Air Canada Pilot Nose Dive Report Sounds Bogus

[Tropicana]

I just can't see this happening:


A groggy Air Canada pilot who mistakenly believed the planet Venus was another plane in his path, forced his aircraft into a sudden dive that caused 16 injuries among un-seat-belted passengers and crew on a transatlantic flight.



The Transportation Safety Board report released yesterday notes that those hurt aboard the Boeing 767 had failed to comply with lit seatbelt signs.

``This occurrence underscores the challenge of managing fatigue on the flight deck,'' Jon Lee, the investigator in charge, said in a statement.

``It also shows that inflight passenger injuries can be prevented by wearing seatbelts at all times while seated.''

The terrifying 46 seconds in which the plane dived 120 metres then lurched 240 metres back upward occurred in January 2011 aboard an overnight Air Canada flight from Toronto to Zurich.

The first officer was napping during a controlled rest period aimed at combating pilot fatigue when he was awakened by the captain's report of their flight position.

At the same time, a US air force Boeing C-17 was coming from the opposite direction about 300 metres below them. The approach sparked cockpit alerts, which the captain mentioned to his groggy flight officer.

The ``confused and disoriented'' co-pilot first mistook the planet Venus for the approaching aircraft. When he did spot the oncoming plane, he thought it was descending straight at them.

To avoid what he thought was an imminent collision, the first officer overrode the auto-pilot by forcefully pressing on the control column, pushing the passenger jet into a dive.

The captain was able to regain control as the C-17 passed safely below them, and returned the plane to its cruising altitude.

In all, 14 passengers and two flight attendants among the mostly 103 sleeping people aboard suffered bruises and cuts from slamming into aircraft fixtures. Seven were treated in hospital on arrival in Zurich three hours later.

Continued: http://travelindustrytoday.com/web/i...m&id=13931

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

what part sounds bogus?

[Tropicana]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

This part:

<div class="ubbcode-block"><div class="ubbcode-header">Quote:</div><div class="ubbcode-body"> The ``confused and disoriented'' <span style="font-weight: bold">co-pilot first mistook the planet Venus for the approaching aircraft</span>. When he did spot the oncoming plane, he thought it was descending straight at them.
</div></div>

Give me a break. How is that possible?

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Tropicana</div><div class="ubbcode-body">This part:

<div class="ubbcode-block"><div class="ubbcode-header">Quote:</div><div class="ubbcode-body"> The ``confused and disoriented'' <span style="font-weight: bold">co-pilot first mistook the planet Venus for the approaching aircraft</span>. When he did spot the oncoming plane, he thought it was descending straight at them.
</div></div>

Give me a break. How is that possible? </div></div>

well that might be the excuse he is using for his inappropriate action.

he is trying to protect his job. sounds to me like he broke some rules and is making up a cover story.

[Tropicana]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

Sounds like he was probably drunk.

Let's see what Captain xigaM has to say. I am sure he will agree it sounds bogus.

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

A fatigued, napping Air Canada co-pilot who awoke, wrongly believed his flight was on a collision course and pushed the plane sharply downward, is to blame for a January 2011 incident that left 16 injured, the Transportation Safety Board reported Monday.

Pilot fatigue, listed as the cause of the incident involving an overnight flight from Toronto to Zurich, has dogged Transport Canada for years, and safety advocates seized on the report to press Canada to update its “significantly deficient” flight and duty times regulations that take into account people’s circadian rhythm and address time-of-day sensitivities.

“We know and we understand the human condition. We cannot change that, but we can change the conditions that pilots work under,” Barry Wiszniowski, head of technical and safety division of the Air Canada Pilots Association said Monday. “It’s our strong belief that safety trumps politics, safety trumps commerce, and safety trumps competition.”

Unlike past reports, the TSB does not make any recommendation to Transport Canada, but Jon Lee, the lead investigator, acknowledged that “this occurrence underscores the challenge of managing fatigue on the flight deck.”

The report also notes that the airline’s “controlled rest” procedures were not followed on this flight. The report also discussed an elevated risk on Europe-bound overnight flights.

“North American-based pilots flying eastbound at night towards Europe are at increased risk of fatigue-related performance decrements,” the report concluded, following a year-long investigation.

