And unfortunately we have had a few accidents this year so we aren t duplicating last years success.

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2 Good Afternoon Last year in particular was a very good year for commercial aviation fatalities, though with the San Francisco taxiway landing incident we came within 100 ft of potentially being the worst. And unfortunately we have had a few accidents this year so we aren t duplicating last years success. Still, we have seen a remarkable decrease in aviation fatalities over the years. Society holds commercial aviation to a very high standard. Aircraft accidents are big news and 100 deaths in an aircraft somehow more intolerable than 100 deaths on the highway. For comparison there were 37,461 deaths in automobile accidents in the United States in 2016 compared to 325 aviation fatalities world wide. 2

3 To investigate the cause of the improvement, it is necessary to look at accident data. I asked for NTSB data going back far enough to include the accidents that the first simulator training recommendation in 1969 was based on. These particular datasets are for scheduled US cargo and passenger air carriers. There was a division in what was recorded in As you would expect, there is more information in the more recent data. Also it was possible to find supplemental data sources for some accidents. While these datasets were needed to go back 50 years, there were categories where they weren t representative of world wide data. There were also categories where several non-fatal accidents, had they been included, would show the category was worse than the plots to come indicate. I will point out a couple of these when we come to them. 3

4 Going through the scheduled US cargo and passenger air carriers fatal accident dataset several accident factors can be identified. These factors are not exclusive. For example a system failure accident may also have improper procedures and bad CRM. Also, there is greater understanding of accidents now than in the 60 s. For example there were probably wind-shear accidents prior to the mid-70 s, but these would not have been classified as windshear before windshear was discovered. Further, while thousands parameters are available on recorders today this wasn t the case for most of this history. I dealt with 5 parameter recorders as recently as the 1990 s. 4

5 As a result of it s accident investigations, the NTSB, and our sister agencies worldwide, make recommendations to mitigate future accidents. The Safety Board believes in the value of simulator training as a accident mitigation tool as evidenced by the Board s 61 simulator training recommendations since the first for engine out simulator training in

6 Some themes recur in these 61 simulator training recommendations. The leading theme here is surprisingly basic; do simulator training. The remaining themes refer to specific types of simulator training and developing simulator fidelity for these types of training. Notable among these are : and Stall/high AOA/stick pusher training UPRT Engine out training Often simulator training mitigations are coupled with recommendations for other accident mitigation strategies. In these cases we can say simulation training contributed to the improvement but can t uniquely isolate it s contribution. 6

7 CFIT, the leading cause of fatalities in this study, is an example of this. CFIT accidents significantly reduced in the late 70 s. The credit for this must go to GPWS. In response to a 1972 NTSB recommendation In 1974 (CLICK), the FAA required GPWS for Part 121 aircraft. In 1978 (CLICK), the FAA extended the GPWS requirement to Part 135 Of course we had to train the GPWS system. In 1997 the FAA provided guidance to do this. /////////////////////////////////////////////////////////////////////////////////// A Develop a controlled flight into terrain training program that includes realistic simulator exercises comparable to the successful windshear and rejected takeoff training programs and make training in such a program mandatory for all pilots operating under 14 CFR Part 121. (result of Cali CFIT accident) 7

8 Weather is the 2 nd leading cause of fatalities in the study. This is a rather broad category and would include windshear and icing where simulator training is a mitigation that we will discuss separately later. Improvements in these subcategories due to training certainly positively impacted these broader results but I suspect improvements in weather detection technology also had a major role. In 1965 we hardly knew what weather to expect beyond a general sense. Now even my personal RV-12 displays weather radar and other weather data in the cockpit. 8

9 LOC-I is a broad category that includes the subcategories of Stalls, icing and spatial disorientation to be discussed latter. The NTSB has issued 5 recommendations for UPRT. Mitigations include the industry Airplane Upset Recovery Training Aid (1988) (CLICK) And the FAA s AC , Upset Prevention & Recovery Training (2015) ///////////////////////////////////////////////////////////////////// If you are curious the peak in the 1985 to 1990 time block includes the Gander DC-8 ( 256), Sioux City DC-10 ( 111 ), Romulus MD-80 stall (158 ) 9

