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Poor Pilot Training Blamed For Virgin Galactic Crash
astroengine writes: SpaceShipTwo co-pilot Michael Alsbury was not properly trained to realize the consequences of unlocking the vehicle's hinged tail section too soon, a mistake that led to his death and the destruction of the ship during a test flight in California last year. Responsibility for the accident falls to SpaceShipTwo manufacturer Scaled Composites, a Mojave, Calif., company owned by Northrop Grumman Corp, the National Transportation Safety Board (NTSB) determined at a webcast hearing on Tuesday (PDF). Poor oversight by the Federal Aviation Administration, which oversees commercial spaceflights in the United States, was also a factor in the accident, the NTSB said.
Chrysler got hit, now Northrop?
If there was a criteria for safe unlocking of the hinged tail section then why wasn't it interlocked until the criteria was satisfied?
A bigger error here is reliance on operator training. It's the least reliable form of ensuring a certain outcome.
I'm no expert on pilot training... far from it.
But if I were learning to fly a spaceship, the first question out of my mouth would be "what all could kill me?"
From the report:
The unlocking of the feather during the transonic region resulted in uncommanded feather operation because the external aerodynamic loads on the feather flap
assembly were greater than the capability of the feather actuators to hold the assembly in the unfeathered position with the locks disengaged.
So maybe the copilot thought that he was preparing for the future feathering operation by unlocking it, and he did not think he was initiating the feathering. Usually an "unlock" switch is only a permissive, and it does not initiate the actual operation.
It's interesting as the unique tail section was actually touted as a "safety feature" by the company. I'm not necessarily saying it can't be the case, but like any feature, even a safety feature (see: exploding airbags), defects or improper use can cause more harm than in it's absence.
The moveable booms are intended to provide a fail-safe mechanism for positioning SpaceShipTwo during the fiery re-entry into the atmosphere. Scaled pilots were well aware of what could happen if they unlocked the feather too late, but training about its early release were ignored, accident investigations found.
It's a bit strange, as it seems like such a fundamental error - not some obscure feature that could be overlooked. What pilot would say to himself "Hey, I know I'm supposed to unlock the tail at time X, but what the hell, why not just do it now?" It seems really strange that they wouldn't have precise procedures for this, since it's such a critical part of the entire design.
It's a hard way to learn a lesson like this.
Irony: Agile development has too much intertia to be abandoned now.
You're an experienced test pilot of a rocket powered ship and you have to be specifically trained to anticipate the effects of slamming on the brakes while traveling at supersonic speed?
I suspect he knew full well the likely outcome but just had a brain fade. Probably what was missing was some kind of hardware interlock so that this couldn't have happened, or else it required both pilots acting at once to enable it.
But if I were learning to fly a spaceship, the first question out of my mouth would be "what all could kill me?"
Almost everything. The question I hear astronauts apparently ask is "what is going to kill me next?" It seems to be about 90%+ of their training. Trying to figure out all the ways they can die and how to mitigate the chances of it actually happening.
Perhaps that's one reason other spacecraft use names that are very specific. I always wondered why they would, say, command the pilot to "disengage the IVVIM (Intra-Vehicular Visual Illumination Mode)" instead of telling them to "turn the light out". If the unlock switch had some god-awful name describing exactly what it did, then maybe the pilot wouldn't have thought "let's unlock this now so we'll be ready".
His ignorance covered the whole earth like a blanket, and there was hardly a hole in it anywhere. - Mark Twain
Comment removed based on user account deletion
If the unlock switch had some god-awful name describing exactly what it did, then maybe the pilot wouldn't have thought "let's unlock this now so we'll be ready".
You mean like "self destruct button"?
It appears that unlocking it just allowed dynamic forces outside the craft to move the feather without being commanded to. The external forces simply overcame the mechanical system that was holding it retracted. A transonic slipstream exerts a hell of a force.
In my view this is a dual failure- a failure by the pilot who (apparently) wasn't trained on when not to unlock the system, and an engineering failure as well- it seems a common-sense thing to lockout potentially (or positively) fatal mis-operations. I'm sure that one or more existing sensors could have been used to prevent unlocking the feather if current conditions could/would cause a catastrophe.
And yes, I'm playing Monday-morning quarterback, and yes, I have the benefit of hindsight, but still- foreseeing the "what could go wrong" possibilities is what good engineering is all about.
Just cruising through this digital world at 33 1/3 rpm...
It appears that deploying the feather was a multi-step operation. The flap covering the feather is unlocked, then the flap is opened, then the feather is deployed. The pilot probably knew that the feather could not be deployed at the speed they were going, but did not know/understand that the flap could not stay closed if unlocked at the speed they were going. Thus, the pilot unlocked the flap, and from there, whatever other latch that made step 2 work broke, the flap opened and the feather deployed on its own.
