Aircraft Accidents and Grandmother’s House

Ah, we all know the words, “Over the river and through the woods, to Grandmother’s house we go.  The horse knows the way …”  Lydia Maria Child (1802 – 1880) wrote those lyrics in 1844.  It was originally written as Grandfather’s – not Grandmother’s – house, but I guess the thought of crotchety old Grandfathers like me do not allude to fun and good food, like Grandmother does.

Going to the grandparents’ house for youngsters in the mid-1800s was as simple as getting the horse attached to the sleigh, climbing in and you’re on your way; the only hardships were the wind, an occasional smack with a tree branch or Old Glue throwing a horseshoe.  It was a different experience from the treks I experienced in the 1960s; we’d load up in Dad’s old Ford Falcon, jump on the Cross Island Parkway and fifteen miles later I’m elbow deep in lasagna.  Today, trips to Grandma’s are unlike everything before; we are now a worldwide society; families are spread out over many states and countries.  Air travel has never been so important.

In my younger days, the Commercial Industry still had Regulation; it really was a different world.  In October 1978, President Carter signed into law, Public Law (PL) 95-504, commonly known as the Airline Deregulation Act of 1978.  The purpose of PL 95-504 was: “To amend the Federal Aviation Act of 1958, to encourage, develop, and attain an air transportation system which relies on competitive market forces to determine the quality, variety, and price of air services, and for other purposes.”

Among many things, the Act “encouraged air service at major urban areas through secondary or satellite airports”; it prevented deceptive, unfair or anti-competitive practices, e.g. excessive market domination or monopolies; or the unfair practice of increasing prices or tampering with service.  Many feel that this was the decline of air commerce; that the Pan Am Clipper glory days of flying were reduced to a metropolitan/public transportation bus mentality.  Indeed, I remember when flying was a privilege; people dressed up, enjoyed onboard meals in coach and wider seats.  Flying was fun; it was exciting, a bragging right at school; it was a world I remember fondly.

But those days were also full of airlines too poorly managed to survive.  The gate was flung open to the free market, allowing upstarts to prove they had a better product for the traveling public or be crushed underfoot in an eat-or-be-eaten arena.  Many legacy carriers were happy to remain to feed at the regulated trough with heavy subsidies since the Chicago Convention of 1944.  They were confident that passengers would show up and pay their prices.  Suddenly these airlines stumbled in the presence of competition and, like the dinosaurs of old, gradually died out with a whimper or were absorbed by smarter competitors.

But deregulation not only encouraged self-preservation for the airlines, it spawned a surge in technology improvements.  Cries for cost-savings and aircraft accidents played important roles in bringing to light major aircraft shortcomings, e.g. metal versus composites; practices demanding upgrades, e.g. wind shear detection and training; and smarter aircraft that could operate with fewer pilots, less fuel and more reliable repairs.

Having made the leap – as an aircraft mechanic – from analog technology to digital, from the B727 and DC10 to the MD11 and the modified A300, the technology is incredible.  I am not a supporter of full technology reliance – I’ve often spoken out about the yet unseen dangers of this dependence – but one must give credit where credit is due.  The advances in technology would have been delayed in a world before deregulation, simply because the market wouldn’t have demanded the air carrier industry invest in it.

As a result, companies like Boeing, Airbus, Pratt & Whitney, Embraer, Rolls Royce, Cessna, et al, wouldn’t have been compelled to design fuel efficient engines, lighter composite materials, fly-by-wire, if not for the market’s cries for help.  As competition squeezed less adaptable carriers from the industry, the survivors searched for ways to remain viable in a market that kept everyone on their toes.  Today, the average age of airliners is half the age of the old-time  legacy carriers.  While older aircraft are destined for cargo operators, even old hulls, e.g. the DC-10, receive new life in hardware and software modifications that turned it into the MD-10.

The market also allowed for new players: the regional airlines, contract supporters of the majors into smaller markets.  Looking at the latest estimates for departing passengers out of the top ten busiest domestic airports, the regional carrier has contributed to the large numbers of grandchildren heading to Grandma’s house this Thanksgiving.  Phoenix comes in at number ten with an estimated 613,443 scheduled departing passengers, while Atlanta comes in number one with an estimated 1,382,846 scheduled departing passengers.

