Aircraft Accidents and Radiation

 

 

I just read an article that has all my cell nucleuses exploding with dread … literally.  The article, in Business Insider: http://www.businessinsider.com/flying-airplane-cancer-radiation-risk-2017-12, for a brief second, made me question the industry I have worked in for decades.  And here’s why – – – The title is, and I quote: Flying In Airplanes Exposes People To More Radiation Than Standing Next To A Nuclear Reactor – Here’s Why.  Wow!  Excuse me while I call my Funeral Director and prepare for the wave of aircraft accidents related to radiation poisoning.

Imagine my concern, entering an airliner and being met by Flight Attendants resembling the cast of The Walking Dead; you know, the zombie-looking cast members; they stand there munching on Brain McMuffins.  The First Officer exits the cockpit to do his walk-around, looking remarkably like Tales From The Crypt ‘s Crypt-Keeper, making quips like, “Have a nice FRIGHT! Cackle!  Cackle!”  And he doesn’t require a flashlight because the airplane glows with a sickly green hue.

I would expect an article of this nature to be found in a medical journal, not a business circular.  Is this Radiation story good journalism?  Not really.  It’s a three-legged stool with a leg missing; a nothing-burger.  If you read through the article’s supporting information, the ‘facts’ have no foundation; they’re meant to confuse, like leaving an unsigned nasty-gram on your hard-working neighbor’s car windshield, then hiding behind a bush to see his reaction.  Aviation’s social media is full of people who torture the facts to sell themselves as knowledgeable, e.g. applauding an airliner Captain for defying his airline’s De-ice Program to remove dangerous wing ice … with a broom; or using one’s status to say that flying drones near airliners full of passengers poses absolutely no threat to safety.  Once it’s out there, it can’t be pulled back; melodrama aimed at an impressionable audience: the traveling public.

In the article there are two types of radiation discussed: Ionized Radiation (IR) and Cosmic Ionized Radiation (CIR).  According to the Occupational Safety and Health Administration (OSHA), IR is Any electromagnetic or particulate radiation capable of producing ion pairs by interaction with matter.  It does this by separating electrons – or ionizing – mating them with free electrons into ionized pairs.  IR can be found on the earth’s surface, e.g. radiation treatments.  According to the World Health Organization, IR can cause cancer and reproductive problems.

Now, according to the National Institute for Health and Safety (NIOSH), there’s a difference between IR and CIR: Cosmic Ionized Radiation comes from Space, e.g. solar flares.  Per its website, NIOSH has no idea whether CIR causes cancer or reproductive problems; there just aren’t any facts to support it.  https://www.cdc.gov/niosh/topics/aircrew/cosmicionizingradiation.html.

Does being in an airliner increase your chances of exposure to CIR?  Hmm – maybe?  Again, nobody knows.  Is flying really like standing next to a nuclear reactor?  Are we talking about Three Mile Island (1979) or Chernobyl (1986) reactors?  I doubt it.  Safety modifications of today’s reactors makes that comparison ridiculous.  My cousin has worked around nuclear reactors since 1985; I’ve never asked him over during a blackout to … GLOW.

The Sun’s energy is pretty radioactive, right?  Think of it this way: are you likelier to get hot standing in the middle of a parking lot paved with black tar as opposed to standing on a white sidewalk?  Yes.  Does that make the parking lot more dangerous?  Maybe, if you’re susceptible to heat stroke.  However, on a white sand beach, overexposing one’s bare skin to the sun’s rays can result in skin cancer (melanoma).

We receive protection from solar and cosmic radiation from both the Earth’s magnetic field and the Earth’s atmosphere; they filter out a majority of harmful cosmic radiation before reaching the Troposphere (5 to 9 miles above the ground).  Are airliner passengers, flying at an altitude of 40,000 feet (7.5 miles), exposed to more cosmic radiation than someone walking in a grass field?  The truth is, NIOSH … does … not … know; the United States has no dose limits for aircraft.

But consider: The Mount Washington Observatory in New Hampshire sits at 6288 feet above sea level (ASL) while the Maui Space Surveillance System at the summit of Maui’s Haleakalā Crater sits at 10,000 feet ASL.  They have both been occupied for decades, yet no one has reported suffering from Cosmic Ionized Radiation exposure.

