1

Captain John M. Cox, FRAeSCEO

Safety Operating Systems

“Loss of Control, Avoidance, Recognition and Recovery”

2

Fatalities 2000-09

Flight International

3

Fatalities Per Million Departures

1990-94: 1.32 serious accidents/million deps. 1995-99: 1.06

2000-04: 0.58

2005-09: 0.55

4

Rate of Fatal Accidents

1990-94 1995-99 2000-04 2005-090

0.2

0.4

0.6

0.8

1

1.2

1.41.32

1.06

0.580000000000001

0.55

Rate of Fatal Accidents

Rate per million de-partures

CAST/ICAO Accident Taxonomy

CFIT Decreasing

• 1997 – 2006 – 20 of 89 accidents CFIT or 22.5%

• 1998 – 2007 – 18 of 90 accidents CFIT or 20%

• 1999 – 2008 – 17 of 91accidents CFIT or 18.7%

Loss Of Control Continues As The Number 1 Cause Of Accidents

• 1997 - 2006 – 19 of 89 accidents LOC-I or 21.3%

• 1998 - 2007 – 22 of 90 accidents LOC-I or 24.4%

• 1999 - 2008 – 22 of 91 accidents LOC-I or 24.2%

• Trend is not improving

8

CFIT vs. LOC-I

Commercial Jet Fleet1997-2006 1998-2007 1999-20080

5

10

15

20

25

CFIT vs. LOC-I

CFITLOC-I

9

CFIT vs. LOC-I

Commercial Jet Fleet

1997-2006 1998-2007 1999-20080%

5%

10%

15%

20%

25%

30%

21%

22%

24%

23%

20%19%

CFIT vs. LOC-I

LOC-ICFIT

10

Results of Business Jet Data Review

• 35 accidents

• 14 would have been helped with Upset Training

• 6 might have been helped with Upset Training

• Avoidance – Recognition - Recovery

11

Breakdown of LOC-I Training NeedLOC-I Accidents

Training would not help

Avoidance and Recognition

Recovery

12

Threat

• Stall is leading cause of LOC-I – NTSB Study 20 LOC-I accidents 1986-1996

• Veillette Aviation Week May 2009– 29 LOC-I accidents• 13 of 29 on takeoff – usually not recoverable• 16 approach and landing

– 6 circling approach

Loss Of Control AccidentCauses

Upset Recovery Training Aid rev1

14

Critical Skills

Avoidance!

Critical Skills

• Recognition– What is happening?– Am I stalled? – Avoidance of upset

• Recovery– Before the upset• Stall

– After the upset• Stall

Colgan 3407

Colgan 3407 – NTSB DFDR Plots

Angle of Attack

Control Column

Pitch

Roll

Control Wheel

19

LOC-I C-5 Near Loss

This is the most terrifying video I have seen

Upset Recovery Training

History • Causes • Solutions

Baseline Knowledge

Pilots today are not aerodynamicists

22

Baseline Knowledge

• Past assumptions were WRONG• Many pilot do not know needed aerodynamics• Most have not seen a transport fully stalled

• Simulators do not accurately replicate this portion of the envelope

• Power out recovery techniques may not work• High altitude• High drag

– Full stall

Angle Of Attack

Angle of attack (AOA, α, Greek letter alpha)is a term used in aerodynamics to describe the angle between the chord line of an airfoil and the vector representing the relative motion between the airfoil and the air. It can be described as the angle between where the chord line of the airfoil is pointing and where the airfoil is going.

Wikipedia

Basic Aerodynamics

Aerodynamics for Naval Aviators

Wild ride

DifferentWingsDifferentStall Characteristics

Basic Aerodynamics

Lift

Drag

Aerodynamics for Naval Aviators

How many pilots really understand this?

Basic Aerodynamics

Aerodynamics for Naval Aviators

Thrust available

vs.

Altitude

At 40,000 feetonly 30% thrust is available

Basic Aerodynamics

• As coefficient of lift increases so does drag

• There is high drag coefficient at critical angle of attack – stall

• Powering out of a stall may not be an option

Basic Aerodynamics

• At stall there is high drag – wing and fuselage

• At cruise altitude there is limited thrust available

• Recovery at cruise altitude is different than at 10,000 feet

Stall Characteristics

• Jets are unstable when stalled• Jets will roll when stalled• Ailerons are not effective when stalled• Angle of Attack must be reduced to regain

control

It May NOT Be Possible to Power Out Of A Stall At Cruise

Altitude

• Reduce Angle of Attack

• Accelerate

• Recover to NORMAL flight–Monitor “G” loading in recovery

31

New Stall Procedure

• Airbus and Boeing have recently changed stall recovery procedure– Reduce angle of attack – Nose down– Wings level– Thrust Increase– Speed brakes retracted– Return to normal flight

There will be some altitude loss

32

Power vs. Pitch

Courtesy of Captain Dave Carbaugh

33

CAA UK 3 The standard stall recovery technique should therefore always emphasise the requirement to reduce the angle of

attack so as to ensure the prompt return of the wing to full controllability. The reduction in angle of attack (and

consequential height loss) will be minimal when the approach to the stall is recognised early, and the correct recovery action

is initiated without delay.

NOTE: Any manufacturer’s recommended stall recovery techniques must always be followed, and will take

precedence over the technique described above should there be any conflicting advice.

34

Zero Altitude Loss Stall TrainingPower Out Only

IS NOT THE RIGHT WAY

Wait a Minute! What if I Am Not Stalled?

12.5 % PUSH-Possibly-Valid Region (20% Chance? ~ 2.5%)

87.5 % PUSH-Valid Region

• We Can’t Just Push Indiscriminately!!!

4.9 %

FAA Upset Definition

FAA Upset Definition (45 AOB, +25 & -10 Pitch)

Roll (Right)Roll (Left)

Pitch (-down)

Pitch (+up)+ 90o

+ 50o

+ 30o

+ 25o

+ 10o

- 10o

- 50o

- 90o

90o90o 180o180o 135o135o

Courtesy of APS

Normal flight envelope

Simulator Aerodynamic Model

David R. Gingras John N. Ralston

37

Boeing Study

38

Boeing Study

39

Boeing Study

40

When It Goes Right

Fly By Wire Aircraft

• Some people have said that FBW technology can eliminate LOC-I– Always respect and follow manufacturers

guidance• Follow SOPs

• Pilots usually train in conventional aircraft • Often Pilots transition to conventional aircraft• Pilots need more extensive LOC-I training

How Does This Turn Out?

It is a matter of the RIGHT training