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UK News Air accident investigators reveal how they discover causes of crashes to help ensure airline safety

02:20  22 october  2019
02:20  22 october  2019 Source:

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Have you ever been trapped on a plane in a mid-air emergency? Surely you’d know if you had been, right? Not always, says Robert Vickery. “We could have an aircraft full of holidaymakers, and none of them will know that anything has happened.”

Vickery is part of the engineering team at the Air Accidents Investigation Branch. The organisation normally receives media attention only after a tragic crash, such as the one that killed the Leicester City FC owner Vichai Srivaddhanaprabha a year ago.

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Most of the time, however, the investigators are working to spot problems and suggest solutions before something serious happens. That often involves cases that fly under the radar - including trips when we have sat on board, oblivious, while the pilots battle a problem.

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When air started sucking out of a loose seam around my window, I really started to panic. You might save a hundred, or even two hundred, dollars. How much is your life worth to you, really? Cubana Airlines is considered one of the most accident -prone airlines in the world, with an accident rating

One case that springs to mind for Vickery was a British Airways flight from Paris to London on 27 July 2015. The Airbus A320 was 100 miles away from Heathrow, when “the flight crew became aware of an unusual noise and an electrical burning smell”, according to the official report. “The noise quickly developed into a high pitched squeal, with some associated vibration and the smell became stronger”.

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'Last year we had 365 accidents or serious incidents – we’re never not busy'

Crispin Orr

The crew issued a mayday call. It sounds like a terrifying situation and you can imagine their pulses quickening. “They were very worried it was a noxious gas, so they bunged their oxygen masks on,” says Vickery. But until they landed safely and were met by fire engines, the passengers “knew nothing of it”.

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The cause was found to be “worn bearings in the avionics blower fan” - nothing too threatening. But if you ever step off a plane and spot the captain removing an oxygen mask and breathing a sigh of relief, make no mistake - the AAIB will soon begin an investigation. It’s a daily occurence: they launched 365 last year, involving not just airliners but all kinds of civilian flights.

Often taking a year or longer, they can involve light aircraft, such as the Piper Malibu that went down over the Channel in January carrying the late Argentine footballer Emiliano Sala; helicopters, like the one that crashed onto the Clutha pub in Glasgow six years ago; and machines starring in public displays, such as the Hawker Hunter in the 2015 Shoreham disaster.

The moment prior to the Hawker Hunter flown by Andrew Hill crashing during the Shoreham Airshow on 22 August 2015 (Photo: Sussex Police/CPS/PA Wire)

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“A lot of people ask me: what do you do in between the accidents?” says Vickery’s boss, Crispin Orr, the chief inspector. “That’s not a question I recognise. Last year we had 365 accidents or serious incidents. We’re never not busy.”

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Airline accidents are statistically rare. Expect one fatal accident in every 16 million flights. But few events can cause such devastation. No wonder jobs at the branch require great skill, attention to detail and emotional strength. Some of the investigators, like Vickery - a friendly, professorial man who served in the Royal Navy before becoming an investigator - study the machinery to work out what happened. Others interview pilots and analyse flight plans, or examine the “black box”.

Orr, a former military helicopter test pilot, meets i in his office at the AAIB base next to Farnborough Airport in Hampshire. On the wall is a plaque bearing the “wings” insignia of the Joint Helicopter Command he served in, and a photo showing old comrades. He knows the human cost of accidents from personal experience. “I’ve lost a number of colleagues and friends over the years,” he says soberly.

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  Air accident investigators reveal how they discover causes of crashes to help ensure airline safety © Provided by Johnston Publishing Ltd

Crispin Orr, Chief Inspector of Air Accidents, in his AAIB office in Farnborough (Photo: Rob Hastings)

The simplest of mistakes can cost everything. Then there are the lucky escapes. Orr shows me a photo of a Boeing 737-800 that accelerated slower than it should have done while taking off from Belfast International Airport on 21 July 2017. “It staggered into the air right at the end of the runway, climbed at a very slow rate, and one of its wheels took out a runway light.”

