ironically as "the socialist" airship as it was a labour government, the other "the capitalist" because it was the brainchild of the Vickers company.
But there were issues - It was already known that both the R100 and R101 were lacking in the enough lift originally planned at the outset of the Imperial Airship Scheme in 1925. So the engineers decided to stretch the airship and plonk in another airbag.
This was to lead to a critical failure and the R101 crash in France as you'll hear. -
We’re going to look at a few examples of trigger happy pilots and missile operators, starting with the 5th April 1948 Gatow Air Disaster over Berlin as the Cold War ramped up after the Second World War.
A British European Airways Vickers VC.1B Viking airliner crashed near RAF Gatow air base, after a Soviet Air Force Yakovlev Yak-3 fighter aircraft flew into it from below.
All ten passengers and four crew on board the Viking were killed, as was the Soviet pilot. This incident is a warning to aviators in the contemporary world, witness the tension between Chinese and Taiwan, North and South Korea, near-misses above the Baltic, and less reported but as dangerous, incidents across the middle East.
First, 1948.
The Gatow Air Disaster was a mid-air collision that sparked an international incident between the USA, Britain and Russia – leading to heightened tensions and which escalated into what we know as the Berlin Blockade. That was a rather clumsy attempt by Joseph Stalin to force Europe to back down about the Marshall plan.
So let’s take a look at some other examples of the military behaving badly.
On July 27, 1955, an El Al flight from Vienna Austria to Tel Aviv Israel blundered into Bulgarian airspace and was shot down by two MiG fighters.
All 58 people on board were killed. After initially denying involvement, Bulgaria admitted to having downed the aircraft. Despite occurring during a low point in relations between the Soviet bloc and the US and its allies, international fallout was minimal.
Moving east, on July 23, 1954, mainland China's People's Liberation Army fighters shot down a Cathay Pacific Airways CA 54 Skymaster.
The plane was flying from Bangkok to Hong Kong when it was hit - 10 out of the 19 passengers and crew died. In apologizing for the attack to Britain days later, the Chinese government claimed they had thought the plane was a military aircraft from Taiwan which they presumed was on an attack mission against Hainan Island.
Trouble spots include the Qatar and its neighbours, Turkey, North Korea, parts of East Africa, Yemen, China and Taiwan. That's quite a list. -
A listener asked me to take a closer look at the crash of a Lear jet in 1999 that was carrying golfer Payne Stewart so here we are.
Of all the crashes we’ve looked at this has to be one of the more frustrating and needs quite a bit of sleuthing. The main reason is the NTSB still has not published a final report and probably never will.
The basic facts are not in dispute – it was a case of a plane decompression at high altitude. But how it happened is another matter.
So let’s try and dig deep and discover what led to the death of one of the best known sportsmen in the United States.
The basic story goes like this.
On October 25, 1999 a Learjet 35 registration N47BA, operated by Sunjet Aviation based in Sanford, Florida departed Orlando, Florida, for Dallas, Texas, at around 0920 eastern daylight time (EDT). Radio contact with the flight was lost north of Gainesville, after air traffic control (ATC) cleared the airplane to flight level (FL) 390.
The learjet was then intercepted by several U.S. Air Force and Air National Guard aircraft as it headed in a north west direction. The military pilots flew close enough to see that the windshields of the Learjet were frosted or covered with condensation.
Later the airplane engines began spooling down, controlled flight was not possible, and the learjet stalled and spiralled to the ground, impacting an open field between the towns of Mila and Aberdeen in South Dakota just before 12h15 central daylight time on October 25th 1999.
The NTSB scrutinised the maintenance logs and found a snag reported in February 1998 that the cabin occasionally would not hold pressure at low altitudes. Maintenance checked this on the ground but could not replicate the problem, so it wasn’t fixed.
IN May 1999 Sunjet maintenance personnel were checked out as part of the Phase A1-6 inspection, which included pressurization system checks. All seemed fine once more.
But it wasn’t.
A Sunjet Aviation pilot reported to Safety Board investigators that a month later, July 22, 1999 during a flight in the very same Learjet, the pressurization system would not maintain a full pressure differential and that later the cabin altitude “started climbing well past 2,000 feet per minute” he said.
