I just need the resident aviation experts to chime in with opinions, or expressions of various forms.
“The blocking of the flight controls during loading operations is a non-standard procedure,” the report said, “as such, there is no regulatory guidance to prohibit the act, or to address the proper placement and removal of the object blocking the controls.”
Okay, do we really need to ban, well, everything one can possibly imagine?
I know the pilots are at fault, but where are we going to take this?
“Now forbidden to stick your gum to the bottom of the seat”
I imagine pilots are doing all sorts of things and workarounds to make things happen. Just the point at which the controls aren’t working, you’d think the pilot would have the epiphany.
Had me confused why Google caused a plane crash. Case blocking doesn’t allow upper case maybe? They couldn’t enter commands into a Android smart phone?
Then I read the article and it dawned on me. :smack: Goggle not google. I haven’t read that word in so many years.
It’s just normal human error. The pilot jury rigged the controls and forgot about it. Dumb stupid error.
A standard item on the pre-takeoff checklist is ‘Controls free and correct.’ You’re in the run-up area, you make sure your controls move to their limits in all directions, and the control surfaces move in the expected directions. Basic.
This. This is why goddam checklists exist, and why pilots are supposed to go through them. Watch a plane back away from the gate at a commercial airport, and you’ll typically see the control surfaces go through their full range of motion. The guys in the cockpit clearly didn’t do this.
This isn’t the only recent accident of its type. A charter Gulfstream IV was destroyed and all aboard were killed in Bedford, MA simply because the pilots forgot to remove the gust locks that prevent the control surfaces from moving due to wind when the aircraft is parked, didn’t follow the checklists to catch the problem before the takeoff roll and somehow failed to reject the takeoff for way too long after it should have been obvious that something was terribly wrong. The aircraft reached 162 knots on the ground before the pilots decided to take emergency action to try to stop the plane but it was way too late for that. It went straight off the end of the runway, broke up and burned.
It sounds like this accident was similar except the control locks were jury-rigged. The solution is simple and already exists. Follow the checklist every time and take special care during the steps to ensure that the controls are indeed free and can travel through their full range of motion correctly.
!) How does the investigating agency KNOW that was the problem? There’s scant info in the article, though there may be CVR data to give them an idea. But even if the controls were locked, how are they sure it was the googles case?
It is standard procedure for the military to blame all catastrophes on the dead guy. Preferably, a (maybe) gay dead guy.
I was thinking the same thing when I read the article; just wasn’t sure if that was standard practice on large planes as well.
Somewhat ironically, two of the dead airmen on the C-130 were based at Hanscom. Sounds like they were the security team, though, and not the flight crew.
Well, decaying airspeed and increasing deck angle first, then the noisemaker and the yoke shaker. But even then, the crew might not have recognized it as an actual stall and made the corrections. There have been several airliner crashes due to the crew’s not having experienced an actual true-life stall, maybe only a few times in structured situations in basic training. Maybe the military training system is just as deficient in instilling and reinforcing basic airmanship skills?
They’re not only supposed to go through them, they’re supposed to know why each step is there, and they’re supposed to pay attention. It’s easy to fall into the habit of rushing through it by rote, missing blatant problems because the crew has tuned them out, and even skipping steps.
I will have to look at the more detailed reports when they are available but my best guess is that the goggle case in question was still present even after the crash. Crash investigation experts are used to dealing with much more subtle clues. It sounds like a shoehorned control lock caused the problem with the elevators and would have gummed up those critical surfaces even more as the pilots tried to react against it.
Imagine a large piece of machinery that fails and catches on fire. It seems like a mystery until you learn that someone used an old shoe as a makeshift tool and forgot to remove it before it was restarted. It isn’t that difficult to determine the cause after you learn that.
Well, the flight data recorder will show the yoke in full nose-up position from engine startup through taxi, takeoff, and crash. Ask the other aircrews about jamming things behind the yoke to hold the elevator in place and you’ve got a pretty good start.
