Archive for the Accident Reports Category

On the Ethiopian Crash Report

Robert Chapin
2019-06-27T09:44:42+00:00

The crash of Ethiopian Airlines flight 302 is certainly the most important event being discussed in the aviation industry today.

Having read the just-released investigation report, I now see several pieces of new information that will profoundly change the direction of this discussion.  For my part, I am making an armchair analysis of a preliminary, though official, report.  My expertise in some areas of aviation should not be taken as authoritative nor anything more than added speculation toward a very large media frenzy.

Critique of the Report Summary

While the latest Executive Summary seemed careful to avoid drawing conclusions, I was dismayed about the focus on details such as the Angle of Attack values and the crew’s request to return for landing.

Here was an opportunity to accurately summarize the content of the report while still remaining impartial.  For example, the summary simply stated, “The crew lost control of the aircraft,” but this is hardly an accurate summary of the reported data.  In fact, it appears the crew was struggling but did have control of the aircraft during the first four minutes of the emergency.

Similarly, the summary mentions stick shaker activation and, vaguely, “flight control problems”, when the only glaring control problem in the flight data recording was a series of Automatic Trim Down Commands that created a heavy control bias for the pilots to fight against.

The Elephant in the Room – Missed Opportunities

In retrospect, the Boeing Max fleet should not have been in operation after the previous Lion Air crash.  I can’t say this is easy for the aviation industry to accept, even now.  Before the second crash, there was simply not enough attention on the design flaws in these aircraft, and those in the industry who should have been made aware of the underlying risk were not made aware.  Possibly worse, the traveling public had no idea the severity of the problem.  I am not immune from this lack of oversight, as I found myself on the flight deck of one of these aircraft hitching a ride to work a few months ago.  Knowing what I know now, I would not have taken that flight.

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4 Apr 2019

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St. Ignace Fatal Flight of Amazon.com Exec

Robert Chapin
2014-01-31T12:41:02+00:00
VFR navigation chart excerpt showing St. Ignace and Mackinac Island.

From the Michigan Aeronautical Chart

Airplane crashes often make sensational headlines in the news, yet thousands of them go mostly unnoticed by the media.  Consider the count of fatal accidents in the United States during 2011.  There were 285 investigations initiated by the National Transportation Safety Board (NTSB), or about one crash every 30 hours (NTSB, 2013).

On 7 March 2013, one month ago, the NTSB published a factual report on the St. Ignace, Michigan accident of 3 December 2011.  Amazon.com executive Thomas Phillips and his pilot were killed in this accident, which garnered national headlines in 2011.  In contrast, there was only one article about the recent factual report in The Detroit News (Miles, 2013), plus an Associated Press article that appeared sporadically in newspapers such as the Wisconsin State Journal (“Bad Weather”, 2013).

I have followed this investigation since 2011 when I was coincidentally in contact with a relative of Mr. Phillips.  I was not personally acquainted with Mr. Phillips, but I learned that he was a cousin-of-a-cousin to me.

While speaking with this common relative, I reviewed the NTSB preliminary report available at the time and explained my opinions:

  1. That the investigation would be a very long and potentially painful process from the family’s perspective.
  2. That the circumstances of the accident strongly suggested poor decision making by the pilot and the airline, which likely involved violating multiple Federal Aviation Regulations (FAR).

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8 Apr 2013

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