When confronted by the NTSB, the Sunjet Aviation Chief pilot denied this, saying that he hadn’t noticed any differential.
However, a July 23, 1999, Work Order discrepancy sheet 5895 noted the following: “Discrepancy: Pressurization check and operation of system.” -
We’re focusing on Air Canada Flight 797 that developed and in-flight fire that turned into a conflagration after it landed and the doors were opened.
23 passengers burned to death of were asphyxiated in that terrible incident.
The response to this was crucial to global aviation safety as it led to rules such as airline manufacturers having to ensure that planes could be evacuated inside 90 seconds, visible lights on the floor, smoke detectors on all flights, firefighting training for crew and the briefing passengers sitting in exit rows.
Air Canada Flight 797 was an international passenger flight operating from Dallas/Fort Worth International Airport to Montréal–Dorval International Airport, with one stop at Toronto Pearson International Airport.
It took off from Dallas Forth Worth international Airport at 16h25 local time on 2 June 1983, the plane was a McDonnell Douglas DC-9-32, registration C-FTLU.
There was a single scheduled stop at Toronto International Airport, en route to Montreal's Dorval Airport.
51 year-old Donald Cameron was the Captain in charge, and had 13 000 hours flight time, 4 4939 in the DC-9 and had been flying with Air Canada since March 1966.
First Officer Claude Ouimet was 34 and had flown for Air Canada since November 1973. He had 5,650 hours of flight time, including 2,499 hours in the DC-9, and had qualified as a DC-9 first officer in February 1979. -
This is episode 30 and I am delighted to have special guest Jim Spaeth join us for this episode to talk about his experiences at TWA.
His life intersected with a number of accidents and he had a unique view of events he’s going to describe working as a salesman, ticketing agent and senior manager at TWA. He’s written a book called Up, Up and Astray, Memoir of an airline bachelor during the golden age of Air Travel.
Jim is a great story teller, and his eye for detail captures the background to some of the accidents I’ve already covered, particularly in the 1960s and 70s.
We start with Jim arriving in Kansas City in 1964 where he has just found out he’d got his schedule wrong in his attempt at joining the police force and he’s wondering what to do next. Little did he know what aviation had in store for him. -
We’re going to cover an example of what happens at low altitude when pilots activate the Take Off/Go Around or TOGA switch by mistake. When there’s turbulence and a lack of situational awareness, this can be deadly as you’ll hear.
A number of aircraft recently have crashed because of pilots inadvertently activating this switch and I’m going to explain how this can happen if you’re not paying attention – and if the crew are prone to panic.
One of the incidents involved a cargo flight – and Herman who’s an avid listener suggested I do a few cargo plane crashes for a number of reasons. While there are no passengers involved, or very few, sometimes the cargo itself is the danger, and in the case we’ll hear this episode, it is believed that was a failure to check the stated credentials of a commercial pilot could have exacerbated the situation that led to the crash involving a Boeing 767 flown by Amazon’s Prime Air.
It never made it in on February 23rd 2019, the Boeing 767-375ER crashed on approach into Trinity Bay near Houston, killing two crew members and a pilot hitching a lift in the jump seat.
It’s also the first crash involving a 767-375ER Cargo plane. As you’re going to hear, flight crew training issues at Atlas Air and across the U.S. commercial aviation industry have been implicated in this accident. -
It was some trepidation that I’ve decided to eventually cover the Pan Am Flight 103 disaster over Lockerbie, Scotland, in 1988 which killed 259 passengers and crew as well as 11 people on the ground.
Very few aviators or people interested in aviation are not aware of what happened to the Boeing 747 when a bomb loaded on board with other luggage blew up over Scotland. The shocking truths that were unearthed afterwards changed aviation forever.
But Pan Am’s lax security also created the hole that the terrorists exploited.
Two listeners in particular have prompted this episode, including Alison who was an 8 year-old living in Lockerbie when the plane came down. She has told me how the small community banded together despite their own loss and then extended their arms to help families of the victims.
There is a great deal to cover so let’s dive straight in starting with the latest developments first.
