Tag: aviation-safety

Tragic VoePass ATR72 Crash

2024 was going so well. Looking at the indicator of worldwide fatalities in commercial aviation for the first six-months of this year, and it is exceptionally low. The time between major fatal accidents across the globe is another indicator that my team once looked at on a regular basis. Aviation is an extremely safe mode of transport but when accidents happen, they can be devastating.

Yesterday, the situation changed in Brazil. A VoePass ATR72-500 aircraft[1], registration PS-VPB, flight number PTB2283 crashed in the Brazilian state of São Paulo. The twin-engine aircraft crashed in a residential location.

Yet unknown events resulted in a loss of control in-flight. On-line videos of the aircraft flying show a dive and then a spiralling decent to the ground. The aircraft was destroyed on impact, and it is reported that all lives were lost.

The publicly available flight data shows a sudden decent from a stable altitude[2]. The aircraft was about and hour and twenty minutes into its flight.

Looking at the video information it might appear that local weather may not have been a factor in the accident. However, there was known to be severe icing conditions at the altitude that the aircraft was flying.

It’s speculation on my part but unrecognised severe icing is one of the conditions that can bring about a catastrophic outcome for such an aircraft. It is sad to have to say that there is a record of a major accident to an ATR-72 that has some of the characteristics of this new accident.

In fact, it is one fatal accident that is etched on my mind given that it happened in late 1994, when I was still fresh in my job with the UK Civil Aviation Authority as an airworthiness surveyor. It’s known as much by its location as by the name of the aircraft, namely Roselawn[3]. The accident was extremely controversial at the time.

Crews are told that they may be operating in severe icing conditions but there is no specific regulatory requirement for on-board advisory or warning system on this generation of turboprop aircraft. An ice detection system can serve as a final warning to alert a crew that ice protection is needed.

Work to update the technical document; In-Flight Ice Detection System (FIDS) Minimum Operational Specification EUROCAE ED-103 is completed. Issued in April 2022, ED-103B – MOPS for In-Flight Icing Detection Systems is available[4].

In the case of the current accident, it is a matter for Brazil’s highly capable independent accident investigators to determine what happened. Anything I have written here is purely speculative.

POST 1: Reports of statements made by Agência Nacional de Aviação Civil (Anac) say that the aircraft was in good condition.

POST 2: Accident flight recorders have been recovered from the accident site. Flight recorders retrieved from crashed Voepass ATR 72-500 | Flight Global

[1] https://asn.flightsafety.org/wikibase/409335

[2] https://www.flightaware.com/live/flight/PSVPB/history/20240809/1450Z/SBCA/SBGR/tracklog

[3] https://www.faa.gov/lessons_learned/transport_airplane/accidents/N401AM

[4] https://eshop.eurocae.net/eurocae-documents-and-reports/ed-103b/

Highways

The last time I visited the city of Baltimore was in 2012. It was the location of the annual seminar of the International Society of Air Safety Investigators (ISASI)[1]. That was when I was representing the European Aviation Safety Agency (EASA) at such international events.

The relationship between aviation accident investigators and regulators are generally cordial. There’s a great deal of work that requires cooperation and good communication. That’s not to say that the relationships between these two vital parts of national and international aviation safety systems is easy. It’s not. My reflection on that fact is that a degree of constructive tension is inevitable and not always a bad thing.

One way of seeing that relationship is that the primary role of an investigator is to make findings to prevent the repeat of a given accident. For a regulator the primary role is to ensure the complete aviation system runs safely on a day-to-day basis. Both organisations have the public interest at their heart. However, their operational context and perspective are different.

Firstly, my condolence to the families and friends of those who perished because of the Francis Scott Key Bridge accident[2]. The collapse victims and survivors had no way of knowing what was to happen on the night of the accident. I use the word “accident”. This was not an act of God, as some commentators would have it. The safety risks involved in the operation of the port in Baltimore could be anticipated.

In the US there’s an independent federal agency that is tasked with such major investigations. Interestingly, it’s the same one as that investigates aviation accidents and incidents. The National Transportation Safety Board (NTSB) is a multi-modal organisation. That is something we don’t have in the UK. Also, we don’t have a divide between federal and state organisations. Since in the UK we have separate independent national Air, Marine and Rail investigation agencies that cover the country (England, Scotland, Wales, and Northern Ireland).

