Tag Archives: accident

Highest Duty

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A book review.

Highest DutyLast night, I stayed up late to finish reading Highest Duty by US Airways pilot Chelsey B. “Sully” Sullenberger. Captain Sullenberger was the pilot in command of US Airways Flight 1549, which landed with no loss of life in the Hudson River on January 15, 2009.

I’d been wanting to read the book for a while but I kept putting it off. I wanted it to be my first purchased ebook experience. I was supposed to get a Nook for Christmas, but the idiots at Barnes & Noble were completely clueless about customer service and timely order fulfillment, so I canceled the order. I wound up with an iPad in April. After weighing the benefits and drawbacks of ebook reader software — iBooks, Kindle Reader, and B&N Reader — I decided to go with the Kindle software and ordered the Kindle edition of the book from Amazon.com. From what I hear from Twitter friends, the iPad makes a better “Kindle” than Amazon’s Kindle.

On Heroes

I’ve always been intrigued by Captain Sullenberger’s modesty and apparent reluctance to bask in the limelight of his extraordinary experience. People call him a hero but he [rightly] refuses that title. He quotes from a letter he received after his Hudson River landing: “I see a hero as electing to enter a dangerous situation for a higher purpose, and you were not given a choice.”

I agree with this definition of a hero. Captain Sullenberger did what he had to do and was fortunate enough to have the knowledge, experience, demeanor, and team to carry it off successfully. His love and respect of life — including, of course, his own — is what motivated him to do everything he could to succeed.

In many ways, that’s better than being a hero. When a terrible situation was thrust upon him by circumstances he could not change, he rose to the occasion and emerged victorious, saving the lives of 105 people. Along the way, he gave the rest of us hope — after the terrorist attacks of 9/11, in the midst of a serious economic recession, with wars going on in the Mideast — he showed us what people can accomplish when put to the test. He gave us the happy ending we all needed.

It Wasn’t a “Miracle”

Another thing that intrigued — and, I’ll admit, pleased — me about Captain Sullenberger was his failure to credit his success to the intervention of some supernatural being. I’m talking about God.

I can’t tell you how sick I am of seeing famous athletes and celebrities and just plain people thank God for something good happening to them. Scored a record number of goals in a basketball game? Thank God! Won a Grammy? Praise Jesus! Tornado took out the house next to yours but left yours unscathed? God was watching out for you!

It makes me sick. People don’t want to give themselves credit where credit is due. They work hard, they train, they practice, but they give God credit for getting the ball through the hoop. They learn music, they practice singing, they get a great producer who helps package their material, but they give Jesus credit for winning that Grammy. They don’t want to admit that luck has a place in our lives — good luck preserves one house while bad luck takes the one next door away. What of the people who lost the basketball game or the Grammy or their home? Did God simply not like them as much? And what about when these winners get their own dose of bad luck — injury, illness, scandal, death? Did God change his mind about them?

Captain Sullenberger, however, did not thank God or any other supernatural being for the positive outcome of his Hudson landing. At least I didn’t hear him do so in any article, interview, or elsewhere. I wanted to read the book to be sure that he didn’t thank God within its pages. He didn’t.

And that just makes me respect him even more.

The Story

The book mingles autobiographical material with events from the day of the landing. The autobiographical material was presented in a roughly chronological order, but did bounce around a lot with side stories, including references to the Hudson landing. I’m not sure that was the best approach, but it did keep me reading.

Captain Sullenberger is clearly a true pilot. He entered aviation because of his love of flying. From his start as a teen, he took aviation seriously, learning what he could to be a better, safer pilot. He understands the importance of knowing an aircraft’s systems inside and out. He understands the value of studying past accidents to prevent future ones. He also understands that all the things that happen in our lives define who we are and how we will react in a given situation.

Flight 1549 from Wikipedia

This iconic photo of US Airways Flight 1549 in the Hudson River by GregL originally uploaded to Flickr can be found on Wikipedia under a Creative Commons 2.0 license.

A detailed discussion of the events of January 15, 2009 begin about 60% through the book. The story is riveting. He combines his narrative of what happened with references to his past that he believes influenced him to make certain decisions. For example, his knowledge of research into why military pilots sometimes ejected too late is part of why he decided not to worry about saving the airplane by attempting an airport landing and instead concentrate on saving the people by landing in the river. (There’s a lot more to his decision than that; this is just part of what went into it.)

Throughout this part of the book are bits and pieces of the cockpit transcript, recorded by microphones during the flight — the so-called “black box” data. Even though I knew how it would end — don’t we all? — I found the details fascinating. It was a great example of teamwork between Captain Sullenberger and his first officer, Jeff Skiles. Later in the narrative, it was clear that the flight attendants were also part of the team, helping passengers off the plane in as orderly a manner as possible.