10 Though the third leading cause of aviation accident fatalities in these 50 year dataset of US registered aircraft, LOC-I is more important now world wide than that data would indicate. In fact a few years back LOC-I has replaced CFIT worldwide as the leading cause of aviation fatalities. This has led to the new training requirements for LOC that we will discuss a bit latter. 10

11 Airframe failure accidents have decreased markedly over the years but I don t think we in the simulation training community can take much credit for it. 11

12 You may notice the similar shape between the trend for accidents involving stalls and the LOC-I slide two slides back (CLICK). As mentioned, LOC-I is the leading cause of aviation fatalities. Stalls remain the leading cause of LOC so the similarities in shape are to be expected. Stall training is one of the focus s in the new 2019 FAA training requirements. AC Stall and Stick Pusher Training (2012) AC A Stall Prevention and Recovery Training (2017) 12

13 Stall is one of the categories where looking beyond the US registered fatal accidents gives a better understanding. This slide list some no icing stall accidents and the crews response to the shaker (POINT), Pusher (POINT) and Stall break (POINT) cues that are in the flat area on the right to the preceding plot. Note the number of cases coded NR, where the crew has not responded to these cues. There was insufficient information to determine the pilot s response in most of the other accidents.

14 We do see some improvement in the occurrence of improper procedures in accident over the years. One would like to think that, considering the time we spend training procedures, training must have contributed to this improvement but I didn t find evidence to isolate this contribution. 14

15 Collisions accidents have decreased significantly. Mid 70 s Beacon Collision Avoidance System (BCAS) (CLICK) The FAA started development of the TCAS Traffic alert and collision avoidance system in 1981 adding additional capacities to the basic BCAS design full equipage TCAS was required (CLICK) Of course we needed to train how to use this equipment. The NTSB recommended such simulator training in 1993 and the FAA now recommends a simulator for TCAS training. //////////////////////////////////////////////////////////////////////////// A Amend 14 CFR Parts 121, 125, and 129 to require traffic alert and collision avoidance system (TCAS) flight simulator training for flight crews during initial and recurrent training. This training should familiarize the flight crews with TCAS presentations and require maneuvering in response to TCAS visual and aural alerts. 15

16 The accident rate due to icing shows improvement over the years. Mitigation: Sim training: Ice detection Ice protection systems NTSB recs for sim training 2011 Simulator icing training is part of the new 2019 training requirements. FAA : sim fidelity for icing Part 60 (aerodynamic degradations, early stall) SAFO

17 Icing is also one of the categories where looking beyond the US registered fatal accidents gives a truer picture. This slide list some icing stall accidents and the crews response to the shaker (POINT), Pusher (POINT) and Stall break (POINT) cues. Note the number of ES codes where the early stall precluded warning from the shaker or pusher.

18 The contenders for the improvements in spatial disorientation as a factor in accidents are training and display and warning technology and perhaps on the left side of this chart, the use of autopilots. Certainly there has been training in this area over the years but I can t point to anything specific from our training community here. ////////////////////////////////////////////////////////////////////////// Improvements in display technology such as synthetic vision and upset recovery guidance are new and/or coming. 18

19 The data shows a significant reduction in fatal accidents involving engine failures in the early 1980 s. Part of this is due to a reduction in fatal accidents involving asymmetric engine failures. 19

20 As can be seen on this slide. After a series of accidents in 1969 (CLICK) the NTSB recommends engine out training be done on simulators (initially rejected) In 1978 AC B (CLICK) specifies engine out capability on simulators so it would seem engine out simulator training started during this period with positive results. 20

21 The US registered aircraft fatalities data doesn t reflect the Worldwide rate of bounced landing accidents. We have many without fatalities and some non-us registered bounced landing fatalities accidents. 21

