Sebelum mencedok atau memetik 'ilmu' dari laman ini, anda tidak perlu meminta kebenaran tetapi diingatkan membuat semakan sendiri terlebih dahulu dengan doktor anda atau guru anda sebelum mem'forward'nya kepada orang lain dan memikul tanggungjawab akibatnya.

Pohon doa kesejahteraan dan limpahan rahmat Allah ke atas guru-guru saya dan juga pesakit-pesakit saya yang banyak mengajar saya bidang ini. Segala pujian bagi Allah (peringatan ini untuk diri sendiri) . Mudah-mudahan, taubat saya diterimaNya dan segala dosa saya diampunkanNya serta saya terus dilimpahi rahmatNya. Sekiranya ada kesalahan, pohon dibetulkan, saya terbuka kepada teguran.

Sebarang percubaan berbentuk komen atau soalan bertujuan mengiklankan apa sahaja perniagaan atau blog sendiri tidak akan disiarkan. Blog ini bukanlah untuk iklan menjual barang. Peace.....

Monday, 28 November 2016

(selingan) My Unfounded Fear of Air Turbulence (on board the aircraft)

In the name of Allah, Most Compassionate, Most Merciful.

Mesmerising view near Sepang area, "macam lampu likur!".

(This part is additional to the original post. 29th November)

Special thanks to my cousin big brother Captain Norizan Omar. He replied my whatsapp (asking him a favour - to proofread this post)  after touchdown at KLIA from LHR this late afternoon (it must have been the 1825hrs usual ETA MH flights from London), saying that he'll  do it . A few hours later, done, thankfully with no correction needed. (some additional info on turbulence, but for now, I save it for myself, heheh).

Captain Norizan (or Abang Ijan as we fondly call him) is a true representative of pilots. In fact, he is a true reflection of Homo sapiens (Latin binomial nomenclature for human species which actually means 'wise man'). He is indeed a wise man, always calm and collected too.

He started flying at 18 years old and he is turning 57 soon (the same age Captain 'Sully' was in 2009 when he piloted Flight 1549 for an emergency water landing in the Hudson River), almost 40 years in aviation, with MH all the time (except during his cadet training period in the Philippines).

He now flies A380.

There was this only one time Abang Ijan flew us. My-Clone and I flew on MH A380 once, many years ago, to CDG Paris, (now MH A380 only flies to London and to Jeddah) initially in economy (Y) class and when he found out that we were on his flight, we were invited for seat upgrade to business class (as F class was full). That was our first time on board an A380 with any airlines. Any aircraft, seated upfront, is always a wonderful experience!

Does he fear the weather after all these years of flying?
He has great respect for the weather. 
"We should have great respect for the weather" - the exact words he has been using when telling his co-pilots about his opinion on weather.

I'll insert his picture later....


Many thanks too to my ex-classmate Captain Azwan Sairin for his comments/input on turbulence, the first in our MRSJ Jasin batch to start working (while we were still/struggling with our studies/exams). He was also with MH until a few years ago and now, he is with Etihad Airways.

Academically, you have to be good in Mathematics and English, and have good vision (correctable to 20/20) to be a pilot.

"Keep calm and  carry on  fly the aircraft"


(and now the original post continues)

School holidays have begun (except for SPM candidates). Holiday season is in for non-schoolgoers too. Some of my patients are going for Umrah during these 2 months, while some others are traveling abroad for holidays. In this modern era, the mode of transportation to overseas destinations is commonly by flying. 

Flying ...

Are you afraid of  the dark? circumcision? the dentist? height / roller coaster? flying?

Well, I am ......

No matter how much I had read and reread about air turbulence, I easily became apprehensive when the aeroplane approached the Andaman Sea or the Bengal Bay (when I traveled west). The calming effect of 'knowing the truth about air turbulence' from my past reading somehow dissipated when we flew through these infamous areas of turbulence, especially the Bengal Bay.

I hate turbulence!
I hate turbulence!
I hate turbulence!

I hate turbulence because of the associated palpitations.
I hate turbulence because of the mind-boggling 'is-it-just-turbulence-or-is-it something-else-so-are-we-going-to-crash' questions alike, 
no matter how unreasonable they seem to be.
... and I have no one to blame for that groundless fear and palpitations except for myself.