The airliner continued its flight to Corfu. “There was no accident, no smoking hole, no media,” says Orr. “But as soon as we heard about it, we went: woah, that's really serious.” If this had happened at an airport surrounded by hills, or if the airliner had experienced an engine problem, that slow takeoff “would have been a disaster”.

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What had gone wrong? “The crew had entered an incorrect figure, so their computer demanded only 60 per cent power from the engines instead of 80,” he explains.

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The investigators discovered that the same mistake was being made time and time again around the world. “We found 33 occurrences of this happening in the last 15 years.” The AAIB called for the introduction of an automatic system to detect slow acceleration at takeoff as a result.

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Sometimes, however, even software designed to make aircraft safer can cause a catastrophe.

The Boeing 737 Max investigation

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Robert Vickery got the call on the morning of Sunday 10 March. A Boeing 737 Max 8 had crashed minutes after leaving Addis Ababa, killing all 157 people on board Ethiopian Airlines Flight 302. Among them were nine British nationals.

The next day, Vickery and his team flew out to Ethiopia to offer assistance to the Ethiopian and US authorities, borrowing a 4x4 from the British embassy and driving out into the countryside across dirt tracks.

“It was a huge accident site. We’d had a 70-tonne machine hitting the ground at high speed.” So severe was the impact, it may have registered on seismographs used for detecting earthquakes, says Vickery. “The site was surrounded by local people. It was really out in the sticks on farmland with lots of animals around.”

People stand near collected debris at the crash site of Ethiopia Airlines Flight 302 (Photo: MICHAEL TEWELDE/AFP/Getty)

Before leaving the UK, the team was already hearing about eerie similarities between this crash and that of Lion Air Flight 610, when the same type of airliner went down in Indonesia four months earlier, killing 189 people. Erratic changes in speed and altitude were common in both. “You get a sixth sense of, ‘This is something we've seen before’,” says Vickery.

Suspicions focused on software used by the Boeing 737 Max called the Maneuvering Characteristics Augmentation System, or MCAS. Originally this had been designed to automatically manoeuvre the airliner’s nose downwards slightly, to aid pilots if they were at risk of stalling. It would be triggered using information from multiple onboard sensors.

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'There is no such thing as ‘pilot error’; they make an error because they’re human'

Julian Firth

It soon emerged that Boeing had made the system more powerful, so that it intervened more often and made the nose move more dramatically. The number of sensors it relied on had been reduced to just one, making the aircraft vulnerable to erroneous readings from a single faulty piece of equipment. And mentions of the system, let alone explanations, were kept out of crew manuals - saving airlines millions in re-training their pilots - a decision that was waved through by US regulators at the Federal Aviation Authority.

The Ethiopian and US investigation is still ongoing, and questions have also been raised about pilot training. But it appears that MCAS may have been an accident waiting to happen.

While families of victims wait for the official report, Boeing’s entire 737 Max fleet - 387 aircraft with 59 airlines - has been grounded. More problems have been found. Deliveries of 250 have been put on hold. Airlines and pilots are pushing for compensation.

Southwest Airlines Boeing 737 Max aircraft parked at Southern California Logistics Airport after being grounded (Photo: Mario Tama/Getty)

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For a major design flaw on an airliner that’s used around the world to cause one disaster, let alone two, is “unprecedented” in modern aviation history, says Vickery.

“We have to be very careful in drawing assumptions and pointing fingers,” says Vickery, but he is concerned about potential regulatory failings in certifying the aircraft as safe to fly. “You have to ask yourself: is the system we have in place robust enough?”

The black box

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Whatever the complexities of the Flight 302 investigation, at least finding the crash site was easy. It took nearly two weeks to locate the Piper Malibu flown by David Ibbotson, carrying Sala, which is thought to have crashed after they were poisoned by carbon monoxide. But it can take far longer.

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The Inspector of Air Accidents has legal powers, but must work closely with the Police and Emergency Services. Just some of the powers they have are: free A good example of a plane manufacturer’s effectiveness in helping to solve the cause of a plane crash can be seen in the crash that killed

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Almost two years went by before the remains of Air France Flight 447 were found, after it disappeared in a storm over the Atlantic in 2009 flying from Rio de Janeiro to Paris with 228 people on board. (The investigation found that speed sensors had malfunctioned, turning off the autopilot. In a “state of almost total loss of control”, the crew stalled the aircraft and it fell out of the sky.)

