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The Asiana Airlines flight crew mismanaged the descent of a 777 into San Francisco International Airport last July, causing a fiery crash that killed three passengers and seriously injured 49, the NTSB said in its probable-cause hearing on Tuesday. The pilots made several mistakes and delayed the execution of a go-around after they became aware that the airplane was below the acceptable glide path, the board said. Contributing to the accident were "the complexities of the auto-throttle and autopilot flight director systems," which the board said were inadequately described in Boeing's documentation and in Asiana pilot training. Other contributing factors were inadequate crew training and crew fatigue. The board also said emergency responders on the scene, who ran over one of the crash victims with a fire truck, should have been better trained and equipped.

The board followed up with 27 safety recommendations, to the airline, Boeing, the aircraft firefighting group, and the city and county of San Francisco. Acting Chairman Christopher Hart said the board's investigation found the answer to the basic question about the accident: Why did this airplane crash while executing a visual approach on a clear day? "The flight crew over-relied on automated systems that they did not fully understand," Hart said, in his opening remarks. "As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway. More than 15 years ago, Professor James Reason wrote, 'In their efforts to compensate for the unreliability of human performance, the designers of automated control systems have unwittingly created opportunities for new error types that can be even more serious than those they were seeking to avoid.'" The board meeting presentations are posted online, and a video of the meeting will be added to the NTSB archive. A synopsis of the board's report has been posted online; the full report will be posted in a few weeks.

 

 

The federal government's no-fly list has been ruled unconstitutional by a federal court in Oregon. U.S. District Judge Anna Brown ruled that because there is no way for those who get on the list to challenge that decision it violates the constitutional rights of those on the list. Brown ordered the government to devise ways that those on the list could challenge their inclusion. She said air travel is a "necessary aspect of liberties sacred to members of a free society" and denying those on the list the ability to board airliners is a "significant deprivation of their liberty interests," according to a Reuters report.

The ruling came from a challenge by 13 Muslim Americans, four of them former members of the military, who are on the list but say they have no links to terrorism. All them found out they were on the list when they were denied boarding. Their case was taken up by the American Civil Liberties Union in 2010 and it successfully argued that the secrecy surrounding the list denies those on it any opportunity to use due process to get off the list. The ACLU said government's security argument for the secrecy was "resoundingly rejected by the court." Reuters said there are about 20,000 people on the list, including about 500 Americans.

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The private pilot who was taking a lesson in a Champion 7KCAB agricultural airplane that crashed last July in Oak Ridge, La., was impaired by his "recent use of marijuana and hydroxychloroquine," the NTSB said in its probable-cause report, released on Monday. That impairment was cited as a contributing cause to the accident. The probable cause was the private pilot and the flight instructor's failure to maintain airplane control while performing agricultural operations turns low to the ground, which resulted in a stall/spin, the safety board said. The purpose of the flight was to practice aerial spray passes and ag-turns. Both pilots were killed in the crash.

Hydroxychloroquine can be used to prevent malaria or to treat conditions such as lupus or rheumatoid arthritis. "The pilot did not report a history of these medical conditions or the use of this drug to the FAA," the NTSB said. Possible side effects of the drug include nausea and dizziness, according to the National Institutes of Health. The NTSB also calculated that the airplane was over gross by at least 32 pounds and outside/aft the center of gravity envelope.

Pilot Jerry Parker, 63, of Livermore, Calif., wasn't wearing a parachute when his homebuilt Loehle Mustang caught fire shortly after takeoff on Saturday afternoon, but he apparently jumped from the cockpit at about 1,000 feet, and was killed. The burning airplane hit the ground nearby and was destroyed. Parker had been working on the airplane for about four years and had recently begun test flights, according to KTVU.com. "He's been flying the past few weeks, over the house, around Livermore, and was saying the plane is about ready," said Tom Gorman, a longtime friend of the pilot. "He was thinking of taking it down south to visit his daughter."

The Loehle Mustang is a three-quarter-scale P-51 lookalike. It's "docile to fly," with handling similar to a J-3 Cub, according to the Loehle website. Parker was a mechanical engineer by profession, and had spent more than a decade in Iraq and Afghanistan, as a military contractor. He bought the airplane kit while he was overseas, according to KTVU.