How dangerous would exposure be to, say, the International Space Station (ISS)?  The National Aeronautics and Space Administration (NASA) website says the ISS cruises at 220 miles (1,161,600 feet) above the Earth in the Thermosphere.  This is well above the protective bubble of Earth’s atmosphere, putting it in direct line with a constant barrage of solar activity.  How high are the aurora borealis, the phenomenon that occurs when solar radiation bounces off the Earth’s magnetic field?  Between 50 and 400 miles above the Earth’s surface.  The ISS is smack dab in the middle of this altitude.  At 40,000 feet, the average airline passenger faces more radiation damage from their cell phones and video games, that is, assuming you don’t turn it off when the flight attendant says to, but that’s another article.

But, Stephen, how do you know this?  Good question.  Having worked in the air cargo industry for twenty years, I’m very familiar with Dosimeters.  What is a Dosimeter?  In the movie Diamonds Are Forever, the character, Klaus Hergersheimer gives James Bond a radiation badge in the Master Villain’s secret Nevada base; that badge monitored radiation exposure.  The same principle is applied to a Dosimeter: a ‘device used to measure an absorbed dose of ionizing radiation’.  According to what cargo is carried onboard a flight, e.g. Radioactive Three-bar, a dosimeter is required to be worn by flight crews and cargo handlers to monitor their exposure to harmful IR.  I, as a mechanic, would wear a Dosimeter when working flight controls that utilized depleted uranium as a counter-weight.

In thirty-six years, I’ve never met a flight crew whose Dosimeter was corrupted by radiation, or whose skin resembled Extra Crispy Kentucky Fried Chicken.  The truth is that any flights conducted inside an airliner’s normal cruise altitudes suffer absolutely no harmful radiation exposure dangers.

To cry ‘Wolf’ by writing articles aimed at scaring the flying public into worrying about non-existent threats is irresponsible.  Professionals in the aviation industry work hard every day to improve safety, assuring the secure movement of people and freight across the country.  The integrity of their efforts do not need any unsupportable bad press to damage their safety records.

 

If one wishes to check IR contamination experienced during a particular flight, the Federal Aviation Administration provides a chart for determining exposure called the Galactic Radiation Received In Flight chart at: http://jag.cami.jccbi.gov/cariprofile.asp

If you would like to check radiation exposure challenges for astronauts, NASA provides a High School level guide at: https://www.nasa.gov/pdf/284275main_Radiation_HS_Mod3.pdf

Aircraft Accidents and Intensity

Two years ago, my experienced accident investigator friend, Bob, read my first book: The Air Crash Files: Jet Blast; Bob’s forgotten more than I’ll ever know.  We had lunch, where he stated, unequivocally, that my book did not teach him anything new about accident investigation.  I stopped his commentary, saying, “Bob, I didn’t write it for you.  I wrote it for people who want to read about the topic; people who have an interest in accident investigation.”

One of the reasons I write articles for my website is to speak to the next generation, the torch grabbers that follow my generation in aviation.

I received a video in LinkedIn; a motivational speaker, Simon Sinek, was communicating some points about Consistency versus Intensity.  I, however, unintentionally pulled something else from the video.  It had to do with applying On-the Job Training (OJT) – or any training – to the job; how and when to apply what is learned is just as important as the quality of the training.

Mister Sinek pointed out that we’re a passionate society, wanting instant results – intensity – because it’s easy to measure, paying the least attention to the details necessary for success.  He stated that management types attend seminars with a couple of speakers, everyone gets certificates and – BAM – they’re leaders.  Why?  Because the certificate says so.  But what have these leaders actually learned that’s applicable to the real world?

It seems, these days, that fewer people are interested in consistency, putting in the necessary effort over a longer period of time.  Even when learning a new job, many are too anxious to move past the toil of being properly instructed – I mean the Tab-‘A’-into-Slot-‘B’; righty-tighty, lefty-loosey, type of instructed. Too quick to break out of the gate, there are those unprepared for taking control.  Do these same people feel brave enough to admit when they’re overwhelmed, unqualified, scared?

It’s not always the fault of an overzealous personality; there may be incentives tied to being overenthusiastic.  In some areas of government, for instance, the desire for accomplishing all one’s training is encouraged by pay grade raises; not exactly a productive way to inspire one to learn their job.  First, one’s training is reliant on a senior trainer’s desire – to be ‘in-the-mood’ – to instruct, especially in some offices where senior trainers are not known for empathy.  In addition, what value is attached to training quality that comes second to rushing through the training process.

