Nothing Good Ever Happened In A Box Canyon
CASA 212 performing an air drop in Afghanistan
The investigation into a 2004 accident raises many questions, and disturbingly, it doesn’t provide any answers. Would your company work safely if there were no enforcement? How safely would you work if you knew no one was watching? Does your safety depend on people who no one is watching?
A U.S. airline was contracted by the U.S. government to provide cargo and passenger service in Afghanistan. Legally, they were under U.S. regulations. Practically, they were unregulated, as there were no inspectors in Afghanistan.
One morning a flight crew decided to fly into the mountains, instead of around them, just for fun. They ended up flying into a box canyon. ‘“At 0803:21, the first officer stated, “yeah you’re an x-wing fighter star wars man,” and the captain replied, “you’re [expletive] right. this is fun.”’* Less than 20 minutes later, as the crew attempted a 180º turn, the plane hit the canyon wall.
Let’s See What This Baby Can Do!
Bombardier CRJ200
One sometimes hears, “The only thing faster than a company truck is a rental!” The Canadair Regional Jet 200 (CRJ200) can carry up to 50 passengers and is capable of altitudes greater than 41,000 feet (12,497 metres). Capable of 41,000 feet in the same sense as the average pickup truck is capable of 96 mph (155 km/h) – you can do it, but there’s no valid reason to.
A “repositioning flight” is when a passenger aircraft is moved from one airport to another without passengers. Some pilots see this as an opportunity to fly aggressively and enjoy testing the limits of the airplane. Several accidents prove that sometimes they end up exceeding their own limits.
Having just reached 41,000 feet, the captain told air traffic control, “We don’t have any passengers on board so we decided to have a little fun and come on up here.” The plane impacted the ground less than 25 minutes later.
Can Too Much Privacy Kill You?
Beech A100 King Air Instrument Panel
It’s not unusual for an employer to check the references of a job applicant. Unfortunately, it is unusual for those references to be useful. Privacy legislation and the threat of lawsuits make many afraid to provide a complete and open evaluation of a former employee. Read about this accident and see if you agree that privacy can create a significant safety hazard.
At Airline #1, a pilot was employed as a first officer. He was reprimanded four times over two years for not following procedures. Airline #1 gave him a letter of reference stating that he had performed well.
Airline #2 hired the pilot as a captain and then demoted him to first officer for repeatedly violating standard operating procedures (SOPs).
When Deviation Becomes the Norm
Beech A100 King Air
A recent crash investigation yielded some very useful insights into why workers deviate from procedures. This analysis applies to any workplace that relies on procedures for safe and reliable outcomes.
Standard operating procedures (SOPs) are a quality assurance tool. In the context of this posting, they define parameters for working safely. Procedures can be perceived to reduce productivity and it seems to be a natural human tendency to deviate from them. Such deviations do not have to be malicious violations (e.g. motivated by laziness or cheating), they can be well-meaning attempts to manage a high workload (including task saturation), to simplify complexity, or to cope with situations not envisaged when the procedures were developed.
With sufficient repetition, deviations can become routine and workers stop recognizing their actions as deviations. The threat of punishment is not a deterrent because these deviations are no longer deliberate (workers don’t decide to risk punishment by deviating, they no longer realize they are deviating). Supervision is the only way to detect deviations and bring them to the attention of workers. Investigating the causes of such deviations can also help improve procedures to reduce the incentive for future deviation.
Part 10: Conclusion – Shuttle Crew Safety Could Be Improved
The Shuttle's replacement: the Orion capsule
Some things have changed for the better. Debris from the Space Shuttle Challenger was dumped into an abandoned missile silo. Out of sight, out of mind, perhaps. Even the data was not catalogued for use in further investigations. The Spacecraft Crew Survival Integrated Investigation Team (SCSIIT) lamented that, “The lack of debris for comparison and methods of data preservation made the Challenger data essentially unavailable for this investigation.”
Not so with the debris and data from Columbia. Both have been preserved to allow further investigation and research into the development of future spacecraft and crew survival equipment. Given the timing of the Columbia Crew Survival Investigation Report, the SCSIIT members might not have had any other option to make their work meaningful. Design of space vehicles for the Constellation program, which are to take astronauts to the Moon and possibly to Mars, has already begun.
On the other hand, as a result of the Challenger accident, NASA made some substantial changes to improve the survivability of a Space Shuttle accident. Unfortunately, the Columbia accident does not appear to have initiated much in the way of further improvements, despite a demonstrated need to do so. Following the report of the Columbia Accident Investigation Board, the Shuttles were returned to service, not waiting for the Columbia Crew Survival Investigation Report.