A female passenger is dead and two others were injured after a gunman opened fire on a Pakistan International Airways landing at Peshawar Airport in the fractious northwest part of the country. The airliner was on a flight from Riyadh, Saudi Arabia, and was on short final, about 300 feet off the ground, when it was hit by at least 10 bullets from an as-yet-unidentified automatic weapon. There were 178 passengers and an undetermined number of crew members on the flight. “When the plane was about the land, we heard shots and suddenly there was chaos in the flight,” an unidentified passenger interviewed by local television is quoted as saying.

The woman who was killed was returning from a visit with her husband and a religious pilgrimage, but most of those onboard were Pakistanis who work in Saudi Arabia. Police were unable to find the shooter but it's likely he or she is a Taliban militant, part of a group trying to overthrow the government. The attack might be in retaliation for a government crackdown on militants in the tribal-controlled region near Peshawar.

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Jeppesen is continuing its Chart Clinic webinar series with a session on the finer points of instrument departure procedures and how to interpret charts on all kinds of departures.  The webinar is scheduled for June 26, 2014.  For more, see Jeppesen.com/webinars.

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In a previous blog, I commented on USA Today’s attempt at an expose on the supposedly awful safety record of general aviation. I think most of us will concede that despite the report’s flawed perspective and flat out factual errors, it raised some legitimate issues. But lacking any aviation sense, it failed to suggest solutions. I’m not sure I have any, either. But I have some observations.

I read a lot of NTSB accident reports and, as we’ve noted before, they are often too hastily and superficially drawn to offer an accurate understanding of what happened. I can’t count the number of reports I’ve read in which an engine mysteriously quits, the report writer has no idea why, but drily observes that the conditions were perfect for carburetor icing. Since the evidence always melts and absent any other facts, the reader is invited to blame the pilot for not using carb heat. Maybe this is fair, maybe it isn’t, but it’s how the system works, conditioned as it is by the fact that pilots make a lot of dumb mistakes. Even good ones who fly a lot and try to remain consciously proficient.

As a refreshing change, the USA Today report almost tried to cast pilots as steely eyed but hapless victims of shoddy manufacturing and outdated aircraft designs. Were it only so. None of us have to look in the mirror to know that although out-of-the-blue mechanicals do cause accidents, preventing every one of that category wouldn’t change the accident rate much. Even in some of the egregiously poorly prepared reports, the pilot obviously did something stupid—like flying into bad weather, overloading the airplane or, a perennial favorite, running the tanks dry because the fuel gauges aren’t accurate. That last item is a cultural thing in which automotive knowledge contaminates aviation thinking. It’s like that GEICO commercial; everybody knows the gauges aren’t accurate and we have means to work around this deficiency. Using a crash as a means of highlighting it seems somehow unsporting. Yeah, the stupid gauges should work, but no, they don’t. So buy a totalizer or learn to use a watch. But unless you, as the owner or pilot, take personal responsibility, your 35-year-old Cessna 172 is not going to be fitted with more accurate fuel gauges.

Which leads me to where I think we are in the evolution of general aviation safety. We have entered the you’re-on-your-own phase. Actually, we’ve always been there—your safety in an airplane has always depended on what you, as a pilot, know, how you apply that knowledge and how you’ve been shaped by your experiences, your mentors and your community. And how consistently aware you are in the cockpit. There was a time in aviation when its inherent vitality just naturally spun off more positive vibes, there were more formal and informal connections and events and the manufacturers—especially Cessna—were intimately involved with their customers.

When I started flying in a military club with about 15 airplanes, every few months a brand new model would appear on the flightline in leaseback. Imagine that. And I recall the club would put together an event and someone from the factory or sales force would show up to extol the virtues of the new airplane. Then we would all go out and fly it. But it being 1970, we would pretty often wreck it, too. I remember one of the club members just trashing a brand new Yankee on landing, because that thing sure didn’t fly like a Cessna.

The accident rate was much higher then than now. Many of those accidents involved alcohol, which you rarely see these days. But the potential was there to do better and we eventually did. Training methods just got better, smarter and more effective. That’s still going today. I’m convinced that the FAA Wings program—which I participated in as an instructor—gave a gentle downward nudge to the accident-rate needle. There were other programs that did the same, but the manufacturers don’t seem as involved as they once were, perhaps with the exception of Cirrus for new buyers. To me, this is a direct result of the relentless, depressing erosion in the industry. Almost all of the trends are downward, which doesn’t put companies in the mood to hold ice cream socials for their customers. (That’s why I was kind of impressed last month with Continental actually did have an ice cream social.)