As those enter the workforce – or re-enter, as it may – what kind of trainee do we wish to be?  Do we want to get trained quick or do we want to get trained right?  I’ve stood on the flight deck three minutes to pushback; staring at the Attitude Indicator doing something silly; the Captain looking at me for answers; and I have no idea what the cause is.  I could have pulled a circuit breaker, reset it and hoped it made me look smart; hoped the aircraft didn’t fault in flight – or worse.  Or I could have done what I did, and say, “I’ll take the delay; I’m calling Maintenance Control for help.”  The Captain?  He looked annoyed.  But I figured: Hey, the life I save, could be his own.

In aviation there are several forms of training we employ: On-the Job Training, computer-based and stand-up (instructor-based).  I’ve been exposed to all three; they each have their strengths and weaknesses, but I’ve always felt that OJT has the longest lasting effect on the instructed.

I’ve sat through hours of computer-based training, listened to the computer drone on, often repeating irrelevant information while flying through the ‘good stuff’.  It’s not like sitting with the HAL 9000 computer, one that interacts, answers questions and can pull knowledge out of billions of files.  It’s a screen that’s the equivalent of a slide show.  There’s no feedback; the computer projects information, but can’t answer a simple question.

Stand-up-based instruction is better, lots of interaction, levity, war stories.  Most likely the instructors are out of the field for several years, retired and stayed, or are teaching, e.g. engine repair, lessons that they learned in a teach-the-teacher class.  They do, however, have the ability to get the class talking, perhaps help with questions they never heard before.  The fact is, it works because the class works together.

OJT is, without a doubt, the best form of instruction.  It’s hands on, get dirty all the way past your elbows, clothes stained, hydraulic fluid running down your arms.  All the while, the instructor is making sure you are getting it right; that, ‘though they look the same, a B737 and an Airbus A320 are very different, and here’s why’ kind of way.  And the more consistent you are in relearning the previously learned, the better you’ll be when you strike out on your own.

Of course, you may end up with an instructor with no sense of humor or one who feels they must torture you for being, oh, I don’t know, from New York (yeah, I spent seven years in Memphis; it’s a thing, trust me).  You might get instructors you don’t get along with, but you knew the job was dangerous when you took it.

In the end, if taught right, you do the job right, you learn your limitations and you make the world a little safer … okay, a lot safer!  There are too many accidents I know of that when one finds the cause of, the TRUE cause of, it’s often the training, or the lack thereof.

So, to those who are making their way into an industry, be consistent; be smart; be so safe.  Leave the intensity for … well, writers, like me; for tackle football, playing piano, mountain climbing.  Better yet, save the intensity for your Family; make intense memories, make for intense laughter, get into intense snowball fights …

Have an intensely Merry Christmas and/or Happy Holiday.

Be safe.

Aircraft Accident and ETOPS

Remember that old pre-ETOPS joke?  Generic Airlines’ twin-engine airliner is making its way across the Atlantic Ocean; the Captain gets on the intercom, “Ladies and Gentlemen, this is the Captain; we’re sorry to report we have lost an engine.  Please don’t be concerned; we still have one good engine.”  Twenty minutes later, the lights go out and the aircraft gets quiet.  The Captain gets back on the Intercom, “Ladies and Gentlemen, we’ve just lost the second engine; we’ll be ditching in the ocean.  Emergency procedures dictate that all those who can swim, please get to the left side of the aircraft.  When the aircraft comes to a stop, swim as hard as you can to land one hundred miles northwest of here.  For those of you who can’t swim, thank you for flying Generic Airlines.”

ETOPS – Extended Twin-Engine Operations, is a product of the economies: fuel, financial and time.  Aircraft manufacturers abandoned the gas-guzzling three- and four-engine aircraft, e.g. B747, MD-11 and A380.  Instead, air operators began demanding two-engine airliners that can safely fly quicker routes formerly monopolized by the aforementioned gas-guzzlers.  The goal: design and build aircraft and engines with never-before attained reliability; capable of flying over water, five hours from the nearest airport; and doing this with only one engine.

The benefits of flying an airliner with just two engines are numerous.  In 1985, when ETOPS was first developed, the age of the twin-engine, long-range aircraft, e.g. B767, B757 and A300 was born.  These airliners were designed with only two pilots, cutting manning costs per flight by one pilot to pay for, e.g. benefits, travel expenses and training.  Two engines use less fuel than three or four, resulting in better passenger or cargo transport miles.  Twin engines have less upkeep costs, e.g. maintenance, overhaul and reliability programs.  As the technology improved from 1985 to the present, the airliners became more reliable, parts are utilized longer before replacement and fuel economy improves with engine modifications, e.g. better materials used, tighter tolerances and ramped up power due to blade design.