I don’t know how the trim works on a C130 but in some trim/elevator systems a jammed elevator can’t be overcome by using trim.
So these guys were using a work-around. My question would be how often is this work-around employed? Was it a once off deal or do they do it regularly? If it is done regularly then they’ve been let down by the system. A regular work-around means their procedures or available tools were deficient in some way, e.g., there should have been a mod done to the aircraft to allow the controls to be held in the appropriate place or a formal procedure put in place for what they were doing. You shouldn’t have to do work-arounds. If it was a once off then I’d suggest they probably just shouldn’t have done it or they could have come up with a way of remembering they’d done it. Example: If they’ve just used the goggle case to hold the control column, put the goggles themselves somewhere conspicuous. The goggles don’t get moved other than to put them back in the case and the case where it belongs.
Even if all that has failed, it seems very unusual that they didn’t do a full and free check prior to take-off. They’re not the first to do something like this though and as with all accidents it’s a sequence of errors that aren’t life threatening on their own but when put together it all turns to crap.
I don’t think they were let down by the system, and I don’t think the system was deficient. The system included a provision (i.e. the pre-flight checklist) for ensuring full range of motion of the flight controls prior to takeoff. It should have been possible to weld the yoke at its full back position without causing a crash (because it would be noticed when the pilots go through the checklist).
Checklists are not a subtle or model-specific thing that only becomes a factor once in a great while and so can be easily missed when it finally matters (cf. the little “which joystick is in charge” light on AF447); checklists exist for every plane and are supposed to be performed by every pilot before every flight. If a plane crashes because the pilot didn’t do the things he was supposed to do, that’s not a system failure, that’s a pilot failing the system.
Any method(s) you implement to try to make something “dangerous” safe REALLY needs at least TWO steps that must be ignored/screwed up before the shit hits the fan.
Any “one step” safety protocol is just asking for trouble, because people forget shit. Forgetting TWO steps at the same time is WAY less likely.
So, in this case, the goggle case was a big no no because now you are relying on remembering you did it or the second step catching it. You’ve just lost your two step safety buffer.
Not checking for free motion was a big no no because something might be jamming the controls.
Sometimes perfect storms of bad things just happen, but a good fraction, if not a majority of such accidents are people knowingly breaking the rules.
Or in other words if anyone says “the goggle case jam” was an okay thing to do because the flight control check should catch it is IMO missing the whole point of how to be safe.
I understand a similar philosophy is applied to computer operating systems, in which dangerously powerful commands should not be trivially easy to execute, thus helping to ensure they don’t get executed by accident. Thus the frequent “are you sure you want to <execute this sweeping, irreversible command>?” checks for things like formatting a hard drive.
That said, is the presence of two people in the cockpit not considered a redundancy that should meet the requirement you describe? One guy may forget (or willfully disregard) the checklist, but two people, at the same time? That seems like slim odds, unless it’s deliberate. How robust should the system be when it comes to coping with sloppy air crews?
I had a long reply to the above typed up but I thought I’d read the actual report prior to posting. It has clarified a few things. (I skimmed a lot of it as it is laden with the usual irrelevant shit that pad out these reports, so I apologise if I’ve misrepresented or missed something.)
[ol]
[li]The crew were performing an ERO, Engine Running Onload/offload[/li][li]They were asked by the loader to hold the elevator up to help clear some tall cargo.[/li][li]The FDR recorder indicated the elevator being held up at various angles for several minutes.[/li][li]The CVR recorded the Captain stating that he’d used the NVG case to block the column.[/li][li]The elevator then remained at the same 6-8º deflection until the accident.[/li][li]There was no control check as part of the ERO checklist so it was entirely up to the crew to remember to remove the case.[/li][li]Once the take-off was conducted and the control problem became apparent it was misidentified as a trim runaway and their attempts to remedy the situation focussed on the trim.[/li][li]Finally their use of NVGs and cockpit lightning made it difficult to see the NVG case.[/li][/ol]
The report focusses almost entirely on the fact that the crew used a non-standard procedure to hold the elevator back without carrying out a risk assessment and subsequently became distracted by other operational activities and forgot to remove the case. It lists some relevant human factors that played a part. Although it mentions the fact that the ERO checklist does not call for a control check it does not attribute this fact as a cause other than to mention that the pilots needed to remember to remove the case.