In December 2020, the United States announced charges against a Libyan suspected of making the bomb that blew up the Boeing over Lockerbie. Masud apparently allegedly carried out the attack on the orders of late Libyan leader Muammar Gaddafi directly – although Gaddafi always denied that. Of course Gaddafi’s own luck ran out in 2011 during the Arab Spring uprisings when he was deposed, bayoneted and then shot. Live by the sword .. die by the sword they say – unfortunately he took his many secrets to the grave with him. The bombing led to many improvements in airline security, particularly how baggage was handled.
A special session of the International Civil Aviation Organisation or ICAO council was held in February 1989 with improving airport security number one on the list.
ICAO organization and powers were strengthened after this conference, and training rehashed.
ICAO also implemented what’s known as the Convention on Marking Plastic Explosives.
This lays out the rules for countries manufacturing explosives to mark them chemically in order for a bomb to be detected by sniffer dogs – and chemical analysis devices. There were many other improvements. -
We’re focusing on the US-Bangla Airlines Flight 211 that came in too high and fast at Kathmandu Airport on 12th March 2018 then slid off the runway and burst into flames.
51 of the 71 on board died including both aircrew.
Of all the accidents I’ve covered so far – this has to be one of the worst examples of cockpit resource management – it verges on a suicide flight particularly the last two minutes as you’re going to hear.
There was an unusual and intense psychological undercurrent that caused this accident. We have all been in situations of stress while flying, but the emotional trauma on the flight deck was beyond reasonable.
You’ll also feel some sympathy not just for the passengers killed by crew erratic emotional behaviour – but also First Officer 25-year-old Prithula Rashid the First women airline pilot hired by the Bangladeshi Airline. Her senior partner let her and the passengers down.
This is another of those terrible stories of what ifs. It’s also an example of when a highly experienced pilot and an inexperienced pilot work together, coupled with cultural quirks. -
This is episode 26 and we’re focusing on one of the most conspiracy-theory speckled accidents in history, the October 1986 crash of a Tupolev TU-134 jetliner that was carrying Mozamibican president Samora Machel. 37 of the 43 aboard died.
To say that the accident is shrouded in controversy is a bit like asking if Vladimir Putin thinks he’s Catherine the Great.
Affirm.
This is one of those incidents where correlation does not prove causation unless of course you’re prone to conspiracy theories.
A lot that could go wrong during a flight did on the Tupolev that day and it led to the death of a man who was a symbol of post-colonial rebellion. This amplified the conspiracy theory avalanche of course and has driven folks into paroxysms of perpetual pontification.
The plane deployed to transport Mozambique’s president that October day was a Tupolev manufactured in 1980 – registration C9-CAA. It had flown about 1,100 flying hours since it rolled off the production line and had undergone its last major inspection in August 1984 in the Soviet Union.
The number of flight crew on the deck was substantial and they were all Russian.
The Tupolev operated with a crew of five, which on the night of 19th October 1986 included 48 year old Captain Yuri Viktorovich Novodran, co-pilot 29 year-old Igor Petrovish Kartamyshev, flight engineer 37 year-old Vladimir Novolesov, navigator 48 year-old Nikolaevich Kudryashov and 39 year-old radio operator Anatoly Shulipov.
The crew was experienced in Africa aviation as had logged many landings at Maputo Airport both day and night.
Judge Cecil Margo chaired the six member body and the hearings were public between January 20th and 26th 1987. He’d soon chair another investigation into the crash of South Afrcan Airways flight 295 in 1988 – the Heidelberg accident we heard about in an earlier episode.
The Machel inquiry rapidly threw out any suggestion of a bomb causing the crash and found that the 37 degree turn was initiated by the navigator using the autopilot’s Doppler navigation mode. That’s crucial.
He did so because he saw a VOR signal indicating that the aircraft had intercepted Maputo’s VOR 45 degrees radial which is its compass direction from Maputo which the crew needed to intercept in order to approach to land on runway 23. -
This is episode 25 – and I’m going to take a closer look at the Pakistan international Airlines Crash in Katmandu in 1992 along with a Thai Airlines accident there a few week earlier.
The Pakistan crash comes via a suggestion by a listener called Herman. Thanks for the chat the other evening and also a big thank you for your great suggestion Herman.