When I worked for the Federal Aviation Administration (FAA) Flight Standards department, I took an ETOPS class twice; it’s a great course and I’m proud to be managing a like course now.  But of all the courses I teach, this is the one I don’t personally instruct; the information delivered by my very qualified instructors, is based on teachers with years of ETOPS experience, not familiarization.  It’s one of those subjects where, after three decades of ETOPS operations, splashing an airliner is never a question of ‘if’; it’s a question of ‘when’.

That statement sounds ominous.  However, there is a risk analysis demonstration called the ‘Swiss Cheese Model’ of system failure; the theory is that for catastrophic failure to occur, holes in several slices of a metaphoric ‘Swiss Cheese’ must line up.  Swiss cheese is symbolic because slices of Swiss cheese do not have holes that line up … until that one occasion where they do; that’s when a catastrophic event occurs, like an accident.  A further concern is that the National Transportation Safety Board (NTSB) would not be able to properly investigate an ETOPS accident because it lacks any knowledge or experience in the subject, so the probable causes would be in error.

ETOPS is the only FAA-approved program that stipulates: everything must work precisely according to plan for each and every ETOPS flight; if not, any flight could fail with no hope for survival.  Each ETOPS flight has to be unique; each maintenance check, each flight plan, each adherence to the process, by the book; complacency cannot enter the equation … EVER!  Consider this: if a twin-engine airliner ditches (hopefully, successfully) with five hours of flight time away from land, how long does it take for the rescue plane to reach the survivors?

To qualify for ETOPS, each aircraft-engine combination must have thousands of hours of successful operation, e.g. a Boeing airliner with Pratt engines can’t be used to qualify the same Boeing aircraft with GE engines.  Each airline requesting ETOPS has to have thousands of hours with each aircraft-engine combination they’re applying for.  Rigorous training must be given to pilots, mechanics and technical support personnel.  Thorough procedures must be developed, tested and approved.  When the airline is ready to fly ETOPS, the FAA, who has been overseeing the qualifying process, starts their own testing, drilling various scenarios on practice runs or in simulators.  And when this is finished, the real work begins.

An ETOPS aircraft isn’t awarded a permanent ETOPS designation; it earns it every time it flies.  Every system must work; the maintenance checks for every flight are accomplished by qualified mechanics; ETOPS pilots are trained for all emergencies; technical support and flight operations are prepared for every contingency; and many aircraft systems are given regular inflight checks to assure reliability, e.g. auxiliary power units are started and run at cruise altitude after being adequately cold-soaked.

All this is done to assure that any passenger looking out on the wings and seeing only two engines, will just shrug his shoulders and return to his Sudoku puzzle.  It is possible to fly 180 minutes from shore; it’s proven every day to be the norm, not the exception.  The concern is that every norm breeds complacency; when complacency occurs, the holes in the cheese line up.  There’s a list of all accidents and disasters that are born of complacency, including the Challenger, the Columbia, the Titanic, et al.  It’s why when I instruct, my students are required to take accidents and reverse the domino effect back to the original cause(s); nine times out of ten, complacency is at the heart.

There are many boxes to check in order for ETOPS to work correctly; diligence and commitment are not just words, but necessities for each and every ETOPS flight; complacency has no place in ETOPS success.  No one wants to hear, “Thank you for flying (insert airline name) Airlines,” unless it’s at the destination gate.  Besides, the thought of swimming for land just makes me want to take an Ocean Liner to Europe, instead.  Unless it’s Iceberg season; I’ve heard those things can cause their own problems.

Aircraft Accidents and Fuel

First, a recognition: Thank you, Mr. Colacino, for the investigation alert.

A Notice to Air Men (NOTAM) was sent out from the Boston Center on Friday, December 1, 2017, concerning fuel contamination problems, allegedly, out of a Fixed Base Operator (FBO) in Omaha, Nebraska’s Eppley Airfield.  The questionable fuel, according to a November 30, 2017, Aviation International News Online article, was instrumental in causing two Air Force aircraft to make emergency landings immediately after take-off.  According to the NOTAM, the fuel concerns were found in both military and general aviation (GA) aircraft.  The article adds that two Learjets also experienced fueling problems after visiting the same FBO.