The aftermath of the experience also made interesting reading. Getting an inside look at the mail Captain Sullenberger received from people on the plane — as well as many people who had no direct connection to the flight or its passengers at all — revealed the psychology of people. I’m not the only one who appreciated the happy ending to that seemingly doomed flight.

The Soapbox

One of the complaints people have had about the book is the soapbox aspect. Captain Sullenberger believes that airline pilots are not treated as well as they should be by their employers considering the hours and responsibilities of their work. He believes that pay cuts and pension cuts are making it ever more difficult to attract and retain quality pilots who actually care about their work. He suggests that airline pilots are like bus drivers of the sky.

Although I don’t have intimate knowledge of the airline industry, as a professional pilot who has worked for a large tour operator, I know exactly what he means. Aviation employers don’t care how good a pilot is. As long as the pilot meets insurance requirements and can do the job, all that matters is how much that pilot costs. In my experience, many employers would rather hire a cheap, entry level pilot than a seasoned professional who costs more. They don’t see the benefit of the experience. They’re gambling, of course, on the equipment and circumstances of flight — when something goes wrong, will the entry level pilot have the experience and knowledge to bring the aircraft and passengers back safely?

In the airline industry, pilots are locked into their employers for seniority. If they leave one airline, they lose all seniority and start at the bottom at their new employer. This prevents experienced pilots from looking for better jobs. It stagnates the employee pool. And although Captain Sullenberger didn’t mention this, it prevents good ideas from one airline from migrating to another.

Captain Sullenberger does discuss how many airline employees have simply stopped caring about anything other than what’s in their job description. As budget cuts reduce non-essential staff, customer service suffers. Captain Sullenberger talks about his personal experiences going the “extra mile” to help passengers who can’t get the help they need from other airline employees. He talks about how most airline employees are simply tired of doing other people’s jobs. He doesn’t blame them — he hints that they’re underpaid for what they’re supposed to do — but he does decry the system that results in this poor attitude.

He also believes that budget cuts have the potential to reduce safety. A good example of this is the emergency procedures book that his first officer needed to consult on the loss of both engines. In the past, the book had numbered tabs that made it easier to find content. The airline, in a cost-cutting measure, had stopped including the tabs, making it necessary to thumb through the book and look at individual page headings to find content. In the slightly more than three minutes the cockpit crew had to land the plane without engines, every second was valuable. Yes, this flight had a happy ending — but could other flights be lost due to cost cutting measures like this? It certainly makes you wonder.

My feelings about Captain Sullenberger’s soapbox are mixed. I didn’t like reading his complaints, but, at the same time, I knew they were valid. And I know that his experience and the interviews, articles, and books that come from it are the perfect way to get the message out.

While Captain Sullenberger was careful not to criticize his airline, it’s clear that US Airways is just as bad as the others when it comes to matters of pilot compensation and cost-cutting. Perhaps his insight will help make the situation better?

Sadly, it probably won’t.

Thumbs Up

In all, I give the book two thumbs up. While it’s especially good reading for pilots and others interested in aviation, I also think it makes a good guide for young people who want to make something of their lives. And for the rest of the world, it’s a great look at one of the most amazing emergency landings we’ll likely ever see.

Autorotation is Not a Low Rotor RPM Emergency Procedure

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Especially when you’re two miles out at sea.

Picture this: An R22 helicopter without floats operating two miles off the coast of Miami, FL. On board is the CFI-rated pilot with 600 790 hours of total flight time and the private pilot rated “passenger” with 115 hours total flight time. They’re operating at about 40 knots 100 feet above the waves on an aerial photo mission, photographing boats. The wind in Miami, 13 miles away, is from 120 at 13 knots and it’s 26°C with a dew point of 21°C, resulting in a balmy 74% humidity.

The pilot had just completed a 180° turn to the south when the low rotor RPM horn sounds.

The pilot adjusts the throttle to compensate — in other words, we should assume that he adds throttle. The horn stops blaring, but 3 seconds later, it does it again.

So what does the pilot do? Despite the fact that the helicopter does not have floats, he enters an autorotation. The helicopter crash-lands in the ocean, the occupants escape, and the helicopter sinks. The pilots are rescued 10 minutes later by a privately owned boat. The helicopter is left unrecovered (so far) in 150-250 feet of seawater.

What We Don’t Know

There are a few things we don’t know that could explain the reason for the low rotor RPM horn:

  • How much did the pilots and their equipment weight? An R22 Beta (not Beta II) is a very small helicopter. Although they had burned off 45 minutes of fuel, there is a possibility that they were still heavy for the flight conditions.
  • Which direction did they turn? A turn that would have put them into a tailwind situation — especially at low speed — could rob them of airspeed. If airspeed dropped below ETL, the helicopter would have to work harder to stay in the air.

