I once wrote an article about the dangers of heavy reliance on technologies. I don’t usually read the criticisms of articles I write; my mentor, Bill O’Brien told me not to. I also NEVER EVER respond; it’s a surefire way to get into arguments that are endless and pointless. But a responder wrote a comment that was heavy on ‘you-don’t-know-what-you’re-talking-about’ and with a good dose of the ‘technology-is-the-best-thing-since-sliced-bread’ lecture.
I don’t know why I did it; I immediately regretted it from the moment I hit SEND, but I wrote back, “Tell that to Sully.” Later that day the commenter wrote another page long response ending with “… and he had a RAT.”
I didn’t write back, convinced the commenter heard the term ‘RAT’ somewhere and used it as a weapon to make his/her point.
The acronym RAT stands for Ram Air Turbine; Douglas employed a similar device called an Air Driven Generator (ADG). It is used to power systems on a crippled airliner during emergencies. The RAT/ADG deploys from the fuselage into the airstream, its turbine or propeller catching the rushing air to turn it. The RAT or ADG turn this air energy into mechanical energy that powers the hydraulics or electronics of the aircraft. I had been trained on the A300 so I know Airbus employed them. However, I didn’t read the USAir 1549 report or see the movie ‘Sully’, so I’m not sure if he deployed the RAT in flight.
But I can think of reasons he would or wouldn’t.
Would: he would have gained hydraulic pressure for maneuvering. The RAT enables either hydraulics or electronics, but not both. The hydraulics would have enabled them to steer easier. They would have been able to use standby gauges – of the analog type, not digital – to track the aircraft’s rate of descent, altitude, attitude and direction.
Would not: the aircraft at that moment with no engines becomes a flying rock; it has a glide ratio, but without the altitude needed, the glide ratio only works best with the wind helping. To deploy the RAT creates drag. The fully loaded aircraft (full fuel, passengers and luggage) needed two things to stay aloft: altitude and speed, otherwise it gives out to gravity and drag. Adding an air driven unit into the airstream adds drag. And then there’s the question of the aircraft moving fast enough to make the RAT usable; it was a glider with a slow speed, perhaps not sufficient to turn the RAT enough to benefit from it.
And then the question of what happens when they hit the water. The RAT would surely break free; it could puncture the fuselage, decreasing the precious time to evacuate considerably. The RAT could also have become a missile propelled back by the airliner’s forward momentum to pierce the fuselage and bounce around the cabin. And yes, it has happened where something as soft a seagull broke through the metal and took out a pilot.
I’m going to have to find time to read that report.
First things first, let me make one thing abundantly clear: the FAA, like the NTSB and all agencies, is a bureaucracy. This means that all operations are run by presidential appointed party officials. Their experience in the appointed Department may be substantial or may be non-existent. They make promises that are unrealistic and often unobtainable; these assurances may be dangerous or devastating, according to the Department.
That being said, the inspectors, investigators and specialists that do the job of the Agency are usually experienced in the FAA. Whether they come from a GA background or with an air carrier history, the FAA inspector, for the most part, is experienced to do the job.
The same can’t be said for management, who have, at times, been placed in slots their experience doesn’t support. They then try to manage a division that goes against everything they understand.
But how does the FAA fit into the accident investigation field? The FAA inspectors I’ve had on my NTSB investigatory teams are professional; I’ve never run into one that didn’t understand the industry we were investigating. Sometimes, according to where the aircraft crashes, the inspector assigned to the various investigatory groups doesn’t have the basic knowledge of the aircraft or airline. This is rare because the FAA has a vested interest in the final report.
I worked an accident one time where the evidence pointed to an FAA inspector who fell behind the curve, unaware of the games the air operator was playing. The FAA has to run interference in cases like this; the investigation wasn’t corrupted in any way, but the inspector was prevented from any further self-inflicted damage.
And here is an irony: the NTSB management types reveled in ridiculing the FAA in the media and in their reports at every opportunity. The irony was that, as I pointed out earlier, the NTSB’s experience was not near the level of the FAA. That is not a defense of the FAA, but one can understand their efforts to keep the Board at bay.
The last two weeks I’ve been talking about the NTSB and its experience handling major aviation accidents. I introduced what happens when the industry takes on the Board investigators during the course of an investigation; how important information can be hidden from the Board in broad daylight. But what about the FAA?
In any aviation accident investigation, the FAA plays a very important part; they are the government liaison between the industry and the Board. Often when the NTSB is overwhelmed, the FAA handles General Aviation accidents. But during the major accidents, the FAA serves a sort of advisory role, keeping the NTSB investigators unschooled in the industry from catching their toes on the industry’s sleight-of-hand tricks.
The FAA is directly involved with the industry; they serve as the surveillance arm of the government, so they are more involved with the day-to-day movements of the industry. Entire offices of FAA inspectors ‘rub elbows’ everyday with certificate holders of every type, e.g. airlines, repair stations, to the point that the inspectors become very knowledgeable about how these certificate holders operate, what they can hide and what they can’t. That’s what accident investigators need – a thoroughly face-to-face relationship with the airline – to better understand where the problems lie.