The wreckage of Malaysia Airlines Flight 370 has still not been found, more than five years after it vanished over the Indian Ocean, though pieces of debris washed up in south-east coast Africa.

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The AAIB had a large role to play in that investigation, as MH370 was powered by Rolls Royce engines and because a British company, Immarsat, provided crucial satellite data.

Light aircraft such as the one Sala was flying in have no flight data recorder or cockpit voice recorder - which are known together as the “black box”, despite being luminous orange, and are fitted in the tails of airliners with underwater locator beacons.

A flight data recorder in Mark Ford's AAIB lab (Photo: Rob Hastings)

“We rely on witness evidence, we rely on what was said over the radio,” says Vickery. “Our experts can extract data from personal devices - people fly with iPads and phones, using them to navigate.” Black boxes remain a primary focus for any airliner investigation, however.

Mark Ford, a senior inspector who specialises in extracting and analysing recorded data, was among the British contingent who flew to Australia to aid in the MH370 search, which went on for 21 months. While there are many theories about what happened, Australian investigators believe that the pilot, Zaharie Ahmad Shah, was unconscious before the airliner went down.

Could MH370 still be found? “If somebody with deep pockets goes out there to search again, yeah, absolutely,” says Ford. And might the recorder still reveal what happened? “There's a very good chance of it being in a condition where we'd be able to recover information from it. Memory content does degrade, but it takes years. If it's deeper in the ocean, that's probably better because although the pressure is higher, the salinity and the oxygen level can be lower, slowing corrosion.” After a decade or two, however, “perhaps there won’t be an awful lot of it left”.

On board a Russian search aircraft flown by the Vietnamese Air Force to look for missing Malaysia Airlines flight MH370 in 2014 (Photo: HOANG DINH NAM/AFP/Getty)

Flight recorders “can be difficult to find even on land”, Ford continues. He remembers Korean Air Cargo Flight 8509, which crashed within four minutes of taking off from London Stansted a few days before Christmas 1999, killing the four crew on board. Locating a flight recorder in a field in Essex sounds like one of the team’s easier jobs. But the Boeing 747 freighter had been full of fuel, resulting in a fireball.

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It took a whole week for the recorder to be found amid the debris. It now rests here in Ford’s lab. “That was recovered from a crater about 30 feet deep,” he says. “The whole thing came apart, and a lot of people on the site were looking for a pristine orange box. In reality, when there’s been a high-speed impact and a fire, you end up with something like this.” The flames had turned the box black. “It almost ended up going into a skip.”

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Mark Ford of the AAIB in his lab with two flight data recorders and drying cabinets (Photo: Rob Hastings)

Downloading data and recordings can be hard, especially if the unit has been in the sea. “You read in the newspapers: ‘They’ve recovered the flight recorder - why is it taking so long?’,” says Ford. “If the thing’s wet, you can’t just plug it in. It's the same as if you’re getting your phone out of the sink.” Here in his lab, Ford has drying cabinets to remove moisture without damaging the electronics. This usually takes 48 hours.

The data and voice units vary in how they’re made and may take hours to disassemble. Sometimes the microchips are damaged. Occasionally international relations cause headaches too.

When Russian-backed militia in Ukraine were accused of shooting down Malaysian Airlines flight MH17 with a missile in June 2014, killing 298 people including 10 British nationals, the eyes of the world were on the high-security investigation.

The UK assisted in the safety investigation, which was led by the Netherlands, and Ford was tasked with retrieving data from the recorders. He had to carry out his work watched by Dutch police and officials from many different countries.

“When we're working on the flight recorders in here, the last thing you want is a group of 18 people all crowded around, asking: ‘What are you doing now?’” A video feed was set up to ensure that everyone - including a Russian official - could see that the evidence was being analysed fairly.

The conclusion of the Dutch investigation was firm: a Russian missile was to blame. Following a criminal investigation, three Russians and one Ukrainian were charged with murder earlier this year.

