Aircraft Accidents and Surveillance Part One

My wife and her class of high school students watched a documentary about the food processing business. Not to elaborate on the video’s content, but one point was that the most … disturbing violations occurred at night when government overseers were off duty.
The truth is that most government surveillance is conducted in daytime; reason being that in government service overtime is frowned upon and a majority of extended surveillance trips are limited by budgetary concerns. In a continually expanding aviation industry, the FAA struggles with these restrictions.
The average response might be, “cry me a river”; the FAA needs to do their job whatever the issues; these airlines won’t oversee themselves. And in some cases, perhaps that’s true. For instance, a regional airline makes numerous short two hour hops between close points, so a trip out and back can be accomplished within a work period. Line maintenance is accomplished all the time; plenty of opportunity to stand over a mechanic’s shoulder in any given airport.
However, the larger worldwide operators require a more creative planning process. A Boeing 777 can fly from San Francisco to Taiwan in 14 hours. Most heavy maintenance takes place at night. What is an FAA inspector to do?
The air operators know about these constraints; it is human nature to ‘play while the cat is away’. So how does this affect aircraft accidents? When you consider that there is, maybe, one FAA inspector for every 100 mechanics OR pilots OR planners OR flight attendants of each airline; that these 100 are scattered through a twenty-four hour period across the face of the Earth and sky every … single … second of the day, how is proper surveillance conducted?
Over the next few weeks let’s look at the different modes …

Aircraft Accidents and Reality

The International Federation of Air Line Pilots Associations (IFALPA) wrote an article on April 13, 2015, in Global Travel Industry News about the Germanwings flight 4U9525 accident:
In the article the IFALPA reps voice concern with the French authorities’ non-compliance with the provisions of ICAO Annex 13, the International Standards for Accident Investigation. They are 100% correct; this investigation has been a sham in as far as the guidelines of ICAO Annex 13 have not been followed.
Chapter 3, subchapter 3.1 states: “The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability ….” It further states in Appendix: Format of the Final Report (Doc 6920) that a Factual report must be written; that all information pertaining to the crew is factual. It makes no mention of reporting any crew member’s ALLEGED mental, physical or emotional health.
I have been mentioning in previous Blog entries on my website that the accident should have been turned over to Law Enforcement immediately when question of the cause went outside normal accident circumstances (allegedly intentional), especially as the unprofessional manner continued to become more and more destructive to the crew, the victims and ultimately to the victims’ surviving family and friends. Unfortunately we will find out the mistakes of the improper handling of this tragedy only when the fix can no longer help or will cause further mishap.

Aircraft Accidents and Integrity

Last week I wrote about the missteps being taken by the BEA in the Germanwings accident; I stated that the lack of incontrovertible evidence did not support the allegations being thrown around about the First Officer, Andreas Lubitz and his actions. Since, as of April 8, 2015, the investigation has failed to produce anything of substance in the way of proof, I don’t yet back off the position.
The Bureau d’Enquêtes et d’Analyses, or the BEA, is, according to their website, “the French authority responsible for safety investigations into accidents or incidents in civil aviation” ( In other words, they are the French version of the NTSB. I worked with the BEA before or, I should say, they worked for me; in November 2001, representatives of the BEA assisted the NTSB in the accident investigation of American Airlines flight 587. They were there because an Airbus A300 crashed and they had an interest in the investigation. Their representative was a professional who worked diligently in all disciplines of the investigation.
However, the BEA and the NTSB are not criminal investigation organizations.
What does this mean? In July 1996, in September 2001, and in November 2001; the Federal Bureau of Investigation initially assumed control of the accidents TWA 800, the four 9/11 terrorist attacks and American 587, respectively. Until TWA 800 and American 587 were determined not to be intentional attacks, the FBI controlled the investigation. In Shanksville, PA, at the Pentagon, and Ground Zero, as an NTSB investigator, I was under the authority of the FBI to assist them with the investigation, even though my aviation experience was greater, the FBI was investigating a criminal activity: the intentional destruction of a federally registered vehicle used to kill innocent victims.
I had seen this FBI authority before when I worked for Federal Express in Memphis, TN. In April 1994, an employee of FedEx attempted to hijack a DC10-30 and fly it into the main sorting facility. His efforts were foiled by the brave flight crew, who he tried to kill. Again, the FBI prosecuted the ex-hijacker for trying to seize control of a federally registered vehicle.
The fact that Germany’s Bundeskriminalamt (BKA) and/or France’s Direction Générale de la Sécurité Intérieur (DGSI) are not the investigatory bodies in charge of the Germanwings 9525 crash is foolishness on a grand scale. The BEA is not trained to control evidence of this nature; their irresponsible parading of crucial information – that can be described as ambiguous, at best – through the media makes the Malaysian Airlines MH370 accident investigation – an investigation reminiscent of a Marx Brothers movie – look professional by comparison.
The consequences of this mistake are huge; the ripple effects will last for years. And the victims’ families will be reliving these days for years to come.

