Sully-Hudson-and FEW safety changes

[CONSO]

Safety recommendations unfulfilled 7 years after Flight 1549



Safety recommendations unfulfilled 7 years after Flight 1549 | The Seattle Times (http://www.seattletimes.com/nation-world/safety-recommendations-unfulfilled-7-years-after-flight-1549/)



By JOAN LOWY (http://www.seattletimes.com/author/joan-lowy/)
The Associated Press


WASHINGTON (AP) — More than seven years after an airline captain saved 155 lives by ditching his crippled airliner in the Hudson River, now the basis of a new movie, most of the safety recommendations stemming from the accident haven’t been carried out.
Of the 35 recommendations made by the National Transportation Safety Board in response to the incident involving US Airways Flight 1549, only six have been successfully completed, according to an Associated Press review of board records. Fourteen of the recommendations issued to the Federal Aviation Administration and its European counterpart, EASA, are marked by the NTSB as “closed-unacceptable.” One has been withdrawn, and the rest remain unresolved. . . . Recommendations that got an “unacceptable” response deal with pilot training, directions for pilots facing the loss of power in both engines, equipping planes with life rafts and vests and making it easier for passengers to use them, among other issues.

Goes on :(

[tdracer]

I don't know if it was one of the NTSB recommendations, but in the aftermath the FAA came to us and wanted us to create an EICAS message that would tell the crew that the engine that just quit was too badly damaged to restart. The idea was to keep the crew from wasting time trying to get the engine(s) restarted and let them focus on flying the aircraft.
We responded that we didn't know how to do that - it was particularly difficult to determine the health of an engine when the engine wasn't actually running. Further, an engine rundown is a dynamic transient phenomena, and nearly all of our engine health algorithms are dependent on quasi steady-state conditions.
The FAA must have realized how impossible their request was because we never heard any more about it.:rolleyes:

[lomapaseo]

There are things that can be done to recover some power, but it requires training for the uniqueness. Best to let some black box do this on command and leave the crew to fly the aircraft as well as they can.

[Preemo]

Lomapaseo,
Pray tell - what are those things that can be done?

[jetdriverbr]

The thing I would like to be changed is a FADECS ability to shut down engines automatically. In multiengine transport aircraft I would like the fadecs to have a "cross talk" which allows an automatic shut down only one engine, but not any more without crew action. If it is over temping, rolling back, slowly disintegrating, shedding parts, I don't care as long as any thrust is being made.

[Cyberhacker]

From a functional safety viewpoint, surely switching something off should always be a last resort... the turn it of then back on again attitude we have become used to with our PCs should not be acceptable in any safety-critical environment.

Autonomy is all well and good, but if you permit a FADEC to switch off an engine automagically, I'd like to see your PROOF that it can't turn off another.

[Tinribs]

One of the issues to come out of the Kegworth crash was that we hadn't been given training on restarting using the APU air as in a ground start.
It was hard to use the systems correctly without prior thought but v simple once a method was established . all the outer air switches off the APU air on press the start button, simple but only with training

[ExXB]

Six have been implemented. Great the system works as it should.

14 have not. Before deploring FAA/EASA inactivity I'd like to understand what the recommendations were, and why the FAA/EASA believed them to be unacceptable.

Too little information here.

[.Scott]

Autonomy is all well and good, but if you permit a FADEC to switch off an engine automagically, I'd like to see your PROOF that it can't turn off another.From a system engineering prospective, this would not be difficult to do.
For example, each engine controller could determine the health of its own engine and specifically if it was reliable enough to allow another engine to shut down. If it was, it would send a continuous coded "reliable engine" message to the other engine controller. A controller would only shut down the engine after it had terminated its own "reliable engine" message for some period of time (a few seconds), was receiving the "reliable engine" message from the other controller, and had determined that running its own engine was unsafe.

[patrickal]

A controller would only shut down the engine after it had terminated its own "reliable engine" message for some period of time (a few seconds), was receiving the "reliable engine" message from the other controller, and had determined that running its own engine was unsafe.

Would you not want altitude and airspeed to also be a function of that equation? It goes to the time you may have to react and/or restart (if possible)

[Yankee Whisky]

With the brilliance of hindsight............................but Sully was in a position where the book had to be thrown out the window and go with his instincts. I am very happy he got cleared and commended for what he did; save the passenger's lives !

[vapilot2004]

Six have been implemented. Great the system works as it should.

14 have not. Before deploring FAA/EASA inactivity I'd like to understand what the recommendations were, and why the FAA/EASA believed them to be unacceptable.