The possible causes being investigated – and here I note, the FBO is cooperating fully – are flameouts, clogged fuel nozzles, fuel filters and fouled wing fuel tanks.  The article and NOTAM are unclear as to the types of engines used by the GA and military aircraft; I, myself, have had limited dealings with either aircraft, so I asked my colleagues about what may have caused this situation; by ‘this situation’, I mean: Are military aircraft, GA and Learjet aircraft using the same type of fuel called out in the article: Jet-A, or are there two problems?

Since the two news sources are unclear, let’s elaborate; most GA aircraft – and possibly some military trainers – use regular Avgas, a more robust fuel with higher octane than the fuel found in the average family car.  Learjets, military fighters and some other GA aircraft use Jet-A, a more robust version of diesel fuel than found in some trucks.  Why is this confusion a problem?  Because, Jet-A fuel and Avgas fuel are not stored together in the same tanks; they are incompatible, just as regular automobile gas isn’t stored in diesel tanks.

If one were to follow the trail that led to these events to the source(s), one would ask: What was the common link?  If all the aircraft involved used Jet-A, then the source of the problem would be clear: either the fueling truck (if the same truck was used to fuel all the aircraft) or the fuel storage tank (which would most likely be the same tank), were somehow corrupted.  However, if some aircraft used Jet-A and some used Avgas, then the common link would be two tanks or multiple trucks … or both.

For the sake of argument, let’s assume they both used Jet-A; there could be different reasons for the symptoms found in these cases.  For one, there could be a problem with improper care of the trucks, e.g. the fueling hoses being left uncapped; improper service drainage checks of the truck’s tank for water accumulation or dirt; the truck’s tank becoming filled with rust or debris; or the truck’s filters not being replaced on a routine basis.

When I used to conduct regular daily service checks of my alumni airline’s B727s after flight, we would drain about two quarts of fuel out of each fuel tank.  This was accomplished after four hours of ground time to allow any water a chance to settle to the bottom.  The check allowed us to assure there was no water build-up in the tanks or bad fuel from another station wasn’t polluting the B727’s fuel tanks.  We would then use the drained samples in the diesel ground equipment, so it wasn’t wasted.

The second reason would be the storage tanks.  Problems could be found in water leaking into the fuel tanks from the ground; not conducting regular maintenance of the filters; or even microbial build-up in the tank – yes, microbes are a problem for both Avgas and Jet-A fuel tanks.  There are different types of microbes; these organisms have been found to consume anything from fuel to iron from the Titanic’s rusting hull.  Perhaps there are some microbes that would even eat my Mother-in-Law’s cooking.

Is fuel a consideration in accident investigation?  Most certainly; in fact, in GA accidents, fuel is commonly the first mechanical cause checked out (drug testing is the first operator cause looked into).  If possible, the fuel is sampled, assuming there is any to test after a post-crash fire.  In 2001, I investigated a tour helicopter accident beside the Grand Wash Cliffs near Meadview, Arizona.  No eyewitness to the actual disaster was available, so several theories were floated, including fuel starvation.  Unfortunately, the accident helicopter’s fuel tank could not provide an adequate sample, so no defined ‘cause’ or ‘no cause’ was credited to the helicopter’s fuel tank; several contributing fueling stations were tested, but no issues were found.

Any aircraft engine, whether combustion or turbine powered, relies on three things for operation: fuel, air and ignition.  As mentioned, a break in an engine’s fuel supply can cause different accident-causing events.  A flameout is when the fuel is cut off to the engine enough to lose ignition, perhaps by water diluting the fuel; the flame goes out because there isn’t enough fuel to keep the fire burning.  This turns a single-engine aircraft into a glider.  If a multi-engine aircraft, feeding off a single tank with bad fuel, flames out, this could result in complete failure of all engines – again, think glider.

Clogged fuel nozzles, filters or fouled wing tanks also contribute to accident-causing events.  The fuel nozzles (or jets) atomize fuel as it is sprayed into the combustion chamber, whether it’s the cylinder (combustion engine) or the burner cans (turbine engine); the fuel is pushed, under high pressure, through very small holes in the fuel nozzles, that cause the atomization.  If the nozzles are fouled, the fuel won’t exit the nozzle or it will not break down into a mist, instead dribbling out in a way that diminishes the combustion.