  • What speed were they operating at? Without the benefit of forward airspeed and effective translational lift, the helicopter would have to work harder to stay in the air. If the speed was close to zero, the aircraft might have gotten into a settling with power situation. The natural (but incorrect) reaction of increasing the collective to arrest the rate of descent could have triggered a low rotor RPM warning if available power was exceeded.

  • Were the engine and its components functioning properly? If the engine or magnetos were not performing to specifications, the resulting reduction of engine power could cause a low rotor RPM horn. We have to assume the engine was still running because the NTSB report didn’t mention an engine failure.

But regardless of the reason for the low rotor RPM horn, it’s the pilot’s decision to perform an autorotation to into the ocean that needs to be questioned.

The Robinson Low Rotor Horn

In a Robinson helicopter, the rotor RPM green arc is 101% to 104%. (Please don’t ask why; I don’t know. Yes, it is weird.) The low rotor RPM warning system is designed to alert the pilot at 97% RPM. (See it in action for yourself here.) This is a very early warning. The idea is that if rotor RPM is deteriorating, once it gets past a certain point, it could could become unrecoverable very quickly. The earlier the pilot is warned, the better off he is.

At the Robinson factory safety course — and, one might assume, at many flight schools that train in Robinsons — pilots are taught that a Robinson can generally fly at an RPM of 80% plus 1% per 1000 feet of density altitude. Given the temperature, dew point, altitude, and altimeter setting (30.01), the density altitude was 1,612 feet. That means that the helicopter should have been capable of flight when operating at only 82% RPM.

I need to stress here that this is a general rule of thumb. Do not attempt to fly around at low rotor RPM to test this. While it’s true that my flight instructor at the Robinson safety course had me fly for a few minutes in the Long Beach, CA area at 90% RPM with the horn blaring just to prove that flight was possible, RPM is not something we play with in non-training situations. The formula is simple: RPM = life.

Low Rotor RPM Emergency Procedures

The Robinson R22 Pilot’s Operating Handbook is quite specific on what to do in the event of a low rotor RPM warning. On page 3-10, in the red-tabbed “Emergency Procedures” section, it states:

A horn and an illuminated caution light indicates that rotor RPM may be below safe limits. To restore RPM, immediately roll throttle on, lower collective and, in forward flight, apply aft cyclic.

The NTSB report indicates that the pilot initially “adjusted the throttle to compensate for the [low rotor RPM warning] condition” and was immediately rewarded with recovery. But that was followed by the horn sounding again only 3 seconds later.

It had to be scary for the pilot. After all, he’s only 100 feet above the water and he’s supposed to react by lowering the collective. But the emergency procedure and repetitive training doesn’t tell us to enter an autorotation, which would be a full-down reduction of the collective. The reduction of the collective, coordinated with the rolling on of the throttle, should be slight — perhaps an inch or so. This reduces drag on the blades while the increased throttle provides power to increase their RPM.

What Was the RPM?

One of the things we don’t know is what the RPM was when the pilot decided to enter autorotation. If it had deteriorated to the point where autorotation and cyclic flare were the only tools to recover RPM, his decision was probably a good one. Better to hit the water relatively softly than from 100 feet up, falling like a brick.

If RPM had deteriorated to that point that quickly, however, it’s important to recover the aircraft to learn why. Other than a complete engine failure — which was not mentioned in the report — it’s hard to imagine what would cause RPM to drop enough to warrant such a drastic recovery action.

Who Was Flying?

There may be more to this than what meets the eye.

The helicopter was operated by Helicopter Academy, a flight school with locations across the U.S. The school’s Web site clearly advertises it as a low-cost training company:

$250 PER HOUR R22 HELICOPTER TRAINING TIME BARGAIN and we are the ONLY company in the world that can guarantee you a job.  We operate a fleet of helicopters and like other schools our insurance requires 300 hours helicopter time and an instructor’s rating to fly for us. We train you to work for us and offer a job to all graduates, including transfer student and instructors who can’t get jobs elsewhere.

Helicopter Academy’s other business is BoatPix, which uses helicopters to photograph boats and then sells the photos to the boat owners and others. It’s widely known that BoatPix pilots pay BoatPix (or Helicopter Academy) for the time they fly aerial photo missions. The company’s Web site alludes to this:

…you pay for the first 100 hours at $250/hr, the second 100 hours at $200/hr and the third 100 hours at $150/hr….It’s  $25,000 for the first 100 hours where you’ll do mostly training, $20,000 for hours 100  through 200 where we’ll introduce you to our photo contract which will subsidize your flying and $15,000 for hours 200 through 300 where you’ll do almost exclusively photo and will learn this skill that is valuable to our photo contract and making you a valuable pilot to us.