Too little information here.

AAR1003 - PDF NTSB Flight 1549 (http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1003.pdf).
Recommendations begin at page 141.

From working with the US Dept of Agriculture to figure out a way to minimize bird strikes (not a bad goal) to requesting Airbus redesign a specific part of the fuselage structure and expand training to (wisely) further explore pitch control issues within Alpha protection, to the (almost laughable) procedural changes when loss of power occurs down low, the recommendations are, not all, but in part, a laundry list of items that narrowly focuses on the unique circumstances of 1549 rather than addressing broader safety concerns.

In a sentence, post accident, the NTSB is typically pie in the sky, while the FAA works with airlines and industry to (for the most part at least) issue practical guidance that tends to be more pragmatic.

[tdracer]

Autonomy is all well and good, but if you permit a FADEC to switch off an engine automagically, I'd like to see your PROOF that it can't turn off another. I can't speak for the other guys, but on Boeing, there are only two cases where we let a FADEC unilaterally turn off an engine (other than during autostart). The first is electronic overspeed protection - if a rotor speed is significantly over redline and the engine is not responding, we shut it down to protect the structural integrity (burst rotor discs are potentially catastrophic - see Qantas A380). The second is when uncontrollable high thrust is detected on the ground. Thrust Control Malfunction Accommodation (TCMA) has very specific logic that if an engine is at high power with the throttle at/near idle, and the engine is not responding, it'll shut it down. It's inhibited in-flight (for what should be obvious reasons) with rather robust air/ground logic that defaults to air if the required inputs are invalid/unavailable.
TCMA was first implemented on the 777/GE90-115B and is basic on the 787, 747-8, and will be on the 737MAX and the 777X. Both the electronic overspeed and TCMA are to meet mandatory regulatory requirements (FAA and EASA).
We intentionally do not cross talk data between the different engine FADECs to maintain engine to engine isolation.


BTW, while I assume automagically is a typo, it did make me smile...

[Capn Bloggs]

BTW, while I assume automagically is a typo, it did make me smile...
Wider English, me lad!:ok:

[Downwind Lander]

Are these the most recent docs?

http://www.ntsb.gov/investigations/Pages/2009-usairways1549.aspx

http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1003.pdf

[No Fly Zone]

Anyone who has read the last several pages of almost any NTSB Final Report will easily understand that this response by FAA is far from rare. FAA often ignores NTSB or makes endless excuses about why NTSB's suggestions cannot be implemented. It is also obvious that FAA Does NOT like being told what to do and NTSB has no authority to DO anything beyond investigate and report; obviously a cluster-f'ing mess, but also our law. Further, FAA often lacks budget bucks and it can take them a year or more to write/revise regulations that the Part 121 carriers must implement at their own expense. Personally, I often envy the nations that use one agency to cover both major functions. Why is this so in the U.S? Turf battles!

[Arfur Dent]

"Profit is our Number One priority".
and
"Our Accounts Department judges that we can accept one hull loss per decade without negatively affecting our bottom line".

[westhawk]

The NTSB staff perform the very important functions of investigating transportation accidents, determining probable cause, contributing factors and making safety recommendations to regulatory agencies, manufacturers and operators. That is the charter of the organization. They recommend and it's up to industry and regulators whether to adopt the advice or not.

Were it not this way, just about all transportation systems might be completely impractical and without economic viability. Without the recommendations made by all the various transportation safety organizations, travel would be much less safe than it currently is. After all, a good number of safety initiatives got their impetus from the accident reports and associated recommendations. The balance between safety and performance (economic and capabilities-wise) is actually very good in that progress continues in both of these seemingly opposite imperatives simultaneously. There remain a number of areas where more emphasis is required and the tides shift slowly. The NTSB does not get all it wants and industry must sometimes accept the recommendations when regulatory bodies mandate them. Not a perfect system by any means, but it's the only one we've got. Debating the relative merits of each and every recommendation continues to be the best way forward.

[Chronus]

The NTSB recommendations do not appear to have addressed the sole and only cause for the Hudson incident. That is bird ingestion at the most crucial and common phase of flight, take off.
Perhaps the only item that seems to whisper some clue to the real issue is quoted below from the report as follows.
"large flocking bird certification test standards to determine whether they should apply to engines with an inlet area of less than 3,875 square inches"

Compelled by the ever increasing need for profit by airlines, aircraft powered by two engines with thrust equivalent to three or more engines is demanded from engine manufacturers. This can only be achieved by increasing intake and fan sizes. The resultant larger area contributes to increased risk for bird ingestion.
Now, the question is how could this be resolved.