22 A review of US Part 121 accidents and incidents for 1982 to 2014 showed 33 bounced. Of these, 15 resulted in a tail strike, four sited windshear or turbulence, five followed an unstabilized approach and three had the power set too high for the spoilers to deploy. 22

23 As a result of a string of MD11 bounced landing accidents, Boeing developed enhanced training in 2012 to address the MD-11 s bounced landings. All US MD11 operators have adopted this training. Boeings data indicates that the number of bounce or skip landings decreased from 1 in 40 in 2010 to 1 in 1200 in Certainly this result suggest that similar positive results can be expected expanding this type of training to other aircraft types. This of course is what we are trying to do with the new training requirements. 23

24 I don t see any trends in wake encounter accidents. The spike is the 2001 American 587 A300 crash where the flying pilot responded to a wake encounter inappropriately with alternating rudder inputs. 24

25 Windshear wasn t recognized as a weather phenomena before the mid 70 s so windshear accidents before that time were not identified FAA contracted for study of windshear resulting in (CLICK) the Windshear Training Aid in 1988 This was followed in 1989 by AC Guidelines for Operational Approval of Windshear Training Programs (CLICK) (CLICK) A hardware mitigation for windshear guidance was required by Of course crews had to be trained to use this equipment. /////////////////////////////////////////////////////////////////////////////////////////////// AC Pilot Windshear Guide (click), which transmitted the Windshear Training Aid in 1988 Windshear Guidance CFR No person may operate a turbine-powered airplane manufactured after January 2, 1991, unless it is equipped with either an approved airborne windshear warning and flight guidance system, an approved airborne detection and avoidance system, or an approved combination of these systems. (b)airplanes manufactured before January 3, Except as provided in paragraph (c) of this section, after January 2, 1991, no person may operate a turbine-powered airplane manufactured before January 3, 1991 unless it meets one of the following requirements as applicable. 25

26 The NTSB has made 14 simulator training recommendations in the runway departure area over the years ranging from reverse thrust to slippery runway fidelity. The FAA s positive response to 5 of these may be partially responsible for the improvement we see here. 26

27 I don t see any trends with fire and beyond continuing to make sure crews know how to use their fire control systems I don t see this is really in our lane. 27

28 There is improvement in weight and c.g. accidents after 1985 but, again, not really something pilot training can mitigate in the Part 121 world. 28

29 I can t say what caused the improvement in system failures. Perhaps more reliable systems has played a role though system complexity has increased. Pitot/static system issues have been one of the more common causes of system failure accidents. 1997: FAA guidance blocked pitot tube training. and there has been other system training guidance 29

30 We have seen a reduction in cockpit coordination problems over the years. There was no technology solution for this purely human issue. The only mitigation for cockpit coordination problems has been CRM training (CLICK). The FAA s training guidance for CRM dates to 1989 only a year after the NTSB s first CRM recommendation so I suspect they were already moving on this. 30

31 There has been a significant reduction in accidents over years since the first simulator training recommendation. Simulator training has been a go-to mitigation tool in this accident rate reduction and our training community should be proud of our important contribution to this record. So what next? I expect we will see further significant improvement in the accident rate as a result of the FAA s training requirements that go into effect next March. 31

32 (READ SLOW) By March 12, 2019 full stall, stick pusher, bounced landing, gusty crosswind and icing training are required. (PAUSE) ///////////////////////////////////////////////////////////////////////////// ///////////////////////////////////////////////////////////////////////////// ////////////////////////////////////////////////////////////////////////////// FAR requires that each training program incorporate extending envelope training. Part 60 refers to SAFO which responded to older NTSB Safety recommendations. 32

33 Part 60 was revised so to ensure simulators can support this training. In addition, the FAA has published guidance for upset prevention and recovery training in AC and guidance for stall prevention and recovery training in AC A. I would like to add a couple of thoughts on developing stall training from lessons learned in accident investigation. 33