I added the emphasis in the above quote. It begs the question: who was actually flying this aircraft? The NTSB report suggests that it was the 600791-hour CFI. But was that really the case? Was the 115-hour private pilot paying $200/hour to be “introduced” to the photo contract — as a pilot — while the 600791-hour CFI took the photos?

High Risk Operations

In March 1999, Robinson Helicopter issued Safety Notice SN-34. The latest version of this Safety Notice is dated April 2009. Titled “Aerial Survey and Photo Flights – Very High Risk,” it starts out saying:

There is a misconception that aerial survey and photo flights can be flown safely by low time pilots. Not true. There have been numerous fatal accidents during aerial survey and photo flights, including several involving Robinson helicopters.

It goes on to list some of the possible dangers of low time pilots conducting aerial photo flights. It also makes some recommendations for minimum requirements for aerial photo/survey pilots, including a minimum of 500 hours pilot-in-command. BoatPix is one of the operations that has chosen to ignore this recommendation.

My question to helicopter pilot wannabes out there: Are you that desperate to become a pilot that you’re willing to trade your safety for flight time?

Pilot Experience and Decision-Making

What it all comes down to is whether the pilot made the correct decision for the situation he found himself in. I’m not convinced that entering autorotation over the ocean on hearing a low rotor RPM warning horn is the correct decision.

True, both pilots walked (or perhaps I should say, swam) away. But if the rotor RPM could have been brought back into the green while in flight — something a well-trained or experienced pilot could have accomplished if there wasn’t a mechanical problem — the watery autorotation and the resulting loss of the aircraft could have been avoided.

Hopefully, the Probable Cause report for this accident will shed some light on what really happened. Until then, it certainly gives pilots some food for thought.

November 1, 2011 Update: The Probable Cause report doesn’t add much to what’s reported here other than to clarify airspeed and PIC experience. The official Probable Cause is “A loss of main rotor rpm for undetermined reasons.”

Update, March 17, 2012: Just found another accident report with someone else using autorotation as a cure for low rotor RPM. He crashed, too.

What If You Crashed a Helicopter and Didn’t Tell Anyone?

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In Texas, anything is possible.

This morning, I did a quick search of the NTSB reports to get some info about an R22 crash in Skull Valley, AZ that happened over the weekend. One of my Twitter friends, @heligypsy, had DMed me on Twitter, asking if I knew the people involved. I didn’t, but I know the terrain. A high density altitude photo mission in an R22 is never a good idea, and I had a sneaking suspicion that the details would confirm this. Again.

While my search for information about that accident came up empty — too new to be in the records — it did turn up another interesting helicopter accident, CEN09LA201, which occurred in Texas. The first paragraph of the preliminary accident report sounded downright weird:

On or about May 15, 2007, at an unknown (possibly, 1300) central daylight time, a Robinson R22, N456PH, piloted by an non-certificated pilot, was substantially damaged when it struck a pole and impacted terrain either during takeoff or landing at a ranch in Midland, Texas. Visual meteorological conditions are assumed to have prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The pilot reportedly was uninjured. The flight originated at an unknown time and location.

How many NTSB reports have you read that include the words unknown (two times), possibly, assumed, and reportedly?

Turns out, the accident did not occur on the report date of March 10, 2009. It occurred nearly two years earlier:

On March 10, 2009, FAA’s Flight Standards District Office in Lubbock, Texas, was contacted by a local rancher, who said there was a 2-year-old wrecked helicopter on his property, and he wanted permission to dispose of it. Unaware of such an accident, an FAA inspector went to the site. The inspector confirmed that an accident had occurred and had never been reported. The rancher said he became aware of the accident around July 2007.

The report continues with some aircraft history that sums up a few facts:

  • The helicopter owner had been taking flight lessons in Tucson.
  • The helicopter owner had planned to use the helicopter to give sightseeing flights in Mexico.
  • The helicopter owner had put exactly 1.9 hours on the helicopter after transporting it by truck from Arizona, where its last maintenance work was done, to Texas.
  • The crash had occurred when a main rotor blade struck a pole while the helicopter was either taking off or landing between two buildings on a Texas ranch.

Here’s the final line from the report:

According to FAA, the pilot’s name does not appear in their pilot database. According to the rancher, after the accident the pilot, who was uninjured, extricated himself and walked away.

Now if he was really smart, he would have come back with a flatbed truck and carted away the evidence of his stupidity.

But then what would I blog about today?