Part 9: Exiting the Shuttle at High Velocity and High Altitude
Astronauts line up to jump out the escape hatch
The Columbia Crew Survival Investigation Report refers to an SR-71 test flight on January 25th, 1966: “The pilot lost control of the aircraft, and the SR-71 broke up while flying at approximately Mach 3 at over 75,000 feet (~400 knots equivalent airspeed (KEAS))." (That is 741 km/h at 22,860 metres.) "The pilot survived, but the reconnaissance systems officer was killed.” The report lists the similarities and differences between this accident and that of the Columbia.
To begin with, “The SR-71 pressure suit is very similar to the shuttle ACES in design and construction.” The most important comparison between the two accidents is that one of the SR-71 crew members survived aerodynamic forces very similar to those which occurred as the Columbia’s Crew Module broke up (the Crew Module Catastrophic Event or CMCE). “The dynamic pressure at the Columbia CMCE was roughly 405 pounds per square foot (psf) and the dynamic pressure at SR-71 aircraft breakup was roughly 398 psf, a difference of less than 2%.” (That is 19.4 kPa vs. 19.1 kPa.) Another positive sign is that simulations indicate the airspeed at the time of total dispersal of the Crew Module reached 560 KEAS (1,037 km/h), which is the certification requirement for ACES.
Part 8: Shuttle Parachute Problems – Poor Heat Resistance
The parachute is attached to ACES
One of the outcomes of the Apollo 1 disaster was a change from nylon to flame-resistant suits for astronauts. The outer layer of the Advanced Crew Escape Suit (ACES) was flame-resistant Nomex. The intended purpose was to protect against a brief exposure to fire, to allow escape.
The outer covering of the parachute pack was Nomex, but the parachute harness was nylon webbing. (The astronauts’ boots, worn over ACES, were also partially made of nylon.) The Columbia Crew Survival Investigation Report notes that nylon loses strength about 250°F (121°C) and melts at 500°F (204°C), while Nomex decomposes at 932°F (500°C). It is very odd to use nylon together with a flame resistant material. This is not permitted for personal protective equipment (PPE) in the Alberta petroleum industry, for example.
Analysis of the helmets revealed that they were exposed to a temperature between 572°F (300°C) and 735°F (391°C) during deceleration. Within this temperature range, the helmets were damaged, but still functional. ACES would also have maintained integrity. However, it seems that if an astronaut were to have bailed out of Columbia, the parachute harness would have failed.
Part 7: Shuttle Parachute Problems – Manual Deployment
The chute cord is attached to the escape pole by a lanyard
The parachute is worn over ACES (the Advanced Crew Escape Suit). The intended method for escaping from the Shuttle is to blow the hatch, then hook the parachute’s D-ring to a lanyard on the Shuttle’s escape pole, and bail out. Imagine paratroopers making a static line combat jump. It’s a jury-rigged system, not originally part of the Shuttle design. It was intended to be used when the Shuttle was intact and in a controlled glide.
The parachute can also be deployed manually. This would be necessary if something goes wrong with the lanyard deployment. The parachute pack does have an automatic Seawater Activated Release System (SEAWARS) that releases the parachute on contact with saltwater (but apparently not in fresh water, e.g. a lake). The parachute does not have an automatic deployment system in case the astronaut were to be unconscious or badly injured.
The report noted that devices for automatically deploying a parachute are used by military and sport parachutists. It recommended that such a mechanism be employed to protect unconscious astronauts. Implementation would not seem to be difficult for the Shuttle program.
Part 6: Shuttle Dynamic Rotating Forces Need Not Have Been Lethal
Advanced Crew Escape Suit
Columbia’s left wing was struck by a piece of insulating foam that fell off the external tank during ascent. On descent, hot gases entered the cracked leading edge, destroying the hydraulic lines, which powered the control surfaces (rudder, elevons, and ailerons). Columbia then entered a “highly oscillatory slow (30 to 40 degrees per second) flat spin,” according to a simulation performed by the Spacecraft Crew Survival Integrated Investigation Team (SCSIIT). This spinning became worse as the orbiter broke up. According to the Columbia Crew Survival Investigation Report, these rotational loads would have been lethal to the unconscious crewmembers for two reasons.
Part 5: Shuttle Depressurization – Flawed Procedures
Launch of the Columbia on its last mission
Three crewmembers had not completed donning the Advanced Crew Escape Suit (ACES). One was not wearing a helmet or gloves, and two others were not wearing gloves. The Columbia Crew Survival Investigation Report indicated that this was not unusual, based on past flights, and there were two reasons for this.