Maybe the button will be renamed "Remove Restraints Holding Feather Flap Closed During Transonic Region".
Nobody likes to "get behind the airplane". I execute checklists as soon as practical and get things set up for the next phase of flight as soon as possible so we're ready. Exceptions being things in the class of the feather on the ship in question: Flaps, landing gear, mostly airspeed and aerodynamics dependent items.
- A commercial pilot
The old sell them on the trade bit......
The collegiate whim worders vs the barnstormers
And the propeller in the mansion has just been installed.
If the pilot is dead in the airplane crash, then it is the fault of the pilot.
ALWAYS.
You know, the guy who can't defend himself anymore. Put everything on him.
It's not the maker's fault, the designer's fault, the maintenance's fault, the ergonomics' fault, the company's fault, nothing of these.
Always the pilot's.
This is sickening.
I think this is a case of "Blame the dead guy, because he can't defend himself."
I cannot believe that an experienced test pilot, in his right mind, would not have thought through the possible consequences of actuating that lever at a higher speed than it was designed for. I simply cannot believe it. Especially given than history is littered with examples of airplanes not being able to pull out of dives due to control surfaces not responding properly (or ripping off) in supersonic or transonic flow. Alsbury would have been intensely aware of these concepts.
I think that it is more likely that that, if he actually did pull the lever, Alsbury was disoriented or mentally compromised due to some other factor.
I have read the NTSB Executive Summary. As far as I have seen, the full report has not yet been made available.
The claim made by the report is the accident was the result of human error because one of the pilots unlocked the feather prematurely and that the actuators that control movement of the feather were overcome by aerodynamic forces (while going through trans-sonic speeds) and the feather moved. Deploying the feather is a two-step process, unlocking, which one pilot can do, and commanding it to move, which require both pilots to take action.
What I didn't see in the Executive Summary was whether Scaled Composites expected the actuators to be able to control movement of the feather while the vehicle was going trans-sonic.
Just after the accident, there were statements attributed to Scaled that the actuators should have been able to hold the feather in position after it was unlocked. If the people working on and with the vehicle thought this, how could it be human error for the feather to be unlocked when it was?
If it turns out that those earlier statements were incorrect and Scaled knew that it was a bad idea to, say, unlock while going through trans-sonic, then the Executive Summary should have indicated that. I just find it odd that it doesn't say anything about what Scaled had communicated to its pilots about the capabilities of the actuators for the feather once it was unlocked.
He was a highly experienced test pilot. A good test pilot knows to operate the craft as designed and, where not, you do things according to a plan. Test flight has NOTHING to do with taking exciting chances (this isn't Hollywood).
He knew when to unlock this thing but chose to do it earlier. He knew the craft couldn't fly with the tail feathered, yet he chose to unlock this earlier. It should not have feathered, but any vaguely competent engineer knows you don't tempt fate like this. Anyone of the tens of thousands of Scaled Composites fanboys knew this - BEFORE the crash.
No amount of training would have stopped this sort of error. He was trying to be clever.
A pilot with years of experience didn't understand that additional drag would be a problem?
I suspect that it wasn't a training issue, but that the pilot was mistaken and performed the operation in error (we are human), or that he was incompetent.
Imma pushin' that button too.
"So long and thanks for all the fish."
Accusing the test pilot of being untrained and/or incompetent or whining about the risks of interlocks is both irrelevant and stupid. Single point operator failures should be designed out of any system that can cost a human life. That's why there are airbags, seat belts, and crumple zones in cars: because people fuck stuff up. If a new car that costs $15,000 can have these safety features then leaving equivalent features out of a spacecraft is engineering malpractice and possibly criminal negligence.
But no one will be held personally accountable. And whatever safety culture does result won't last. By the time there is a 20% staff turn over it will be completely gone. Why? Because: we're makin money here, if you don't get that then get the fuck out.
Just like in the Challenger disaster, when a technical person objects a manager will say "Take off your engineering hat and put on your management hat." And people will die and nothing will change.
Why is Snark Required?
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All this time, I thought they made false teeth for reptiles!
You must be fun in elevators.
His ignorance covered the whole earth like a blanket, and there was hardly a hole in it anywhere. - Mark Twain
Fun for whom? That is an important question.
KGIII - I blathered too much and the most anyone can post is 50 times per day so AC it is.
He died because the bird broke in two after it's donk decided to go off on it's own all of a sudden. The boomcam footage is irrefutable. Next time make the man can break off safely at any speed and have it's own chute, m'kay?