The incident, initially thought to be related to turbulence, was triggered by a misconception of a pending collision with another aircraft passing in the opposite direction roughly 1,000 feet under the plane by the Air Canada first officer. He had just woken from a nap or “controlled rest period.” This resulted in the sudden dip in altitude over the North Atlantic.

“The captain, who was the pilot in control of the aircraft, had visual contact with the oncoming aircraft. Under the effects of significant sleep inertia (when performance and situational awareness are degraded immediately after waking up), the first officer perceived the oncoming aircraft as being on a collision course and began a descent to avoid it,” the report said.

The sudden dip injured 14 passengers and two crew members who were not wearing seatbelts at the time of the incident.

The fatigue level of the first officer, who napped for 75 minutes despite Air Canada’s policy stating naps not exceed 40 minutes, was “magnified by prior fatigue,” the report stated.

“Also contributing to the significant sleep inertia was napping during a period of the night that made deep sleep more likely, and napping longer than allowed by the company’s controlled rest procedure. The investigation also found that crews did not fully understand the risks associated with fatigue or the procedures for conducting controlled rest.”

The report said since the incident, both Air Canada and its pilots union “have taken measures to enhance flight and cabin crew awareness of the controlled rest procedures and to better understand the levels of fatigue experienced by crews flying overnight flights from North America to Europe.”

In a statement released Monday, the airline said an enhanced system to track fatigue issues will be in place in the summer of 2012. Air Canada’s rules respecting duty days and rest periods are more conservative than what Transport Canada requires, the company said.

Wiszniowski of thepilots association said the solution to solving the “significant safety issue of fatigue” for passengers in Canada requires updated flight and duty times regulations covering all air operators.

Unlike the Federal Aviation Administration in the U.S., Transport Canada has not incorporated the scientific knowledge about flying and the circadian rhythm into its air-safety regulations.

That means unlike in the U.S., Canadian airlines are not required to have a third pilot on all Europe-bound flights.

“The fact that you can sleep in the flight deck is really a Band-Aid solution to having proper fight and duty regulations.It is a lot safer to have a third pilot,” said Wiszniowski.

The pilot association has been pressing Transport Canada about pilot fatigue for years.

In 2009, it started tracking incidents related to pilot fatigue to provide the regulatory with empirical data.

Later that year, new requirements of the International Civil Aviation Organization (ICAO), the Montreal-based United Nations civil aviation agency, came into effect. The new standards specified how to define flight time, fatigue and rest periods. Member states, including Canada, were also told their air-safety regulation should be based on scientific principles “where available.”

Transport Canada has consistently said that Canada’s regulations on flight and duty times are “compliant with the principles” and “consistent with the intent” of the UN civil aviation standards.

But theAir Canada Pilots Association disagrees, and union representatives told parliamentarians in 2010 that Canada was in violation of new international standards to combat pilot fatigue in the cockpit because it doesn’t take into account the latest research on why flying overnight is harder on the body than day-time flying.

“Our regulations were written before seatbelts were made mandatory in automobiles. They haven’t changed much since the 1960s,” said Wiszniowski, who “optimistically” estimates that passengers in Canada will have to wait another four to five years before Transport Canada updates the regulations.

In September 2010, the Canadian Aviation Regulation Advisory Council formed a Flight Crew Fatigue Management Working Group to draft new rules on the flight time and duty time limitations and rest period regulations based on the science behind fatigue risk management systems.

TSB’s newly released report says the co–chairs have begun the process of writing the report of the working group.

“One area of consensus was the effect of circadian rhythms on the length of the flight duty period. The longest duration flight duty period available would start from between 0700 and 1200 (p.m.), and the shortest duration flight duty period available would start from between 2300 and 0430 a.m. — accounting for the window of circadian low and the generally reduced performance during this period,” the TSB report states.

Posted in: Canada, News Tags: Air Canada

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

Accident: Air Canada B763 over Atlantic on Jan 14th 2011, control inputs cause 16 injuries

By Simon Hradecky, created Monday, Apr 16th 2012 15:44Z, last updated Monday, Apr 16th 2012 15:44Z
The Canadian TSB released their final report concluding the probable causes of the accident were:

Findings as to causes and contributing factors

- The interrupted sleep obtained by the first officer prior to the flight increased the likelihood that rest would be needed during the overnight eastbound flight.