To me, flying in an area of turbulence is nothing near enjoyable like how the Barney's 'airplane song' sounds. 

This fear of flying has reached another level after I have had children.

The questions of:

"What if I do not survive this crash and the children do?"

"Do they know how to take care of themselves on foreign land, until they reach homeland?"

..... and they were never-ending. Then all the terrible imaginations came in.

Then I started peeping through the window (but I rarely got the window seat, saved it for My-Clone) and changed the channel to watch the 'air-camera' show (but that did not help too, because it was dark outside as we always traveled during night time).  

Turbulence? (Tengok luar jap). Oh! Tak ada apa rupanya (phew!). The aeroplane gracefully cut through the turbulence.  But then again, who can see the wind or air turbulence? A350 is known for its nice tailview. 

Then I checked the FL (flight level). Did the pilot 'climb'? To what FL? To the west : FL is in even numbers (in feet) and vice versa, check the FL again. What was the airspeed? Why wasn't it shown?  Haish! Penat fikir...

Then, I started to supplicate again. On board the aeroplane was one of the places that I became 'more religious', reciting supplications every now and then and turned into a very quiet servant, especially when the turbulence got more severe (must exaggerate the story even though the turbulence I had encountered so far was actually mild or moderate and .....errrrr.... I slept most of the time). 
Every time before I/we travel by air, I will read or watch videos (again?) about aviation :

- the logic behind air turbulence (crystal clear explanation given, but why am I still afraid of turbulence?),

- the importance in knowing what to do/consider (as pilots, not as passengers) when there is change in airspeed and temperature-icing-deicing-etc with higher altitudes,

- watch videos on commercial aircrafts performing during Air Shows. Awesome. Try watch the '787 stall tests' (this was not during air show but during the test flight by its test pilots) or 'near-vertical take-off' (during an air show) videos,

- read about aircraft crash, the news and everything, down to the transcripts and the analysis/report (Why am I into all these?),

- read on a few theories about how aircrafts fly and land and learning a few terms : thrust-drag-lift-weight....... and about how airplanes stall...... and those terrible imaginations reappeared from nowhere.

- the 'language' used eg FL (flight level), ETA (estimated time of arrival), FO (First Officer or co-pilot), charlie bravo (cumulo-nimbus) etc.

- read reviews on people travelling on different types of commercial aeroplanes and the classes/cabins (sambil berangan-angan naik Business class or First class or even the Apartment, ahaha).

- And I watched the movie titled Flightplan. And I wished that I had the knowledge of an aircraft engineer like her (played by Jodie Foster). My-better-half finds it unusual for someone (that is yours truly) who is so-afraid-of-flying but always-look-forward-to-traveling-by-air yet becomes glued to watching TV documentaries about 'Air crash investigations', ironically days before her traveling.

- I have even become an avid (but silent) reader of an online forum discussing on aviation, among the professionals - pilots and engineers (the one important reason why I am being silent is : I am not a professional in aviation so I-better-be-silent).


So, not surprisingly;

This past few weeks, I have been reading about air turbulence . Again.


Let me share with you what I have known about air turbulence, as a 'Google-scholar' (if there is such recognition/award, erk!) and as a layperson/passenger with no experience in flying an airplane (strike  off the word 'no' if you include computer games or flight simulator at the game centre).


What have I  successfully  learnt about air turbulence?

The facts are :

1. Air turbulence does not cause the aeroplane to crash, not during cruising. Turbulence is usually mild/light or  moderate. Like the Captains always describes in layman's term, "bumpy".  Turbulence happens when there are changes in air speed and (not 'or') direction. 

If you consider yourself as a good driver who can negotiate bumpy or challenging roads, we must acknowledge that pilots are good pilots too. Pilots do not create/cause the bumpy ride (turbulence). They have to depend on the warnings sent from aircraft flying ahead at the same altitude reporting to the nearest air traffic control. Also, aircrafts have weather radar which can detect turbulence related to clouds (remember the term cumulous-nimbus cloud we learned at school?). This is very useful especially during summer or monsoon season when there are more clouds (I'll try to explain later).