But, with each addition to the flight schedule comes a greater demand for safety.  Issues including crew rest, maintenance gripes, weather, over-booking, delays, even traffic to and from the airport; each contribute to the safe movement of people to Grandma’s home and back again.  Every one of these factors have contributed to major accidents; they were the first tile to topple, causing the domino effect leading to disaster, e.g. rushing to meet a schedule, bypassing technical glitches, skipping training, staging aircraft, or overloading the aircraft out of balance.  Safety is easy to overlook; it becomes a hindrance when managers are breathing down your neck and tensions are high.  Yet, it is the most important subject; it does not forgive; it has no empathy, even for the innocent.

Holiday travel has changed since the days of Lydia Maria Child; her delightful poem is a call back to a simpler time, where Grandma was a fun ride away.  No sleigh rides through the woods, or even car drives to South Ozone Park; these are the prices we pay for a larger world and advanced technologies.  But we have to remember that, even though the horse knew the way to carry the sleigh, the driver kept an eye on the route.  Even then we knew enough to monitor the technology.

Aircraft Accidents and Uber

It was on the day that Emmett Brown engaged his Mister Fusion with garbage, charged up the Flux Capacitor and blasted into November 2015, that the view of aerial traffic changed forever.  You probably didn’t hear about it; it occurred just over two years ago, but, then, it never really happened.

Science fiction movies made since Back to the Future II debuted in 1989, have made sure that aerial traffic was properly displayed; even reboots of the original Star Wars trilogy suddenly found vehicles making their way across the Tatooine sky in orderly fashion.  There are uniform lines of aerial vehicles, crisscrossing the skyline; methodical ‘On’ and ‘Off’ ramps; no one passing or cutting off.

Okay, here’s the deal: I just read that Uber, the car ride service available in 633 cities worldwide, is planning on launching uberAIR.  This service, which is being tested in Dallas, Texas (test site one); and Los Angeles, California (test site two); will offer cross city routes that move people in electric vehicle take-off and landing vehicles (eVTOLs) at 200 miles per hour.

Having spent some time driving through New York City and many major cities across the United States, I have visions of new and improved problems yet to be conceived of.  For instance, could there be rush hour gridlock above the Business District at one hundred feet of altitude?  Is it possible to double park two Ubers, vertically or horizontally?  Can you drop a lawyer off outside his office … on the 56th floor?

From my review of the historical documents, George Jetson’s home was thousands of feet in the air; Astro’s walking pad was a safety hazard with a five thousand-foot drop.  Now we’re talking about making uber-mobiles (excuse me, aerial uber-mobiles) as plentiful in a major city as pigeons.  My question is: who is responsible for the aerial uber-mobiles?

In the last year we have had a rush of unmanned aerial vehicle (UAV) news; demands by their industry to write Federal Aviation Regulations (FAA) governing the use and safety of UAVs.  There have been discussions about UAVs getting too close to airliners – a disaster in the making – while commercial UAV operators have tried unsuccessfully to distance themselves from amateur UAV operators; they try to avoid being painted with a broad brush of unsafe activities, at the same time trying to kick-start their new business.

UAVs still suffer from the bad press.  The FAA has tried to be timely with regulations, but have had to deal with the rest of those occupying the national airspace system (NAS) resisting the introduction of UAVs into everyday life.

As my mentor, the late Bill O’Brien told me, the changing of a Federal Aviation Regulation (FAR), the rules by which the aviation community is regulated, is a 3 X 3 commitment.  What this means is that the process to change aviation rules, even the rewording of a rule, takes three years and three million dollars … PER RULE.  I have taken part in this process on several occasions and the 3 X 3 estimate doesn’t allow for inflation, so the cost is more like five million.  The point is, this is an accurate estimate.  And with the introduction of a new entity – eVTOLs – there will be many rules – many rules times three to five million dollars apiece – necessary to regulate the new industry, just like UAVs.

EVTOLs are new; they are manned; they are occupied by customers; they have first-hand visual perception.  But they fly, and here’s the rub: Aerial vehicles would normally fall under the FAA’s jurisdiction.  Helicopters found inside a city’s limits, being used in, e.g. construction or police work, are overseen by the FAA.

Under FAA authority, aerial helicopters must be lighted: anti-collision lighting and directional lighting (lights that identify whether a helicopter is flying towards or away from you).  The loss of lighting may restrict an operator from operating at night; require the helicopter to be repaired or lamped per a minimum equipment list that restricts the helicopter’s operations.  Just the ability to be seen makes up many of a helicopter’s restrictions when operating within a city’s limits.

Another restriction is altitude and proximity to structures.  Helicopters and UAVs aren’t allowed to fly willy-nilly through a city skyline; there are proximity issues, flying over people issues, privacy issues, etc.  Also included would be how high they can fly … or how low; there are wires, construction cranes, window washers, banners, street lights and other objects of interference that can limit or endanger an eVTOL.