I will not comment on the accident sequence or causes. It’s the job of an independent investigation to arrive at the technical facts. Recommendations will flow from that investigation.

Where a comment may be in order is that there are many locations across the globe where a vital piece of infrastructure, like a bridge being struck by a large container ship is a possibility. I’d generalise that further. When infrastructure that was designed a built 50 years ago meets modern day operational stress there’s going to be vulnerabilities. Yes, the aviation system is not immune from this fact too. It wasn’t so long ago when I read of PDP-11 computer hardware used for air traffic control (now, historic artifacts[3]). I’m sure there are still Boeing 747s, and alike that need floppy disks to update their hardware.

So, the wider subject is operational legacy systems working with modern systems. This is the interface that requires particular care. The safety risk appetite and exposure in the 1970s/80s was quite different from that which we expect upheld today.

Unfortunately, society is often reluctant to revisit this subject. Additionally, there’s the incentive to go for quick fixes and sweating assets. The example I have in mind the so-called “smart motorways” in the UK[4]. I don’t know how many fatalities can be linked to “smart motorways” but I’m sure, sadly, it’s too many.

POST: In time-off I enjoyed a trip out to Fort McHenry and a walk around the places where The Wire was filmed. The Fort McHenry story is interesting given its role in times of war. The British burnt the White House but the navy didn’t get past Fort McHenry in 1812.

[1] https://www.isasi.org/

[2] https://www.bbc.co.uk/news/av/world-us-canada-68661318

[3] https://www.tnmoc.org/air-traffic-control

[4] https://www.gov.uk/government/speeches/plans-for-new-smart-motorways-cancelled

Comment

Custom and practice are as important as the rules and regulations that are part of our lives. Now and then, someone is criticized for applying the letter of the law without care for the spirit of the law. The same is true for custom and practice. Whereby, acting outside past norms can trigger a backlash.

Because, in free countries we believe in a free press, the rules and regulations that imping on what should and should not be said about events are always hard fought over. The banner of the “public interest” is touted as overriding. It may or may not be, but there’s an argument to be had.

In the aviation safety profession, I’ve grown up with an instinctively “need to know” disposition. I’ve shaken it off, mostly but there are signs that the attitude persists. This instinct can run counter to the transparency and openness that most people expect to see.

Why talk about the way major events are talked about?

A case in point is the recent runway collision in Tokyo. There’s much already written about the newsworthy aspects of the event, so I’ll desist from adding much more. There’s a lot of speculation too.

Graphs can be drawn of the media attention given to such tragic events against time. It’s typical that from moments after a major aviation accident until a few days after most initial facts are known there’s a huge surge in activity. This used to be described as newspaper column inches.

Today, wide ranging speculation is inevitable. It can be highly literate, and, on the other side of the coin, it can be badly informed, and now and then damaging.

In over three decades, I’ve been dealing with aviation accidents and incidents there has been notable changes in media and communications. For one, the universality of the INTERNET is now unquestionable. For another, the deference offered to authorities has diminished markedly. For yet another, the speed of with which images can travel around the globe is astonishing.

Most aviation professionals are tempered by caution. Aware of the techical complexities that can arise in aviation accident scenarios. What can seem in the heat of the moment to be an obvious cause and effect, after detailed analysis turns out to be wrong, or only a partial picture.

So, should aviation professionals be scathing about the enormous growth in commentary and public speculation? Especially when some of it is wild and or even outrageous on social media. No. I don’t think so. Like it or not this is our digital world. The freedom it affords to throw-up any opinion or theory can only be tempered a bit. The hope is always that the pure dross fades away when a reputable authority challenges it.

That then puts a responsibility on someone, with professional knowledge to challenge ill-founded speculation. Or, at least, to ensure that the major media outlets have reliable sources of trustworthy information. I don’t think aviation professionals should remain silent concerning speculation. That may have been the strategy decades ago. It no longer works. The greatest degree of transparency and openness, based on verifiable facts, should be the aim.

Comment?