So, when turbulence is encountered, pilots may find ways to avoid moderate or severe turbulence  (depending on the colours on the radar); usually by either climbing or sometimes going to a lower altitude, or navigating around it, but they cannot 100% predict or prevent encountering other types of turbulences. 

2. Modern and current commercial aeroplanes are built with durability to withstand even severe air turbulence. Turbulence usually does not affect the structural integrity of an aircraft. The wings are flexible and can bend to endure the strong, changing winds. Forget about the Flight 55 crash in 1968 and BOAC Flight 911 crash in 1966, these 2 were 50 years ago and aviation technology has come a long way.  So, I should not be worried when I watch the wings flexing up and down (imagine if the wings are rigid, they can easily break). The wings can take bending up to 60 degrees. Boeing experimented its 777 wing which bent upwards for  24 feet at the tip before it broke. That 24 feet is at least about 2-storey-house high as most houses have 8 feet floor-to-ceiling height, only some have 12 feet ceiling height.

I am not sure what mountain that is. I doubt that it is Mount Fuji, but we saw this during  KUL-NRT flight. Mount Fuji..... BOAC Flight 911......

3. When I felt as if the aeroplane was 'brought down' and I called it 'air pocket', that fear/description was (and is still) baseless. The aeroplane was not going down to crash. There is actually no such thing as 'air pocket' or vacuum that can 'pull' or 'vacuum down' the airplane into the 'Bermuda-Triangle-like' mysterious area. Those are actually the 'up-drafts' and 'down-drafts' air motions causing vertical excursion of the air. Also, when it happens, although you feel that the aeroplane goes down by tens or hundreds of feet, it is actually pushed down much less than that. The airlift of the aeroplane is always much bigger that the power of the 'down-drafts'. There is also this new technology called 'Turbulence Suppression Technology' in some aircraft models. Try fly B787 - the Dreamliner, which has not just side to side suppression but also up and down suppression. It has this vertical gust suppression system which minimizes the stomach-churning sensation when the plane suddenly drops midair.

We had flown on the Dreamliner once or twice. IMHO, on board B787 was the best experience compared to A350, A380 and the rest of both Boeing and Airbus fleets and it felt so good, it is a little wonder why the promotional tickets (the type of tickets that we usually bought) are always quickly sold out as compared to other aircrafts for that day. Ticket price is always factor number one for us in choosing flight. Aircraft type is factor number two although admittedly reason number two is always the truest reason, so, at any given opportunity, we would always look for the type of aircraft when doing flight booking
I don't have to remember by heart about the types of turbulence or what causes turbulence :

1 - Convectively Induced Turbulence - weather patterns caused by thunderstorms or the rain/sun as a result from heat being released by condensed water vapours from the clouds causing 'updrafts' or 'downdrafts'. Guided by the airborne weather radar which can detect up to 650nm ahead (and by vision - this is the advantage of flying during daytime), pilots would try to avoid the colour-coded areas of red and yellow, they start manually deviating the aircraft from the intended tract when the area is about 40nm ahead. That 74km (40nm) is further than Ayer Keroh-Seremban exit-exit distance (only 70.5km) on PLUS highway.

By the way, nm is not nano-meter but nautical mile (a unit of measurement used in air or sea travel). 1 nm is more than 1 mile. 650 nm is close to 1200 km. In IVF/Embryoloy, the unit used is always micro-meter.

2 - or when air flows over mountains creating mountain range turbulence which can extend hundreds of kilometres away and still affecting us,

3 - or clear air turbulence (CAT) from jet streams when the colder arctic air meets warm air from the Equator causing sudden/rapid changes of air speed (wind shears),

4 - or wake turbulence caused by the aircraft in front of us (now I know why we have to wait for sometime after the aircraft in front of us takes off or lands or stay at a distance behind an aircraft when cruising. I also know that apparently there is this reporting system on wake turbulence as this prompts investigations by the Civil Aviation Authority). By the way, have you seen the pictures of patterns made by the wake turbulence? Beautiful 'artistic' patterns. 

Mountain wave, CAT and wake turbulences cannot be predicted using that weather radar.

Whatever type of turbulence it is,

I just have to understand that air turbulence is harmless to the aircraft and to me as well, but at the same time, I have to be aware that turbulence (especially clear air turbulence) can happen anytime and can suddenly get worse anytime.