If they are flying above the city, how does one control them?  Are they controlled by the local airport’s air traffic control system or are there specially designed traffic lights?  Are there ‘lanes’ that they must adhere to, both vertical and horizontal?  How do they enter and exit these lanes?  Are the authorities going to get proactive about these questions or are they waiting until an accident to start to piece together what needs to be done?

Perhaps this is all moot and the local municipalities will be responsible for the new eVTOLs; the local Police Departments could end up being responsible for controlling the new wave of aerial vehicles.  Or perhaps the FAA and their FARs will become the law of the land.

My concern is that this new concept will become a comedy of errors; not the kind causing belly laughs like Old Doc Brown, but the kind that is called Reactive.  It has been my experience that when something this new age comes along, it starts demanding validation right away.  It will not be easy to get back from the future.

Happy and safe Thanksgiving to all.

Aircraft Accidents and Intuition

In one little league game, I was playing left field when the ball was hit over my head and out towards Averill Park’s bicycle path.  My manager, recognizing my hopelessness, yelled out, “AHH-TEE-EE … GEDDIT!”  One of my best friends, Artie, ran all the way from right-center and snagged the ball before it could hit the ground.  Artie saved my neck and rescued me from the walk-of-shame back to the dugout.  Yeah, he saved my bacon; he was one of those guys who pitched great, fielded great, hit great and had great team spirit.  Yeah, good old Artie …

Man, I hated dat guy!

Nah, not really.  Artie grew up to become one of New York City’s Finest, a Hero in Blue.  Later, he and his brother, Tim, went on to be well-known Irish connoisseurs of New York Pizza and unofficial Yankee strategists.  But Artie was one of those guys from my youth that had sports intuition.  For instance, intuitively, he knew exactly where the ball would be, whether baseball, football or basketball.  While I would misjudge the pop fly, Artie made fielding look easy, fading in or out as necessary.  His glove magically appeared, even with a bad hop and the throw homed in on the first baseman’s mitt every time.

I spoke a couple of months ago about a pilot shortage on the horizon; the deficit isn’t limited to pilots, because mechanics/technicians will be coming up shy, as well.  This is not a Federal Aviation Administration crisis; this is a Commercial Aviation Industry crisis, and those are the worst kind.  Why?  Because Industry will manipulate the crisis to its advantage, financial or otherwise.  They will also track the shortest route from Point A (pilot/technician shortage) to Point B (solving the pilot/technician shortage).  Often that involves bending the rules.

There is no doubt to the fact that the industry faces shortages.  Supplementing the pilot and technician workforces by encouraging military personnel to work full time in commercial aviation may not be an option; the military continues to incentivize aviators with reasons to stay.

Larger mainline air carriers, e.g. Jet Blue and Delta, can afford to raise employees up through the ranks by creating opportunities to expand their flight training through the airline’s own flight training program(s).  This is a surefire way for the air carrier to control the turnover of pilots, but it doesn’t guarantee experience, not on the scale older pilots have gained theirs.  This is especially telling due to airliners being technologically advanced, forcing the pilot to a position of babysitter instead of commander.

But what of the Regionals or Air Taxis that can’t pay the higher wages?  Will they be able to hire pilots that fly intuitively; that have a sixth sense?  These smaller air carriers will have large turnovers as the pilots opt to fly for the majors and the benefits they promise.  That is usually where the corners get cut, not out of necessity, but out of desperation.  Already these air carriers are becoming creative in their attempts to get around the training requirements and public fear.

About a year ago, EasyJet, a British regional airline, boasted that it employs the youngest female Captain, Kate McWilliams, who was twenty-six.  Her First Officer, Luke Ellsworth, was nineteen; in America, Luke’s the same age as a College Freshman.  Make no mistake, this is a novelty; I sound cynical, but the employment of these pilots has less to do with skill or safety and more to do with uniqueness and advertising.  It focuses strictly on being the first, but the first in … what?

Let’s look at Mister Ellsworth; in England, Luke is not old enough to drive an 18-passenger bus through London, yet he can fly a 180-passenger Airbus A320 over London; that’s a fact, not opinion.  The ‘bus’ pun is not meant to be glib, but to point out that the British Motor Vehicle Department has stricter guidelines; they have issue with Luke’s age, maturity and lack of experience; they find Luke to be unqualified to drive a certain multi-passenger motor vehicle.