Aircraft Accidents and Probable Cause

Having worked as an NTSB investigator, a process is followed when investigating a major aircraft accident. There are two main reports written by each specialty lead – a specialty is a subject, e.g. maintenance, flight crew, ATC, etc. These two reports are the Factual and the Analysis reports. They are fed into the final report, called the Blue Book, the culmination of all the different specialties. It is in the Blue Book that ALL the Probable Causes are presented.
Despite advances in aviation tracking, there is always unconfirmed information that is referred to in any final accident report. The Probable Cause means that with all the evidence collected and testing performed, the NTSB’s specialists’ best analyses leads to certain conclusions. But let me be clear: Probable Causes are based on analysis taken from the FACTS … period.
What we’ve witnessed in the wake of the March 24th tragic crash of Germanwings flight 9525 is the unleashing of the irresponsible. These myopic trips from the inexperienced are Sharpton-esque in their misdirection and boldfaced ignorance; it serves one purpose: creating turmoil. Even the fact that the cockpit voice recorder information, recklessly provided to the media, is a violation of the control of evidence in a professional investigation. By contrast, an NTSB investigation is a demonstration in professional actions and empathy; actions because they follow the rules; empathy because they care for the victims’ family members’ pain.
The media justifies their folly by employing ‘aviation specialists’ to push their conjectures. Many of these ‘specialists’ are not aviators; they are attention seeking bureaucrats whose only attachment to aviation is in title, one not generated from a knowledge of aviation but political affiliation.
I’ve followed social and news media since the accident. 99% of the ‘facts’ reported would NOT be included in an NTSB Factual report because they are not factual by definition. The media reports with words, e.g. ‘likely’, ‘could’ or ‘might’; ambiguous accusations with a buckshot effect: scattered and deadly.
Where are the truths, the moral convictions, and the supporting evidence? They don’t exist. The media provides speculation, not because it holds up, but because it stirs up. And those fascinated by the tragedy welcome this line of storytelling because they don’t know better.
Let’s re-examine the speculation, but take it a step further because these ‘facts’ would never end up in an NTSB Factual report as unquestionable information:
• The first officer did not open the cockpit door despite the Captain’s pounding on said door. What if Andreas Lubitz COULD NOT open the door? Did he verbally refuse to? Did he inform ATC he didn’t want to? Did he make an announcement? Did he yell to a deity? The problem with this scenario: no one can prove he wasn’t incapacitated. Only breathing was heard, which one can do following, e.g. a stroke, heart attack, etc.; alive, incapacitated, but still breathing.
• No suicide notes were found. Where’s the evidence? Depression in 2009? That was six years ago. What health care professional made the diagnosis? Did he actually open an artery or was he simply expressing regret at a decision or the loss of a loved one?
• He dismissed his sick leave note. What was the sick note for? A cold? Migraines? Sore ankle? Any and all these reasons would cause a pilot to request time off, unless they were feeling better on the day of flight.
• The plane descended steadily to the ground. Think about this one; if he was suicidal, why not just nose it over; why the drama? Why take the chance the captain would get in? Why not shut down the engines?
• After becoming incapacitated, could the autopilot have been disabled, like in Eastern Airlines flight 401? If the autopilot was accidentally turned off the A320 could perform a slow descent to the ground.
If this investigation turns a corner, the media will drag the victims’ families through it all over again; their suffering will be renewed, like salt in a wound, they will live through every … unnecessary … minute … again. And the media will sell more papers, burn more air time, flash photos of grief stricken people. And they will claim, Absence of Malice. As an investigator, I met and have spoken with many victims’ family members: parents, siblings, spouses. They want facts, not speculation; they want the right fixes that honor their loved ones, not band-aids; they want closure, not repetition.
P.T. Barnum supposedly said, “There’s a sucker born every minute.” Are we being played as suckers? This investigation has taken on the frantic speed of a luge race, where each turn is dictated by a paranoid media, intent on controlling the conversation and ignorant of the subject matter at hand. When do we step back? When is someone going to manage this investigation; someone who will not leak out every dubious morsel to the media? Is it beneficial that every passenger now stares suspiciously at a pilot, doubting his or her safety when the door to the cockpit is closed?
Let’s assume Lubitz did kill the passengers. What’s the fix every ‘aviation expert’ is touting? Increased psychological testing of every aviator. My thirty-plus years in the aviation industry and accident investigation tell me how it will play out. A therapist will be hired, one who the union and airline can agree on; one who sits in his office biting his nails while staring at his correspondence school diploma. One who questions a pilot because she hates her place in the seniority list. One who recommends unpaid leave for a mechanic who forgot his wedding anniversary. Or one who retests an air traffic controller who likes to play with model trains.
Now let’s assume Lubitz was incapacitated and the accident was just that … an accident. Now we have a bigger problem. We were so busy demonizing Lubitz, we missed the real cause; the real flaw escaped our notice. And it will only be a matter of time before it happens again.
It comes down to FACTS people. At this moment there are only two possible Probable Causes: Lubitz would not open the door, or Lubitz could not open the door.
Where will the facts point?