[oldchina]

Chronus:

"two engines with thrust equivalent to three or more engines" ... "how could this be resolved? "

Three or four engine planes need smaller engines and less total thrust than twins. So there's your answer.

[lomapaseo]

Chronus

It's a matter of probabilities matched against capability of the engine.

There are all kinds of parameters at play. If you stack the worst together then any single engine is going to lose power.

All the FAA can do in response to the NTSB rec is sort the existing data in-service against the existing technology in their crystal ball.

The existing data, simply put, suggest more planes will be lost for other reasons, not yet addressed fully, vs a Sully repeat in the next ten years.

So the challenge is where does one put the limited resources (manpower, time, money, equipment).

As with all enviromental threats, birds, ice, rain/hail, the balance need also consider avoidance of the encounter as well. Yet such avoidance (birds) also involves actions outside engines, aircraft, airports, operations and also involves the public acceptance of the bird existing as a threat.

The action will be to continue to monitor all these contributions for areas that lend themselves to improvements rather than degradations

Incidently from a cost standpoint, anything you do at the engine level that impacts fuel burn will have the biggest impact fleet wide. It's truly amazing that we got as far as a ten fold decrease in bird ingestion catastrophic risk in the last 20 years and yet still managed to flood the market with long range twin engine aircraft and better seat mile expenses.

[tdracer]

Although the fans have gotten larger (and hence the ingestion of bird(s) more likely, the latest generation of wide cord fans have far better bird (and FOD) resistance than the earlier generation of fans. The composite fan blades on the GE90 have proved particularly robust (I remember a press release where the GE90 had gone over 10 years since EIS without having to scrap a fan blade due to impact damage).
So, while bird strikes are increasingly common, the rate of significant damage/thrust loss due to bird strikes has actually dropped.

[broadband circuit]

Personally, I often envy the nations that use one agency to cover both major functions.

You shouldn't envy us. It leads to a government organisation investigating itself. Not always a good idea.

In fact, here in Hong Kong, HKALPA amongst other transport lobby groups (buses, ferries etc) are lobbying for the HK Government to move away from the single agency model to create an independent transport safety organisation.

[RAT 5]

Sorry to lower the tone of the discussion, but a young son of a friend asked why they did not have chicken wire in the front of engines. I decided it would take too long to explain and detract from beer drinking with his dad. I ask for the shortest explanation possible so I can show him. No bigger than a postcard, please.

[tdracer]

Rat, I could go into a long winded discussion of pressure loss and the effect on performance, icing, etc. But an even simpler explanation would be this:
Ask the young man to consider the damage several six pound birds doing 250 knots did to heavy duty titanium fan and compressor blades (which, BTW, are designed to withstand bird strikes), then think about what sort of "chicken wire" would be required to stop those six pound birds doing 250 knots.

[lomapaseo]

because the birds hang up on chicken wire like tumbleweed on a fence and block the air going into the engine

[RAT 5]

Gracias: I'll pass that on and hope it suffices. I hope he hasn't heard of surges due to disturbed airflow.

[CONSO]

because the birds hang up on chicken wire like tumbleweed on a fence and block the air going into the engine
Think you missed the point- since an x pound bird can destroy strong metal titanium blades- ' chicken wire ' even heavy gage- would be like tissue paper in relative terms- and have NO effect other than to add to the metal debri going thru the engine. !!!

[tdracer]

There was a post earlier postulating that 4 engines would have resulted in happy outcome (apparently now deleted).
However, having four engines is no guarantee of a happy ending if you take out two with birds while taking off:
https://en.wikipedia.org/wiki/1995_Alaska_Boeing_E-3_Sentry_accident

The investigation concluded that the probable cause was the ingestion of Canada geese into No.1 and No.2 engine. Off the top of my head, these are the only major jetliners I know of to go down due to a bird strike in the last 25 years...

[CONSO]

Just got back from the movie SULLY- well done- did not make NTSB types look good- but IMHO mix of actual footage and CAG was well done. It also appears that a few survivors played themselves ?? What a difference 35 seconds can make- even with practice

[Pozidrive]

From a system engineering prospective, this would not be difficult to do.
For example, each engine controller could determine the health of its own engine and specifically if it was reliable enough to allow another engine to shut down. If it was, it would send a continuous coded "reliable engine" message to the other engine controller. A controller would only shut down the engine after it had terminated its own "reliable engine" message for some period of time (a few seconds), was receiving the "reliable engine" message from the other controller, and had determined that running its own engine was unsafe.
And if you wanted to use the last bit of power from an unhealthy engine that the computer shut down, before it failed?