34 I believe the most important thing is recognition and we see in accident investigations that crews do not recognize cues that they are stalled. Stall cues include: buffet, stick shaker, growing roll instability, Un-comanded roll off, pitch break, reduced control effectiveness the initial stick pusher push and the often the resulting stick pusher dynamics. Of these stick pusher dynamics might benefit from a bit of an explanation. 34

35 There are more prominent accidents such as the 2009 Colgan 3407 accident in Buffalo that demonstrate stick pusher dynamics but a PSA incident over Georgia is text book. Here we have Column in blue with the scale on the left Stick shaker in green and Stick pusher in red with on down and off up. You can see when the pusher moves the column forward the pilot responds by pulling the column back. ################################################# The aircraft slowed on autopilot as it climbed through ft. to about ft. The autopilot had disconnected before the time shown here. 35

36 Here we see the results of that column AOA in red and Pitch in blue Note that peak AOA increases through the first 4 cycles. 36

37 Finally we have the un-commanded roll at stall in red And The opposing wheel in blue. Note that the roll-offs correspond to the AOA peaks from the previous slide. The shift at 15:40:50 develops as an engine looses power. I have been told that one training provider sets the pilot up for a stick pusher and that pilot s with few exceptions fight the pusher and get into pusher dynamics. Then with the dynamics from fighting the pusher stall cue experienced it is ok now lets do it right. /////////////////////////////////////////////////////////////////////////////////// An un-commanded roll, roll instability and reduced control authority are typical cues to a stall. 37

38 Historically airline pilots were trained only for approach to stalls. The stall cues that occurred beyond approach to stall were not trained and often caused confusion. This table summarizes stall cues that can be available for the crew to recognize and whether their recognitions has been historically trained. The last five recognition cues should be trained under the new 2019 requirements. 38

39 Icing is an element of the new training that changes the previous stall cue table somewhat. Kinematics parameter extractions of accident and incident data generally shows a linear increase in drag and a decrease in lift with time prior to the stall. But perhaps the most important icing effect is the lower angle of attack for stall. 39

40 As can be seen in this example, which shows extracted lift curves in icing for four flaps up Saab 340 icing upsets, stall with icing contamination can occur at a significantly lower angle of attack than for an uncontaminated wing. With the stick shaker and stick pusher triggered by the angle of attack, stall upsets in icing often occur at an angle of attack below the stick shaker and stick pusher trigger. In other words, stalls in icing often occur without artificial warning. The first indication of stall can be an abrupt un-commanded roll off which was seen in each of the upsets included in this plot among others. 40

41 The effect of this reduced angle of attack stall in icing on stall cues is summarized with these changes to the stall cue table In icing, the artificial stall warnings cues (stick shaker and stick pusher) may not precede the stall upset. Even when the approach cues are there, the accident/incident record shows that pilots miss them. Thus it is important to train every cue since we don t know which cue will be the one that the pilot recognizes. The accident/incident record also shows that crews have often been confused by stall cues they haven t seen in training. This is another reason it is important to train every cue. Confusion in the cockpit in an emergency situation often proceeds a bad outcome. 41

42 There has been a significant reduction in accidents over years since the first simulator training recommendation and our training community has made an important contribution to this record. Keeping in mind that LOC is now the leading cause of aviation fatalities and stall is the leading cause of LOC I expect we will see further significant improvement in the accident rate as a result of the FAA s training requirements that go into effect next March. As mentioned earlier society has a low tolerance for aircraft accidents. Major accidents have contributed to the demise of some companies. So we must continue to strive for further safety improvements. Simulator training will continue to be a primary tool for accident mitigation as new issues are identified in the future. 42

43 Thank you for your attention 43

44 44

45 When looking at accidents over time we typically normalize the data by flight hours to avoid the effect of increased exposure to potential accidents due to the increase in flight hours with time. //////////////////////////////////////////////////////////////////////////////////////// In the 1990 s there were dire predictions that the increase in flying would push the total number of accidents to a high level. Fortunately the decrease in the accident rate was sufficient to nullify these predictions. 45