So, I must always fasten my seatbelt even though the seatbelt sign is not on.
And I must also ensure that my things (usually my laptop and handbag) are secured under the seat in front of me or I hold them etc so that they get thrown and won't hit me when turbulence suddenly becomes more severe. Then I can rest assured that I am safe from physical injury that may be caused by turbulence. 


So, ladies and gentlemen, boys and girls;

1. We passengers must always listen and follow the instructions when we are asked to;

"Ladies and gentlemen, we are about to enter an area of turbulence. Please sit down and fasten your seatbelt".

Try to hold our bladder or bowel if we can. We do not want the possibility of dirty or soiled things thrown onto us in addition to the injury we might suffer from (no seatbelt kan?) especially if the toilet is in the tail of the aircraft (where turbulence is usually most felt).. 

Do not get up and open the overhead storage bin. Not during this time. You do not want the bags to be thrown out of the storage bin injuring you or other pannsengers. The cabin crew can still serve our food and walk about because they are used to do that during light turbulence. We are not cabin crew, we might easily fall or get injured or spill hot drinks onto us etc.

Don't wait until when the cabin member informs;

"..... we will stop serving hot drinks....."

or when the Captain gives firm instruction;

"Cabin crew, please be seated." (add a puctuation mark if you wish to).

Be seated and fasten your seatbelt.
Whenever the seatbelt sign is on, fasten your seatbelt. Don't get off your seat.
Whenever the seatbelt is not on and you are seated (or when you want to go to sleep), fasten your seatbelt too.
Remember, CAT can happen anytime. It is unpredictable and can be chaotic. 

2. Trust that the pilots are well experienced with thousands of hours of aircraft flying experience (we also have thousands of kilometres flying experience, but only as passengers and not in hours, ehehe!).  Watch the video (google Youtube : 'landing gear hammered in touchdown turbulence') on how skillfully the pilot landed the airplane amid turbulence with crosswinds gusting at 40 mph (Yes, at 40 mph crosswinds). Watch the videos posted on Youtube, recorded from inside the cockpit. For example, 'The Pilot Channel'. They are professionals : confident, calm and skillful/experienced.

Furthermore, there is a team of 2-3 pilots (maybe more) inside that flightdeck (cockpit) and the Captain is there supervising/checking what his FO (First Officer) is doing (unless he went to toilet - as what happened in Germanwings Flight 9525 leaving the cockpit locked from the inside by his suicidal FO, but this was not related to turbulence). Just like the in the OT (Operation Theater), there is always a senior consultant surgeon on standby and will supervise or assist or take over the control from the junior surgeon if any unforeseen problem occurs and help is needed. Like doctors too, unfortunately mistakes sometimes (unintentionally) happened, these should be learning processes and therefore we must learn from those mistakes done by us or by others so that they do not recur and we improvise where necessary. Therefore, I must trust that in avoidance of the turbulence or when mechanical system malfunction happens, the pilots would not repeat the same mistake of making a steep climb to a higher altitude that can cause stalling or misunderstanding the Captain's  instruction to "Down, down" or "Climb, climb, climb" or "Pull down" or "Push down" (which refers to bringing down the nose), which led to the tragic unrecovered-stalling and crash of Air France Flight 447 in June 2009 and Air Asia Flight 8501 barely a year ago in December 2015.

The above paragraph makes me realise that the same fear/hope is present with my patients.

My patients are understandably concerned if I am knowledgable or competent enough in that field/disease and give them the best treatment they should receive (not the best treatment that I can offer within my capacity, but the best treatment any patient in that condition should receive). 
Back to my fear or air turbulence;

I may want to consider getting the seat over the wings (because it is the centre of its gravity thus offers more stability) but the view is partially obstructed (sigh). You win some (the least turbulence felt), you lose some (the view).

On our most recent flight (KUL-BKK) last weekend for an IVF meeting, we chose seat number 12 (outbound) and 14 (inbound), over the wings. I only felt light turbulence (but still not free from fear).

and ...