I think it is a bit unfair to be honest. A system that allows an aircraft to land and park for an hour or more without requiring a subsequent control check is broken. Yes the pilots were primarily responsible but the tools they had to work with in terms of procedures were lacking. I hope that the ERO checklist got changed.
A word on checklists. The way checklists are used, in the airline world at least, is to check that certain things have already been done. They are not normally used as a “do-list”, i.e., something you read and do. For example, where I work we get our taxi clearance from ATC and start taxiing. Once clear of any immediate collision hazards the captain checks the brakes and advises the FO they have been checked. The FO them sets the flap and once the flaps are set, sets the trim, unlocks the gust lock, and checks the column and yoke for full and free movement. The captain checks the rudder for full and free movement. Once this is done the captain conducts a check of the flight instruments then calls for the before take-off checklist. The checklist covers off some important items such as the flap, trim, autopilot, and transponder settings. Things that either have the potential to either kill you or severely embarrass you (and unfortunately some things that somebody, normally a management pilot, has decided is a good idea after they forgot to do it once upon a time.)
What this means is that unlike using a checklist as a "do-list, you have at least two chances to catch an error. First the procedure (or “scan”) should ensure the switches are in the right places and things that need to be done are done, second the checklist ensures the procedure has been done correctly and nothing has been missed.
If I were to design a procedure for the situation the accident pilots were in it would go something like this:
[ol]
[li]First design and build a device that will hold the elevator up so that tall cargo can be loaded without requiring the pilot to hold the yoke back for a long time. Paint it red and maybe put a flag on it that sticks up into the pilot’s field of view.[/li][li]Have a stowage for the device where the device can be seen in its stowage from both pilot’s seats.[/li][li]Require that this device, if used, is to be removed and stowed once loading is completed. Tie it into something such as the cargo door being closed or some other event that always happens only after loading is complete.[/li][li]Include a check that the device is in its stowage as part of the starting checklist.[/li][li]Require that during taxi, a control check is done.[/li][li]Include the control check in the before take-off checklist.[/li][/ol]
Given that this was probably an unusual request it is reasonable that a lock such as this had not been made available, however, at the very least the final two items should be in place for any aircraft operation and it surprises me that they weren’t here.
By contrast these guys had was nothing to back them up. There was a need to hold the elevator up, it was not practical for the pilot to hold it up manually so they found a work around. There were no procedures in place to ensure that the controls were free prior to take-off other than the pilots remembering.
Final point. Regardless of the presence or not of a requirement for a control check, a healthy sense of self preservation should cause most pilots to do one anyway.
It should be a redundancy of sorts but psychology dictates that it doesn’t always work that way. Two people can talk themselves into doing things that neither of them would ever do on their own for example. Or a strong personality can completely overpower a weaker one such that the weaker personality becomes a passive bystander. This can go both ways too, a strong FO can have a weak captain under his/her thumb, not necessarily intentionally, just as an accident of the mix of personalities. Two friends who have a good rapport can become unacceptably slack, each trusting that the other is doing things correctly as well as not wanting to be seen to be questioning or correcting their friend. There are lots of ways that a two crew cockpit can break down.
Is this the crash that was caught on a dash cam? I had thought that one was caused by the faulty loading of the APCs (I think that’s what they were?). One of them got loose, knocked all the others out of whack, and made the plane nonviable.
Is this a second crash, or are we discovering that the cause of the crash was not what we thought?
Apologies if I am being slow here and everyone already knows the answer to this.
And thank you, Richard Pearse, for an excellent and thorough reply.