Russian nationals Girkin, Sergei Dubinsky and Oleg Pulatov and Ukrainian Leonid Kharchenko have been charged with murder over the MH17 crash (Photo: JOHN THYS/AFP/Getty)

Human error

If a pilot has survived, they are brought to Farnborough to listen to any cockpit voice recordings and talk through data, explaining what happened step by step. Designers, airline staff, maintenance crew and air traffic controllers may be interviewed too.

“Accidents aren't just bent pieces of metal,” says Vickery. “The ‘Mk I Human Being’, which hasn't really changed much, is involved somewhere.”

The question, says Crispin Orr, is: “Why did they make those errors? Only by understanding that can you work out how others can avoid making the same mistake.”

“There is no such thing as ‘pilot error’,” argues Julian Firth, a principal investigator. “Nobody makes an error because they are a pilot. They make an error because they are human.”

He adds: “The more we can get away from this idea that, ‘Because this person was in control of the craft, it's their fault’, the better. It’s more about understanding: why does anybody behave that way in those circumstances? If you're screaming around the air at 400mph, close to the ground, that's not normal.”

Last year the AAIB appointed its first Human Factors expert, Toni Flint. Her expertise is in studying how people interact with each other and with their equipment - mixing ergonomics with group and individual psychology.

Toni Flint outside the AAIB offices in Farnborough (Photo: Rob Hastings)

Flint gives an example from Edinburgh Airport last year, where a plane that was landing came within 875 metres of another taking off, risking a collision.

“A trainee air-traffic controller was being supervised by a newly qualified trainer. The trainee was working in weather conditions they hadn't dealt with before. The equipment made it difficult too - there was a glare on the screens so they couldn't easily see that the aircraft had been instructed to come in faster than normal. There were some trainees on the aircraft as well, so they were perhaps a bit slower to react.

“When you put it all together and look at those interactions, you really start to see how complicated it is, and how all those little things together can become a big thing.”

'The scale of the tragedy took us all a lot of effort to get our heads around'

Julian Firth

To ensure that the branch’s operations inspectors don’t lose sight of factors like this, they regularly serve as “guest pilots”. Firth says: “I fly in the left-hand seat as the captain of a jet airliner, three or four times a month. That means that we are exposed to the pressures that perhaps we might not usually see, like the hassle of turning the aircraft around at its destination to come back home again, dealing with disruptive passengers, dealing with bad weather, serviceability, luggage - everything that isn’t to do with actually flying the machine. And of course, we get to make mistakes like anybody else.”

The AAIB’s responsibility is not to apportion blame. They work out what happened in the interests of future safety rather than justice. Therefore, to ensure that pilots and other individuals are completely honest about their actions, their interviews are conducted without lawyers present and kept confidential.

This proved controversial in 2016 when the High Court denied Sussex Police access to the interview with Andy Hill, the pilot whose Hawker Hunter jet crashed into cars on the A27 while attempting a “bent loop” manoeuvre at Shoreham, Sussex in 2015. Eleven people were killed.

Orr says that his organisation is always sensitive to victims’ families but that releasing interviews would “fundamentally undermine” future investigations and go against the public interest of ensuring safety.

Andrew Hill arrives for a court appearance after being charged with manslaughter for his a Hawker Hunter crash at Shoreham. Hill was later found not guilty (Photo: Chris J Ratcliffe/Getty)

In 2017 the AAIB found that the jet was flying too low at the apex of its loop - with human error, pilot training, aerobatics guidelines and air show organisation all contributing factors to the accident. Of its 32 recommendations, 31 were addressed to the UK regulator, the Civil Aviation Authority.

The 400-page report was ruled inadmissible as evidence in Hill’s subsequent criminal trial - leaving Caroline Schilt, whose 23-year-old son Jacob was killed as he sat in traffic, “frustrated and angry”.

In March this year a jury found Hill not guilty of manslaughter by criminal negligence. He maintains he remembers nothing about the crash, and an inquest is set to be held next year.

Hill’s survival seems a miracle, especially when Vickery opens the doors to one of the hangars here at Farnborough, where the mechanical remains from crashes are brought to be analysed. Even tiny scratches on a single dial can sometimes reveal clues.