Although the Wings program and other outreaches by various organizations—SAFE is another—are to be encouraged, I think the erosion in GA has advanced to the point that such things are minimally effective. Not to be too harsh, but at one talk I gave a while ago, the average age of the audience must have been 75 and there was practically grid lock of roll-about oxygen bottles. Those guys aren’t flying; they’re nostalgic bystanders. For every fit older person flying, there are dozens who don’t or can’t. So they’re not the safety problem, even though they may be the one attending the seminars out of persistent interest.

In any case, I think we’ve reached the point where such efforts aren’t going to yield much progress. We’ve probably reached most of the people who are interested in that sort of thing. I've never thought that you can teach rational judgment to people who are just incapable of risk-based decisionmaking. We just stop pretending that this is a doable thing and end the delusion that we can jolly those guys along. It's not gonna happen. There will always be stupid people doing stupid things.

This is not a classic freedom-of-the-commons conundrum, but it has an aspect of that to it. When a pilot or owner does something really dumb, the commons that is damaged is the reputation and perception of general aviation. Perception is a mutually shared thing. For an example of how it can be tarnished, look no further than today's news columns for a story in which a pilot planted an airplane in the trees then felt it okay to wander off to a previously planned social event before recovering the wreckage. Seriously? Can't we do better than this?

There’s also wide agreement that over regulation has had a hand in getting us into this mess, so further regulation—of manufacturers or more stringent training requirements—won’t get us out of it. The entire community just doesn’t have the stomach for it. And neither do I, frankly. Not to mention the utter lack of any economic engine to drive it all.

So where to from here? I’m wondering if what we need is just a new age of personal responsibility. For non-commercial operations and despite what regulation we have, the entire GA system is largely unfettered by detailed oversight. We allow people to launch into the wild blue or scuzzy gray with minimal training and minimal requirements for proficiency. We wave the wand, hand them the keys to the airplane and expect them to be responsible, prudent and not do anything profoundly stupid. Yet several hundred times a year, they do just that.

Institutionally, we agree something has to be done, but what? Why must we look to outside agencies or groups to examine, poke and prod and tell us what’s wrong and then proposal “programs” to solve this problem?

I’m probably losing it here, but I was thinking why not just print up a bunch of posters with that old Uncle Sam icon pointing at the viewer, but change the slogan to say: “You. You’re the problem. And you need to own and fix it.”

I’m pretty sure I haven’t seen any better ideas. Got one yourself?

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An extensive report on general aviation safety in USA Today this week doesn't convey the whole story, says GAMA President Pete Bunce.  He took a break from his work in Washington, D.C., on Wednesday to talk with AVweb's Mary Grady about ongoing efforts to build safer airplanes.

Chris Nesin knew he had to have the Piper Cub Special that the Buck brothers flew as Rinker Buck's inspiration for Flight of Passage.  AVweb's Russ Niles spoke with the new owner of the iconic aircraft about its next transcontinental trip.

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Lithium-ion batteries, which have three times the power of lead acid aircraft cells, are starting to find their way into new aircraft.  Mid-Continent Instruments and Avionics has formed a new division called True Blue Power to serve this market.  In this AVweb video, MCI's Todd Winter discusses the new battery products.

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Cessna 172s may be not be fast or sexy, but there are plenty of them out there and prices reflect that supply. There are also lots of aftermarket mods for these airplanes. Larry Gettleman of Louisville, Ky., put that to work in his refurb of this month’s Refurbished Aircraft the Month.

“I have owned this 1977 C172N Skyhawk since 1983 and refurbished it in 2012. New clear windows, headliner, new wingtips with strobes, complete strip and Imron repaint. I used the red and black design from an AOPA holiday card that I send out: ‘Final Approach on Christmas Day,’ by Nixon Galloway.

"Mechanical restoration was by Lance Bartels of Cherryhill Aviation in Seymour, Ind. Paint/detailing was by Hangar 6 in North Vernon, Ind., and decals by Higher Graphics of Tampa Fla. The airplane has 1700 hours TT and 1100 hours on the engine. Radios are 1983-vintage BendixKing. 

"I wish that I had more time to fly it.”

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