But before then we’ll probe two other accidents in the Alps involving Air India planes – and they’re full of mystery and surprises – and a box full of gemstones.
It’s unique that two aircraft from the same airline hit the same place – particularly in a completely different continent to their place of origin but that is what happened to Air India 101 a Boeing 707-437 nicknamed Kanchenjunga registration VT-DMN which hit the 15700 foot high Mont Blanc in 1966.
The other was Air India Flight 245 which crashed roughly in the same place but years before in 1950.
Then the Pakistan International Airlines Flight 268 - an Airbus A300, registration AP-BCP, which crashed while approaching Kathmandu's Tribhuvan International Airport on 28 September 1992.
The final accident in this end of year bumper edition was the Thai Airways International Flight 311 which crashed north of Kathmandu and to be quite blunt this one was categorically one of pilot error. -
This is episode 24 and comes courtesy of a suggestion by one of my listeners called Russell – surname withheld as he’s an operating commercial pilot.
Don’t want to upset the corporation you know.
First of all, a big thank you to Russell for the research documents and information provided. This has helped a great deal preparing for this episode.
We’re looking at Terrain Awareness Warning Systems or TAWS and Ground Proximity Warnings Systems, GPWS – now with the added advantage of an E – Enhanced Ground Proximity Warning Systems.
In 2006 the International Civil Aviation Organisation published a report which included this line
“EGPWS / TAWS technology has entered airline and corporate operations during the last five years; to date no aircraft fitted with such a system has been involved in a CFIT accident. These systems are now mandated for all turbine engine aircraft of six or more seats.”
That gives you some idea of how important these two bits of technology have been to aviators. Unfortunately there have been a few CFIT accidents despite this technology since then as you’ll hear later, but the point is safety overall has improved.
So let’s go over a few examples which Russell has provided and some which ICAO analysed. As usual folks, this series is about how aviation safety improvements after accidents have led inexorably to flying being one of the safest ways to head from A to B and even C, D and E.
Throughout the history of aviation, Controlled Flight into Terrain or CFIT has been a major cause of fatal accidents, particularly at night, poor visibility or when the crew become fixated by technical issues and forget to fly.
One of the accidents that drove engineer Don Bateman to seek a solution was the Alaskan Airlines Flight 1866 accident of 1971. The other was American Airlines Flight 965 – a Boeing 757-223 from Miami International Airport to Cali in Columbia that crashed in mountains outside its destination in December 1995. -
This is episode 23 and we’re dealing with flying boat accidents.
You may be surprised to hear but one accident in particular involving an Imperial Airways flying boat in 1939 set in motion the use of specialised carb heaters for all aircraft. The safety inspector also recommended that all passengers should be instructed in the fastening of lifebelts and location of emergency exits as well as other lifesaving equipment like rafts become mandatory in aircraft flying over the ocean.
So all those trips you’ve taken where the cabin crew point out the emergency exits and spend time showing you how to use a lifejacket can be directly linked to this one accident in 1939.
Remember this series is really about aviation safety more than just a story about a crash. Discovering the cause of an accident usually implies a technical or human error which must not be repeated and much of what we’ve heard so far in the previous 22 episodes seeks to identify those moments.
First a quick word about flying boats and amphibious aircraft.
Frenchman Alphonse Pénaud filed the first patent for a flying machine with a boat hull and retractable landing gear in 1876, but Austrian Wilhelm Kress is credited with building the first seaplane Drachenflieger in 1898, although its two 30 hp Daimler engines were inadequate for take-off and it later sank when one of the two floats collapsed.
A flying boat is not amphibious, just by the way. It’s an aircraft that has to land and take off using water with no fixed landing gear. It’s also different from a floatplane which has two or more slender floats mounted under the fuselage for buoyancy. A flying boat uses its fuselage as part of the buoyancy like a boat – thus flying boat. -
This is episode 22 and we’re going to hear more about an accident in the skies over India that was the final push in the drive to deploy traffic collision avoidance systems known as TCAS.
Initially we need to go back to the days days of commercial aviation in 1922.
Unfortunately the first collision between aircraft took place almost immediately as commercial aviation launched in the same year as earlier aviators were ignorant about each other’s plans, altitude and track. They also spoke many different languages which also didn’t help.