Robert Vickery with a Beagle B121 Pup, of the wrecks he has worked on for the Air Accidents Investigation Branch (Photo: Rob Hastings)

“Are you a nervous flier?” he asks me before we enter. I’m not, but I can understand his reasons for checking. The Leicester and Clutha helicopter wrecks are here in this aeronautical morgue, alongside mechanical remains from other fatal accidents. But the first thing we see when we step inside is what’s left of the Hawker Hunter from Shoreham. It is a traumatic sight. Looking at the burnt-out shell gives some sense of what investigators must go through when they visit a crash site, looking at what Orr calls “complete destruction”.

Firth was the principal inspector at Shoreham. His team of six were on the scene within hours and they stayed for three nights. “The scale of the tragedy was something that took us all a lot of effort to get our heads around,” he says. The scene was photographed meticulously and witness statements taken. From an emotional point of view, “the biggest challenges are working with the bereaved”, he says. “Our first responsibility is to them.”

The AAIB is aware of the mental health challenges facing its staff, who are monitored and have access to counselling. But Firth, and everyone else i meets, also underlines how “tremendously rewarding” the job can be when their problem-solving skills mean that flights are made safer. The constant learning about different types of aircraft - and how humans react in different situations - can make it “really exciting”, he says.

The remains of the fuselage of the crashed Hawker Hunter jet are lifted by crane following the Shoreham Airshow disaster (Photo: Charlie Crowhurst/Getty Images)

Are we placing too much trust in automation?

Flying is becoming safer than ever thanks to improving technology. In 2017, for the first time since commercial passenger jet flights began, there were no deaths.

Investigators are pleased with developments, too. Underwater beacons have improved since the disappearance of MH370 to last 90 days rather than 30. “The most significant advances are in streaming data, that's being recorded live so you don't have to find the recorder,” says Firth.

Incredibly, cockpit voice recorders operated on a loop as recently as the 1990s, so that after two hours they would begin recording over the beginning of the tape again. By the time a transatlantic flight landed, anything that happened in the first half of the flight would have been erased. They now last 25 hours and no longer delete recordings.

Automated computer systems that perform the hardest tasks for the pilots are a big factor in improving safety, according to Flint - but as the 737 Max investigation shows, they also pose worrying risks.

“The difficulty is being able to anticipate every way that the computer system is going to behave, and every way that people are going to respond.

“The complexity is becoming greater and therefore the ability to predict what mistakes someone might make, how they might behave - and therefore what might go wrong - is less and less.”

A Boeing employee works outside of the cockpit of a Boeing 737 MAX 8 airliner in the company's factory in Renton, Washington (Photo: Stephen Brashear/Getty Images)

Firth agrees. “We need to be very cautious going forward about the effects of automation. We're now several generations into some quite sophisticated automatic systems,” he says.

“These aircraft are so capable. They currently can't take off by themselves - or at least we don't let them - but they are capable of landing themselves.”

Problems may arise if pilots are left with too little to do, says Firth. “We've already reached the stage with aircraft design where a lot of effort is going into keeping the human in the loop,” he says. “If they're merely passengers, and they don't understand what's going on, that's where we're seeing the real errors occurring. That's going to be the ongoing challenge: making current levels of automation truly safe, and making sure that we understand the implications of further automation.”

Pilots inside the cockpit of a Boeing 737 MAX 8 (Photo: JASON REDMOND/AFP/Getty)

The full report into Ethiopian Flight 302 is yet to be published, but it could have huge ramifications for airliner design.

With the UK planning to launch rockets from space ports in the future, the AAIB is already looking at how it will investigate launch accidents.

Pilotless vehicles present another issue. The drone “attack” that closed London Gatwick before Christmas last year “really shows is how capable these things are”, says Firth. “We're probably not a very long way away from large cargo drones,” he adds, which will lead to “a really significant change in the way that we operate.”

If reading this article makes you nervous about flying, however, absorb this fact: even if you took a flight every day, the odds are that you could do this for more than 13,500 years without a crash. Credit air accident investigators for their contribution.

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