46 Avoidance, Recognition & Recovery. In my opinion recognition is key. CVR s show crews in stalls are often confused. The recognition funnel list stall cues in a common order. Depending on the aircraft, the stick pusher can be before or after the stall. The height of the funnel represents the number of responses to a given stall cue. Want the crew to respond to first indication of stall, the widest point in the recognition funnel. CLICK We have been training this for years and need to continue but, as we have seen, enough miss this initial cue to cause several accidents CLICK There is a reduction in roll stability prior to the stall which can be a cue to the stall that can be trained. CLICK If the aircraft is equipped with a stick pusher the crew must be trained to recognize and respond to it. The stick pusher dynamic pattern is itself a cue CLICK The stalls that result in crashes almost always have an un-commanded roll. This and the pitch break CLICK are cues to the stall. CLICK Finally, in the stall itself controls are not as effective (and in some cases may reverse) In icing there may be no stick shaker CLICK or stick pusher CLICK Or they may occur after the stall resulting in a stick pusher dynamic pattern. 46

47 The simulation of windshear and microburst provides an early example of the use of FDR data in developing training simulator scenarios. There were a series of windshear accidents from the mid 70 s to the mid 80 s some of which are listed here. 47

48 IN conjunction with this accident, the NTSB issued recommendation A to the FAA for simulator training for stabilized approaches and for avoiding bounced landings. 48

49 The NTSB recommendations for full stall and stick pusher training Public Law refers to were issued with the investigation of the February 12, 2009 Continental Connection flight 3407 crash. (PAUSE) //////////////////////////////////////////////////////// The Safety Board had previously issued recommendations for simulator stall training in association with the December 22, 1996 Airborne Express DC-8 accident near narrows VA and the October 14, 2004 Pinnacle Airlines Bombardier CL-600-2B19 accident in Jefferson City Missouri. 49

50 The NTSB icing conditions training recommendations the law refers to were made with the report on the January 27, 2009, crash of Empire Airlines flight 8284 short of the runway at Lubbock, Texas but referred to several other accidents and incidents. (PAUSE) 50

51 Section 208 of public law , IMPLEMENTATION OF NTSB FLIGHT CREWMEMBER TRAINING RECOMMENDATIONS mandated these new training regulations. ####################################################### These new training regulations were required by Section 208 of Public Law ,. Section 208 is titled IMPLEMENTATION OF NTSB FLIGHT CREWMEMBER TRAINING RECOMMENDATIONS {Pause or read} ////////////////////////// The Airline Safety and Federal Aviation Administration Extension Act of

52 The February 12, 2009, crash of Continental Express flight 3407 in Clarence Center, New York, is another example showing the stick pusher dynamics response and uncommanded roll cues. The aircraft, a Bombardier DHC-8-400, lost control on approach to Buffalo, New York, after a regularly scheduled flight from Newark, New Jersey killing all 49 on board and one person on the ground. //////////////////////////////////////////////////// Though the aircraft had flown through icing conditions during the flight, there was no significant degradation in aerodynamics at the time of the upset. 52

53 Control column for the Colgan turboprop is shown in red and angle of attack is shown in blue. The crew pulled back against the stick pusher entering a stick pusher dynamic pattern we just discussed for the PSA CRJ. The upset continued to ground impact. Converting the vane AOA to fuselage AOA the peak AOA was about 13 deg beyond the stall. ############################################################## The peak angle of attack is 22 vane aoa 43 deg -21 vane AOA 53

54 As with PSA 2386, an abrupt left roll off occurred at the upset. The captain responded as expected by moving the wheel right. The turboprop entered a series of roll oscillations corresponding to the AOA peaks, which were ineffectively opposed by opposite wheel inputs. Such roll dynamics and control wheel ineffectiveness are typical of stall departures and can thus be a great cue to the flight crew that the aircraft is stalled and that the pilot needs to pitch down to recover. The pilots were not required to be exposed to such stall and post stall behavior but will be beginning in 2019 under the new regulations. 54