- The first officer slept for approximately 75 minutes which likely placed the first officer into slow–wave sleep and induced longer and more severe sleep inertia.

- The first officer was experiencing a circadian low due to the time of day and fatigue due to interrupted sleep which increased the propensity for sleep and subsequently worsened the sleep inertia.

- By identifying the oncoming aircraft, the captain engaged the first officer (FO) before the effects of sleep inertia had worn off.

- Under the effects of sleep inertia, the first officer perceived the oncoming aircraft to be on a collision course and pushed forward on the control column.

- The frequency of training and depth of the training material on fatigue risk management to which the flight crew were exposed were such that the risks associated with fatigue were not adequately understood and procedures for conducting controlled rest were not followed by the flight crew.

- Although the seatbelt sign was on and an announcement about potential turbulence was made, several passengers were injured during the event because they were not wearing their seatbelt.

Findings as to risk

- North American–based pilots flying eastbound at night towards Europe are at increased risk of fatigue–related performance decrements.

- The use of multiple safety occurrence reporting systems may result in some safety issues not being properly identified and analyzed.

- Some passengers may not be aware of the inherent risks in not wearing a seatbelt at all times when seated.

Other finding

- As the aircraft cockpit voice recorder (CVR) was only capable of recording for 2 hours, the event was overwritten.

About 3 hours into the flight the first officer (12,000 hours total, 2,000 hours on type) expressed the need to a controlled rest, the captain (14,800 hours total, 400 hours in command on type) agreed, the purser was not informed about the controlled rest however.

38 minutes later the captain turned the fasten seat belt sign on in anticipation of forecast turbulence ahead. Cabin crew followed up with an according announcement and made a visual check of the passengers. Most of the passengers were asleep, many of the passengers were lying down across the three center seats.

Another 37 minutes later the captain made his required position report to Shanwick Oceanic Control Center, this transmission woke the first officer up, he reported he was not feeling well although he had just rested for 75 minutes.

At that time another aircraft was enroute in opposite direction at FL340 and appeared on the Boeing's TCAS display. The captain adjusted his navigation display while the first officer attempted to acquire visual contact with the traffic but mistook planet Venus for the aircraft until the captain pointed out the aircraft was at 12 o'clock and 1000 feet below.

Both aircraft flashed their landing lights, the first officer acquired visual contact with the other traffic but interpreted its position as being above and descending towards them. He reacted to the perceived impending collision by pushing the yoke forward. The captain, who was monitoring the navigation display at that time to monitor the other traffic, noticed the control column move and the altitude to decrease, therefore disconnected the autopilot and pulled the control column to regain assigned altitude. The aircraft crossed at that point, there was no TCAS traffic or resolution advisory. The flight data recorder showed that the altitude decreased to FL346 and increased to FL354 with vertical accelerations between -0.5G and +2.0G in 5 seconds.

None of the passengers in business class had been injured, in economy class however a number of passengers had contacted cabin fixtures and armrests causing injuries. Two medical professionals identified themselves and provided first aid. The cockpit crew established radio contact with medical services and dispatch, the various injuries were assessed, a decision was reached that it was acceptable to continue the flight to Zurich. 14 passengers and two flight attendant had received injuries, all injuries were of soft tissue variety, a few were lacerations. 7 people were taken to hospital after landing in Zurich.

The Canadian TSB analysed that the first officer was fit for the flight despite some sleep interruptions for child care in the days prior to the flight. The sleep interruptions, especially in the 24 hours prior to the flight, likely increased the risk the first officer would feel fatigue however. During the controlled rest the first officer fell completely asleep showing his level of fatigue.

The captain permitted the first officer to rest beyond 40 minutes maximum, that are set to prevent the body to enter the slow-wave sleep. The 75 minutes rest increased the probability of entering slow-wave sleep, interruption from which would increase likelihood of sleep inertia. Given the first officers comment to feel unwell after waking up it was likely the first officer was suffering from high levels of sleep inertia.