It took another 70 years before a system was introduced to ensure separation that was automated and computerised. Before then systems were developed that relied on accurate flying using the semi-circular rules.
The basic tenet is that when flying a track between 0° and 179° or generally speaking, easterly, your flight level or altitude must be odd such as 030 or 050 and so on, but when you are on a track between 180° and 359° generally speaking .. westerly, your flight level or altitude must be even – for example 18000, 16000 feet and so on.
There are other rules associated with this and whether you’re flying IVR or on Instruments.
That is supposed to reduce the chances of planes colliding but it only works if the pilots are flying their planes at those levels. Sometimes pilots do break the levels – and at other times their instruments are faulty.
On 12 November 1996 a Saudi Arabian Airlines Boeing 747 which had just taken off from Delhi in India en route to Dhahran collided with a Kazakhstan Airlines Ilyushin Il-76 en route from Chimkent to Delhi.
The crash killed all 349 people on board both planes, making it the world's deadliest mid-air collision of all time and the deadliest aviation accident to take place in India.
This was an example of a system that was used in a confusing way. -
This is episode 21 and we’re taking a close look at the Mount Erebus disaster where an Air New Zealand McDonald Douglas DC-10 crashed on 28th November 1979, killing all 257 passengers and crew.
At first it looked like straight pilot error - a CFIT or controlled Flight Into Terrain accident.
But that would change as inquiries led to court cases.
Of all the accidents I’ve described, this one has some of the most unfortunate set of circumstances and one of the most difficult recoveries afterwards of any aviation accident in history.
Mount Erebus is on Ross Island part of the Antarctic archipelago and as you’ll hear, a juddge eventually called some evidence presented by Air New Zealand as "an orchestrated litany of lies" and which took 30 years before anyone at the airline formally apologised for that deceit.
To say the court processes which took place were riven by bitterness and a distinct failure of leadership is pretty much an understatement.
In fact, the phrase ‘an orchestrated litany of lies’ entered the Kiwi lexicon for some time and by the end of this episode I hope you’ll see why.
The first aviation inquiry found pilot error caused the accident but then a Judge in a follow up investigation ruled the cause was incorrect data which had been knowingly left in a flight computer despite this error being reported.
When a judge uses a phrase like conspiracy by senior management, then something has gone seriously wrong in terms of governance.
But the legal wrangling didn’t end with the judge – there was an appeal then intervention by the privy council in London as New Zealand is a commonwealth state.
So let’s go over the facts that are not in dispute.
Flight 901 was marketed as a unique sightseeing experience where the passengers paid around $360 US Dollars each to be flown over Antarctica with an experienced guide who pointed out features and landmarks using the plane’s PA system.
Some big names had been involved for example Sir Edmund Hillary had acted as a guide on flights and was actually supposed to be on board 901 that day in November 1979, but cancelled because he had other bookings.
Unfortunately for long-time friend and climbing companion, Peter Mulgrew, he was available and stood in for the hero of Mount Everest. Mulgrew would never return from the Antarctic.
The flight plan was complex compared to a normal commercial route. After the 5,360 miles from Auckland to the frozen south, the pilots would put the DC-10 into a series of low-flying sweeps out to the sea of McMurdo Sound or over the Ross Ice Shelf or both depending on time and the weather, then return home.
There had been 13 previous flights which went off without serious incident and the whole concept had started two years earlier in 1977. It had become a great money-spinner for Air New Zealand, not to mention an excellent marketing tool. Come fly with Air New Zealand and see the world’s least visited Continent for a cool $359 New Zealand Dollars – which now set you back around $1300 US dollars.
The flight left Auckland International Airport 8am on the morning of the 28th November and was due back at 7 that night.
Usually flights would not be filled to capacity so that there would be space allowing passengers to walk about and get a better view of the incredible frozen continent from different places in the cabin.
Cocktails would be served for the travellers as they clicked away on their cameras, many of whom would be puffing away on cigars and cigarettes.
The aircraft that day was Air New Zealand’s McDonnell Douglas DC-10-30 trijet and the plane was registered ZK-NZP. It had logged more than 20,700 flight hours prior to the crash. - Vis mere