By contrast, the crew of US Air flight 1549: Captain Chesley Sullenberger and First Officer Jeff Skiles, successfully ditched an A320 by flying through a maze of suspension bridges into the Hudson River; the US Air A320 – the exact same type of aircraft flown by Ms. McWilliams and Mr. Ellsworth – became an unpowered glider that had the glide ratio of a brick at low altitude.  Both Sullenberger and Skiles each had more than twenty-six years (that’s Captain McWilliams’s age) of flight time and experience; they each have been flying longer than Captain McWilliams is alive.  When the emergency occurred, they didn’t have time to refer to procedures; instead Sullenberger and Skiles acted intuitively; their actions were automatic, disciplined, refined over decades of flying the airplane, instead of deferring to the computer.  They had seasoned maturity, borne from years of taking control.

Is it feasible to believe that Captain McWilliams and First Officer Ellsworth could have landed US Air flight 1549?  Do they have the discipline and the experience to save the lives of all on board?  Could they leapfrog over the London, Blackfriars or Tower bridges on the River Thames?  Perhaps … perhaps not.  How much of their A320 knowledge depends on the reliability of the technologically advanced aircraft’s systems – systems that did not work on US Air 1549 – and how much is reliant on their individual skills?

On October 14, 2004, a standard repositioning flight for Pinnacle Airways – another regional air carrier – went terribly wrong when the pilots exceeded the aircraft’s maximum ceiling altitude; the aircraft became a glider, the engines refusing to restart.  Pinnacle Airlines flight 3701, a Bombardier CRJ-200, crashed in Jefferson City, Missouri.  The fact that the double-flameout occurred to begin with, speaks to the pilots’ disregard for procedure.  It is fortunate the event didn’t take place with anyone else aboard, perhaps deadheading flight attendants.

What about technicians?  It is true that air carrier programs, e.g. FedEx’s maintenance training program are successful due to its experienced maintenance workforce providing the on-the-job training (OJT).  These air carriers also have an inexhaustible supply of employees who have acquired their airframe and powerplant (A&P) certificates before lining up for the opportunity to nab one of these choice A&P technician positions.

Again, the smaller Regional Air Carriers, Repair Stations and Air Taxis don’t have the benefits that draw large numbers of A&P technicians to their ranks.  Nobody cares if a technician is 26; indeed, a lot of them are; I was.  To clarify, technicians don’t have to avoid wind shear; there is no need for a technician to abort a take-off.

But people do care about experience and technical knowledge; they want to know the engine won’t fall off or the landing gear will extend.  In addition, travelers want the technician to be properly trained, instructed by people experienced in the aircraft-type, using approved techniques.  Air travelers today deserve technicians with even a modicum of mechanical intuition.

In January 2003, Air Midwest 5481, a Beech 1900D full of post-Christmas travelers, crashed; the infamous reasons included that the technicians working the aircraft were inexperienced.  The Air Midwest hangars, specifically Huntington, West Virginia, had technician turnovers that overwhelmed Air Midwest’s ability to train the new technicians coming in.  Furthermore, the trainer overseeing OJT of the incoming technicians was, himself, not qualified to train others on the Beech 1900D; he had never been trained on that model aircraft.  The tragedy should never have happened.

Novelty and rule bending are the issues that have plagued and continue to plague the aviation industry.  Safety is not a game; it is not generated from public relations parlor tricks.  This may be what to expect in the way the aviation industry deals with shortages: do best with what is available; make the best of a bad situation.

Unfortunately, there won’t be someone with better intuition or experience to back these people up; nobody is going to ‘catch the ball’ for them and save their bacon.  There are grey skies ahead and I don’t think increasing technology dependence is the answer.  We, as an industry, have to start outthinking this with the basics; intuition, born of experience.  Anything less is just a circus stunt.

Aircraft Accidents and Lessons Unlearned VII: Continental Express 2574

The most frustrating part of accident investigation is when findings and fixes are short-lived.  It’s even worse when the findings and fixes are non-existent.  Aircraft accidents are fickle things; when JFK Jr. died, the world was on edge, yet a cargo aircraft can be destroyed and no one pays notice.  Attention to an aircraft tragedy is dependent on many factors, e.g. how many were lost; that there are no other accidents at the same time; what celebrity may have been on the aircraft; or how it happened.

We live in a 24/7 media society; we are quickly distracted by other events.  But we are distracted at our own peril; the life we save could be our own.