That doesn’t mean that the FAA is the best entity to run an accident investigation; they are, after all, one of those being investigated. Airliners very rarely crash near their base and certificate management office; inspectors assisting on accidents may not be assigned from the airline’s certificate office and may not know the intricacies of the airline. The only NTSB investigator that would guarantee an FAA inspector from the management office would be the aircraft maintenance investigator, and, at the time, I was the one best equipped with airline experience.
But in the end, the FAA has a better working knowledge of the industry; they are more valuable to the NTSB than vice versa. Next week we’ll look at the FAA.
Last week I spoke about the NTSB’s investigators/engineers, how they lacked the general knowledge of industry, the subject of many major investigations. I received substantial pushback from many, including two guys I worked with at the Board, who I’ll call John (a Survival Factors engineer) and Paul (a Systems engineer). Paul is a very talented systems engineer who did work for the airlines, thus is quite adept at his job with a healthy understanding of how the industry operates. John has been handling accidents for many years; he also suffers from a condition identified in Scott Adams’s comic strip Dilbert as the Knack, an uncanny ability to see a bigger picture and know when the wool is being pulled.
Both men are the exception, not the rule. Both men also demonstrate a dislike for attention and bureaucracy. I’ll explain shortly.
The point I made about having a lack of industry experience is in relation to knowing more than the other people you lead. Every NTSB investigator leads a group, whether it is Systems, Air Traffic or Operations, they must lead people from the FAA, the air operator, representatives from the airframe and engine manufacturer as well as union reps. These people have an incredible advantage in that they know the equipment, the people, the environment and the players far better than the NTSB investigator in their group. It is here that the NTSB investigator who lacks industry experience loses control of the group; the reps will understandably protect their paycheck provider; if the NTSB investigator doesn’t know where he or she is being misled, so much the better. The NTSB group leader will be unable to control their group and, thus, the outcome of the investigation. That part of the investigation will be corrupted and consequently wrong.
Which leads us back to Paul and John who refuse to get caught up in the spotlighted world of Investigator-in-Charge, or IIC. These are the inexperienced engineers who ‘grow-up’ to be IICs. This is a position many investigators aspire to, it leads to management and the title of ‘expert’. This is why I made the point that “inexperienced-in-industry” engineers will eventually rise to the level of IIC; he/she will rub elbows with the Board Members. Board Members are the face of the NTSB, the camera icon and the one who enters into every Americans’ living room and smart phone. They repeat the analysis provided by, none other than, the IIC.
And what if the IIC has no idea what’s going on in the investigation due to their inexperience? The investigation is flawed. Furthermore, the peace of mind the families demand will be nothing; the learning from past accidents will be tarnished by the inexperienced IIC’s unfamiliarity with what happened beyond the obvious crash scene. If his/her group leading NTSB investigators are inexperienced, then who is there to rely on?
Inexperienced leaders, flawed analysis, and nothing to catch it; the accident investigation is doomed even before the smoke settles at the scene. As one IIC said during an all-hands meeting, “Flight deck … is that the cockpit?”
Recently I attended a class of aviators; the topic turned to how the NTSB’s aviation division’s accident findings usually gravitate towards, e.g. Pilot Error, FAA Oversight, Operator Error. Since the days I started with the NTSB – and since – that has been the common interpretation, even from people who work for the NTSB.
These feelings aren’t totally off the mark. Let me explain.
Above all, the NTSB is a collection of aviation specialists, mostly engineers. The average background for said engineers is in design or repair – mostly at the manufacturing level – and not in the industry; this is very important. Reason: the majority of major accidents take place in the industry. This means that NTSB investigators looking into topics like Structures, Powerplants, Systems and Survival Factors have no first-hand understanding of what the airline does.
Many may think I’m being cynical or shooting the NTSB down. I’m not, I’m just relaying what is a reality; a vast majority of NTSB investigators never worked in the aviation industry environment, yet these investigators are responsible for determining where mistakes are made in the General Aviation and Air Carrier industries. Bottom line: the NTSB investigates a majority of accidents that deal with problems the NTSB as a collective doesn’t understand.
The second problem that anyone who has worked for a government bureaucracy, served for the military, or has even been exposed to the circus of this Presidential Election would understand is that Bureaucracy and Efficiency do not mix; they are polar opposites, like oil and water.
In my first novel I tried to explain the dichotomy of civil service and effectiveness. I dealt with it for many years; the twenty years prior that I worked for the airlines was a paradise compared with the minefield that is the government. My son, having spent ten years in the Army now understands the dangers of trusting one’s future to an Administration’s whims.
I’m not suggesting the NTSB is corrupt; it’s ironic that they are probably too inexperienced and camera-friendly to be that scheming and manipulative. Perhaps that’s why the NTSB always goes to the fallback position, e.g. Pilot Error, etc. In short, it’s all they know.