The CTSB continued the analysis:

The FO was not in a state to effectively assimilate the information from both the instruments and from outside the aircraft or effectively provide an appropriate response. Despite having been trained to interpret TCAS targets and react to them, the FO was drawn to rely on immediate perceptual information. Under the effects of sleep inertia, the FO was likely confused and disoriented and perceived the aircraft on an imminent collision course. Consequently, the FO pushed forward on the control column to avoid the collision. The FO quickly realized the error because the traffic appeared to be moving down in the visual field, which did not make sense.By that time, the captain had reversed the control movement to return the aircraft to the previous altitude.

Air Canada took four safety actions as result of the occurrence:

- reminders to the crew to followed standard operating procedures to permit controlled rests be performed safely, especially notify cabin crew of the rest and to arrange a call from cabin crew after 45 minutes

- remind flight crew of the benfits of strategical lateral offsets by 1-2nm at all times unless the aircraft is being placed on a less desireable track

- collect data on the Toronto-Zurich route to understand the alertness levels of flight crew

- a reminder to cabin crew that cabin crew are an important part of the standard operating procedures for controlled rest emphasizing the flight deck briefing that is required and the call to the flight deck after 45 minutes have elapsed

http://avherald.com/h?article=4362ebf0/0000&amp;opt=0

[Leddih]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Tropicana</div><div class="ubbcode-body">This part:

<div class="ubbcode-block"><div class="ubbcode-header">Quote:</div><div class="ubbcode-body"> The ``confused and disoriented'' <span style="font-weight: bold">co-pilot first mistook the planet Venus for the approaching aircraft</span>. When he did spot the oncoming plane, he thought it was descending straight at them.
</div></div>

Give me a break. How is that possible? </div></div>

Why not? It can fool people on the ground.

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Leddih</div><div class="ubbcode-body"><div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Tropicana</div><div class="ubbcode-body">This part:

<div class="ubbcode-block"><div class="ubbcode-header">Quote:</div><div class="ubbcode-body"> The ``confused and disoriented'' <span style="font-weight: bold">co-pilot first mistook the planet Venus for the approaching aircraft</span>. When he did spot the oncoming plane, he thought it was descending straight at them.
</div></div>

Give me a break. How is that possible? </div></div>

Why not? It can fool people on the ground. </div></div>

remember how JFK jr flew into the sea because he got confused about which way was up

[Tropicana]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

Yes people get tired. Yes people get confused about direction even on the ground but to mistake Venus for an airplane does not seem plausible to me.

[RichD]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Tropicana</div><div class="ubbcode-body">Yes people get tired. Yes people get confused about direction even on the ground but to mistake Venus for an airplane does not seem plausible to me. </div></div>

the venus stuff is a distraction...not the main issue.



<div class="ubbcode-block"><div class="ubbcode-header">Quote:</div><div class="ubbcode-body">At that time another aircraft was enroute in opposite direction at FL340 and appeared on the Boeing's TCAS display. The captain adjusted his navigation display while the first officer attempted to acquire visual contact with the traffic but mistook planet Venus for the aircraft until the captain pointed out the aircraft was at 12 o'clock and 1000 feet below. </div></div>

[Tropicana]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

Agreed.

[Magician]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

Fatigue is a serious issue in aviation. When you're tired you judgement is clouded. That's when you have to fall back on standard operating procedures and your colleagues to keep you out of trouble. It doesn't seem they did things by the book on this flight.

[Stormmey]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

I was on a plane once on my way to Europe that just dropped suddenly you could hear the audible gasp, that was real scary then they told us that it was air turbulence. I hate flying only do it out of necessity dang I could not wait for that plane to land.

[Tropicana]

Re: Air Canada Pilot Nose Dive Report Sounds Bogus

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: xigaM</div><div class="ubbcode-body">Fatigue is a serious issue in aviation. When you're tired you judgement is clouded. That's when you have to fall back on standard operating procedures and your colleagues to keep you out of trouble. It doesn't seem they did things by the book on this flight. </div></div>

xigaM, part of the problem is that Air Canada only has 2 pilots in the cockpit. I notice Etihad and Emirates have bigger flight deck crews so everyone can get a proper rest. Is this only on the long haul flights?

What about the part of confusing Venus with an aircraft? I just don't see how that's possible.