I look forward to progressively better technologies in the future to forecast turbulence more accurately, detect it better, report it better, totally avoiding it or absorb or suppress/dampen it.

at least predicting it so that I am more prepared. I don't like surprises and turbulence can happen suddenly without warning. The same when watching movies, to me, it is much more exciting when we know the plot (so I would always google about the plot before watching it). 

and ...

I shall fasten my seatbelt all the time on board the airplane (except when it is OK to get off of my seat for whatever reason eg when the need arises for me to go to toilet).

and ...

I shall try to remain calm and pray that the turbulence does not become more severe and quickly disappear (although I know that severe turbulence lasts for only seconds, the milder ones usually last longer). 

and on top of those, I shall ...

- remember that that aeroplane had been tested again and again before it was 'certified' to fly. I read that the test pilots ran a battery of tests equivalent to more than 1000 flying hours on an aircraft. Wah!

- pray harder that the airplane is well-maintained and checked in good function. It is good to know that airplanes are inspected constantly, after every flight.

- pray harder too that the pilots and all others on board are of sound mental health.  

- pray harder that there is no one on board with ill intention, be it the passenger or the cabin crew.

- have faith that my supllication is heard and granted.

" In the name of Allah, with Whose Name, nothing on the earth or in the sky can cause harm, and He is the All-Hearing, the All-Knowing "

- have faith that the pilots' supplications are also heard and granted.

" Glory to Him, who has brought this (vehicle) under our control, though we were unable to control it (ourselves), and indeed, to our Lord we will surely return" (Quran 43:13)

and ...

I wish that the Captain would; from time to time; say something reassuring just to allay my fear (actually I was hoping for more frequent than the usual 2 or 3 announcements : around the take-off, near landing and once or never at cruise level, but then I should not distract them from flying us, right?) . Somehow on board the aircraft, words from the Captain are nerve-calming and reassuring like words of a mother talking to her baby, more so if I hear the Captain himself recites the supplication before take-off. Be a tour guide by telling us 'what interesting sceneries can be seen from the right/left' window (erk....OK ke permintaan khas saya ni?). Perhaps make jokes or poetry ('pantun') too? Have you watched the video on an AirAsia Captain and his poetry (pantun) which has gone viral in social media? People nicknamed him Kapten Pantun (his name is Captain Shahirul 'Alim Aminudin or better known as Captain Shaha). I encountered the same jovial greetings from a Captain during our EK flight from Dubai to Hamburg early this year. Somehow, that brought relief to me (probably because some of the time was spent on thinking highly about the pilot rather than worrying about turbulence).
For the medical students;

Remember the Virchow's triad in DVT (Deep Vein Thrombosis).
Remember the 3 categories that can contribute to thrombosis (imagine the blood vessel as a river with sediments and water flowing) :

1. Hyper-coagulability
2. Hemodynamic changes (stasis/turbulence)
3. Endothelial injury/disturbance

Learn about superficial phlebitis and DVT.
Remember the risk factors for DVT (answer based on the above categories)

and the fact that DVT may lead to Pulmonary Embolism.
Although the incidence of Pulmonary Embolism is very low, when it happens, it can be fatal.
So, learn about the symptoms, the signs and the management of Pulmonary Embolism.
Kepada yang ingin 'menaiki kapalterbang';

Dari sudut perubatan, ada risiko pembentukan DVT akibat 2 daripada 3 faktor-faktor yang dinyatakan di atas :

1. Hyper-coagulability (darah mudah membeku)

- Pengaruh hormon estrogen dan progesteron yang meningkat sewaktu kehamilan menyebabkan darah 'lebih pekat' dan ketulan darah (thrombus) lebih mudah terbentuk di dinding saurdarah (vena).

2. Stasis (aliran darah tersekat/berhenti)

- Stasis boleh disebabkan oleh sama ada : darah pekat (akibat dehidrasi) ataupun aliran darah tersekat (kurang pergerakan otot terutamanya otot betis/kaki atau posisi duduk tertentu yang menekan aliran darah)

Hmm... ada betulnya mengapa orang tua-tua tak bagi wanita hamil malas bergerak (bayangkan air sungai tak tidak mengalir, pemendakan mudah berlaku).

- Cuma yang kurang betul adalah berpantang minum (dehidrasi memekatkan darah dan boleh menyebabkan pembentukan darah beku).