[Ian W]

There was a post earlier postulating that 4 engines would have resulted in happy outcome (apparently now deleted).
However, having four engines is no guarantee of a happy ending if you take out two with birds while taking off:
https://en.wikipedia.org/wiki/1995_Alaska_Boeing_E-3_Sentry_accident

Off the top of my head, these are the only major jetliners I know of to go down due to a bird strike in the last 25 years...
Loss of both engines on one side has been known to be an issue for some time ASN Aircraft accident Boeing 707-123 N7514A Calverton-Peconic River Airport, NY (CTO) (http://aviation-safety.net/database/record.php?id=19590815-0)

[lomapaseo]

And if you wanted to use the last bit of power from an unhealthy engine that the computer shut down, before it failed?

Just don't let the computer turn off the fuel, just let it retard to idle, that way the pilot still can override if absolutely necessary.

Actually this is up to the installers what's best in a computer control against possibilities.

[Langball]

There was a post earlier postulating that 4 engines would have resulted in happy outcome (apparently now deleted).
However, having four engines is no guarantee of a happy ending if you take out two with birds while taking off:
https://en.wikipedia.org/wiki/1995_Alaska_Boeing_E-3_Sentry_accident

Off the top of my head, these are the only major jetliners I know of to go down due to a bird strike in the last 25 years...
Didn't RYR lose a 737 down in Italy around the same time due to a massive bird strike. No loss of life there, but no-body remembers that crew.

[Lonewolf_50]

That crew lacked the breathless New York media hype machine, for one ...

[lomapaseo]

not to mention the river had been paved over

[costalpilot]

good damn thing he started the apu.

[horizon flyer]

Makes you wonder about Heathrow traffic climbing out over the big areas of water to the west, the home of thousands of Canada Geese horrible bird that needs a serious cull on all lakes and water ways in the UK.

[llondel]

Being Canada geese, I'm sure they say "excuse me" or "sorry" just before ingestion.

As for the chicken wire suggestion, someone asked me that once and I dug up a bunch of pictures and videos of engines on the group sucking up water and carrying baggage containers in their intakes to demonstrate how useless the wire would be, and how hard it would be to hold it in place. Also get them to think of a chicken (preferably not frozen) hitting chicken wire at 150mph

As for shutting down an engine automatically, I remember working on a quote for a bit of military gear that had the 'battle override' button. The kit was supposed to protect itself from overheating and other dangers, but if you hit the battle override, it would run itself to destruction, presumably on the basis that if it shut down you were going to get blown to smithereens anyway, so running it to failure might give you the chance you need.

[Chronus]

There is an interesting paper by The Bird Strike Committee Europe published in May 1996. It states the first known bird strike occurred in 1908, when Orville Wright chased a flock of birds.
It can be found at http://www.int-birdstrike.org/London_Papers/IBSC23%20WP1.pdf

There is another report of the same date, by the same organisation. It talks of the efforts of Transport Canada to deal with the problem. http://www.int-birdstrike.org/London_Papers/IBSC23%20WP24.pdf

I suppose they must have felt duty bound to do something about it, given their OEM brand, the Canada Geese.

[slast]

From the Flight Magazine Archives September 1963.
"Very little publicity was given to the BEA Vanguard G-APAT incident at Edinburgh Airport on September 11, 1962, when, during take-off at night, the aircraft flew through a flock of gulls. The circumstances of this serious incident are related for the first time in the Survey of Accidents for 1962 just published by the Ministry (see page 496).

There was low cloud and heavy rain and large numbers of birds struck the aircraft and forward vision was obliterated. No 4 engine failed almost immediately and the other three engines were also affected. The climb was continued on the-power available in order to position the aircraft for an ILS approach. At 3,800ft No 2 engine failed and the propeller was feathered.

The No 3 engine also became critical and preparations were made for an emergency landing, but after an ILS approach a successful landing was made back on runway 13. When the aircraft returned to the apron 30 minutes after departure it was found to be severely damaged and oil coolers and engine cowlings were seen to be almost blocked with dead birds. There were no injuries among the 68 passengers and eight crew, though obviously this could have been a disaster as grievous as that which befell the Eastern Electra which struck and ingested birds after taking off from Boston on October 4, 1960."

I had just started my CPL training when this item appeared, and it impressed on us that birds could be a serious hazard! I seem to recall that the pilot was Dennis Clifton and he was subsequently recognised with a Queen's Commendation for Valuable Service in the Air.