On September 11, 1991, a Britt Airways’ EMB-120RT, operating as Continental Express flight 2574, crashed near Eagle Lake, Texas.  The National Transportation Safety Board (NTSB) describes the accident as a result of an inflight breakup.  The aircraft did break up before impact, yet that isn’t why it crashed.  Simply put: a piece of the aircraft fell off resulting in an aerodynamic upset followed by the inflight breakup.

This is not a trivial point; the part falling off was not due to structural failings or hydraulic system shortsightedness; if the part stayed on, the aircraft could probably be flying to this day.  The reason the part – a horizontal stabilizer forward spar cap – fell off was due to factors that keep plaguing the aviation industry today, twenty-six years later.

The night before the accident, maintenance was performed on the horizontal stabilizer, where the right spar cap was removed.  The horizontal stabilizer, which, on the EMB-120RT, sits high on the vertical stabilizer forming the T-tail, required replacement of the de-ice boots that cover the spar cap’s leading edge; these de-ice boots break away ice buildup that disturbs the flow of air.

During shift turnover, a miscommunication occurred between two work-shifts, resulting in the spar cap not being secured to the Horizontal Stabilizer.  While in flight, the spar cap departed the aircraft; aerodynamic differences between the right and left stabilizer then caused the aircraft to roll and plunge, structure peeling off during the uncontrolled descent.

In aviation, maintenance on certain areas of the airplane dictate that a second set of eyes check the work on, e.g. flight controls, landing gear, doors and certain engine components.  In the air carrier world, this is required per Title 14 of the Code of Federal Regulations (CFR) Part 121.371 (c) No person may perform a required inspection if he performed the item of work required to be inspected.  In the air carrier world, these types of inspections are called Required Inspection Items (RII); they are performed by Required Inspection Inspectors.

In the regular world, a homeowner cannot build a deck without it being inspected by an engineer/inspector for the town or village; house wiring cannot be installed without a similar inspection by a licensed electrician.  These inspections are important to guarantee the house doesn’t catch fire or the homeowner’s safety isn’t threatened by a poorly designed/built deck structure.  It provides peace of mind.

RII inspectors provide similar peace of mind.  The inspector receives extra training on inspection techniques, tools and equipment, that are used to conduct more intricate inspections; this type of training is more than the average mechanic receives.  The inspector provides a ‘second set of eyes’ to assure the job is done completely and within limits.

The caveat is, that according to Title 14 CFR 121.371 (c), the inspector must divorce himself from the job; they cannot lend a hand, because then the separation of maintenance and inspection is broken.  Only by standing outside the maintenance performed can the inspector remain impartial and provide an uncorrupted inspection.

During the maintenance on the EMB-120RT, the inspector joined in the replacement of the right hand de-icing boot, i.e. he broke the separation of inspection and maintenance.  The 2nd shift inspector removed the fasteners on the top edge of the horizontal stabilizer’s spar cap.  As the work progressed, the 2nd shift (the mechanics that began the job, yet did not know that the fasteners on the top edge were removed), turned over the work to 3rd shift.  There was no documentation to this fact and the 3rd shift inspector did not receive turnover information from the 2nd shift inspector about the missing fasteners.

NOTE: There is one unfortunate truth behind accident investigation: important changes to training occur faster in the Flight department of an airline than the Maintenance department.  This is because Flight communicates better and can implement changes easier than Maintenance can, e.g. after Delta 191, an L1011 crashed in Dallas in 1985, wind shear avoidance training became mandatory, almost immediately.  Furthermore, airline pilots talk directly with each other, allowing the safety items to flow unobstructed throughout the industry; Maintenance departments don’t enjoy this type of seamless communication.  One reason was that up until 2001, the NTSB never gave Maintenance much thought beyond the accident aircraft’s records; the Maintenance phases of investigations were accomplished by engineers, not certificated mechanics.

How Continental Express 2574 hurt the future of aviation was that two accidents occurred over ten years later, under similar circumstances.  Air Midwest flight 5481, January 8, 2003; and Colgan flight 9446, August 26, 2003; two aircraft accidents separated by eight months and nine hundred miles.

One common denominator that joins them to Continental Express 2574 is the violation of Title 14 CFR 121.371 (c); the inspectors corrupted the inspector-mechanic separation.  As a result, a combined fatality count between the three accidents stands at thirty-seven, all because persons involved ignored the same Federal Regulation; a simple rule designed to enhance safety; a rule that was proved to be necessary.  And what of the many times since, where the same rule, or others like it, were ignored for the expediting of maintenance.

The most frustrating part of accident investigation is when findings and fixes are short-lived.  It’s even worse when the findings and fixes are non-existent … or ignored.