- Begitu juga dengan berurut. Ia boleh menyebabkan thrombus pada seseorang yang sedang mempunyai DVT terpisah daripada dinding perlekatan salurvena dan dialirkan ke paru-paru sehingga menyebabkan pulmonary embolism. Lebih-lebih lagi sekiranya dia baru sahaja menjalani pembedahan major termasuklah pembedahan Caesarean.
Maka; saya selalunya menasihatkan pesakit-pesakit saya;

Tak kiralah sama ada anda hamil ataupun tidak.

Tak kiralah sama ada anda baru 2 bulan hamil ataupun telah sarat hamil ataupun baru sahaja bersalin (masih dalam tempoh 6 minggu selepas bersalin). Risiko DVT dalam ketiga-tiga peringkat masih ada dan memang lebih tinggi berbanding jika anda tidak hamil.

Cuma sekiranya anda hamil dan menaiki penerbangan 'ultra-long' dan ditimpa komplikasi eg pendarahan, keguguran, kontraksi bersalin, bersalin etc, kemungkinan peralatan di dalam kapalterbang tidak atau kurang mencukupi untuk menanganinya, Malah, kemungkinan tiada penumpang yang mempunyai pengalaman perubatan untuk membantu.

Juga, apabila anda sarat hamil, 'saiz perut' yang besar menjadi penghalang kepada kelancaran aliran darah dari kaki kembali ke jantung, lebih-lebih lagi dengan posisi yang sama untuk masa yang panjang eg duduk di dalam kenderaan sama ada kapalterbang, kereta etc. Stasis aliran darah ini boleh menyebabkan pembentukan thrombus (DVT).


Sentiasa jaga hidrasi anda dengan minum air mencukupi, bukan hanya terhad kepada hari anda 'naik kapalterbang' sahaja.

Amalkan senaman kaki (ada pada brosur di poket kerusi di hadapan anda) untuk mengekalkan 'blood circulation' yang bagus. Bersenam itu elok untuk kesihatan (peringatan kepada diri sendiri).

Anda mungkin ingin memakai stokin khas yang lebih dikenali sebagai 'TED socks' (Thrombo Embolic Deterrent) yang sedia dijual di farmasi.

dan .....

Pastikan barang-barang anda disimpan di dalam tempat penyimpan barang di atas.

dan ...

Pakailah talipinggang tempat duduk dengan kemas.

dan ...

Berdoalah dengan penuh pengharapan dan yakin dengan doa tersebut : agar semua selamat sampai  ke destinasi..
And while the aircraft designers, aeronautical engineers, test pilots, commercial pilots, air traffic control etc continue providing us a safe flight, I leave the task for my dear Arief (he is reading Physics, in his first year) and other physicists to solve the challenge of finding the mathematical equation of turbulence. I have just known that there is this unit called Reynolds number (Re) when concerning fluid flow but how do we quantify turbulence? As the Nobel Laureate and Theoretical Physicist Richard Peynman once said ; 

"Turbulence is the most important unsolved problem of classical Physics". 

Turbulence happens many times in our daily life. I can create turbulence when stirring the egg in different directions and speed.
and with my family, I'll continue playing this simple game of checking which way the airplane is going. 

When we are in a car ride and we see an airplane flying, I would ask her ;

"Which way is the plane going? Towards us or away from us?"

You can simply know the answer by looking at the red-green light on its wings. Red light is on the left (port side) wing and the green light on its right. The same rule with the navy/maritime. 

By identifying the colour of light on the wings, you can tell whether the plane is flying towards you or away from you. 

A simple game. A straight answer. But still exciting.


Have faith when the Captain tells us;

"....... Just sit back, relax and enjoy this flight."

... and this  chicken  doctor wishes you;

"Happy flying, 'uols' !"

Fret no more, flying is by far the safest mode of travel.
(actually, this reassurance is more for me. Why do you think this post is ultra-long?)

'My unfounded fear of turbulence' is now rephrased to 'I still cannot stop hating air turbulence'.

Psssssst... :  I hate amusement rides too.
I shall not fear turbulence.
I shall not fear turbulence.
I shall not fear turbulence.

All praise is due to Allah.

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