Contaminated filters or polluted fuel tanks can also contribute to an accident.  Filters remove the contaminants or microbial impurities introduced into the fuel tank from outside sources; filters do this before the fuel is pumped into the combustion chamber.  However, unlike a car or truck that can pull to the side of the road, an aircraft has to keep the engines running … no matter what damage they incur.  The filter system, if fouled enough it prevents fuel from getting through, will bypass the fuel filter and direct the contaminated fuel straight through to the combustion chamber.

Findings will soon be made known from Omaha’s fuel issues, procedures, inspections and/or maintenance changes adjusted to prevent future events.  Hopefully, the findings will be shared to assure other airport FBOs won’t duplicate those problems.  To point, the fuel issues here must be handled proactively, not reactively; too often these problems can be discovered earlier with no threat to safety.

Aircraft Accidents and Lessons Unlearned VIII: Emery 17

I recently read an article titled: What the Loss of Emery 17 Taught Me, by Joe Yingst, from August 2016; I found it on a Google search and I located it on LinkedIn.  Joe worked for Emery Air Freight at the time Emery 17 crashed in Sacramento-Mather airport, California, on February 16, 2000.  The McDonnel Douglas DC-8-71, tail number N8079U, was trying to make an emergency landing at the departure airport, when its wingtip struck a building; the aircraft crashed into a used car lot just shy of the runway’s end; all three pilots were killed.

I started working for the NTSB in July 2001; this was the first major accident I worked for them.  The investigation was already eighteen months-old before I became involved.  What Mister Yingst learned from the accident was how to survive the downfall of your employer, post-tragedy, i.e. how to succeed in business.  What I learned from Emery 17 was totally different.

The cause of the accident: someone unsafetied the right elevator tab arm-to-right elevator tab attach bolt – the elevators provide longitudinal control, e.g. aircraft nose up/nose down; the tab drives the elevator in an opposite direction, e.g. tab goes up, elevator goes down and vice versa.  The attach bolt was found near Emery 17’s takeoff runway.  The lock nut was missing; the bolt, with regular movements and vibrations, fell out.  With the arm disconnected, the elevator moved to a ‘nose up’ position and could not be overridden in the air.

The airline industry would expect that a major commercial accident at a major commercial airport would require a proper National Transportation Safety Board (NTSB) investigation.  In reality, the NTSB made little effort to investigate correctly.  NTSB management stated, ‘there were only three pilots on the cargo aircraft;’ this view set the stage for major mistakes.

Obstructing an accident investigation happens all the time; it’s one of the lessons I hammer home to my students before they begin their careers.  In this case, the NTSB’s management played a major role in allowing the obstruction to fester by not committing experienced resources to the February 16, 2000, accident; the NTSB’s experience-void was quickly filled by those trying to manipulate the information, to exploit the unfamiliar culture of a cargo airline versus the more familiar culture of a passenger airline.

In August 1999, a Repair Station called Tennessee Technical Services (TTS) was contracted to perform a heavy maintenance check on N8079U, which included replacement of the aircraft elevators.  The elevators, considered a primary flight control, were inspected by a trained inspector who was not part of the team replacing the elevator.  Instead, the Required Inspection Item (RII) inspector double checked the installation to assure the elevator system was properly installed, secured and the expected movements were full range of travel and were unrestricted.

From the paperwork, and by all evidence available, TTS did everything they were contractually required to do, including the RII inspection.  That sounds cold, but a repair station is contractually obligated to provide work per the airline’s standards, which are per the aircraft manufacturer’s standards: to return an airliner in an airworthy condition.  The RII inspector verifies his/her compliance with a signature; there are no tapes or videos, just signatures.

When I joined the investigation in August 2001, Emery was making the case that only TTS’s RII inspector had access to the elevator bolt; that only he could have failed to secure the bolt in a proper manner and that the bolt eventually, over the six months, ‘walked’, ultimately dropping out on the runway.  As I sat though the interview with the TTS RII inspector, I reviewed the records and found that the ill-fated bolt had been touched only one other time: November 25, 1999, after N8079U arrived in Dayton, Ohio, for a package sort.  The problem was – and this is what the Quality Control manager for Emery said – that N8079U was only on the ground for four hours on November 25, 1999; after loading and unloading the aircraft, Emery’s maintenance department could only have worked N8079U with two hours of ground time, not enough time to remove and replace the bolt.

And this is where the NTSB’s unfamiliarity with a cargo airline’s culture prevented them from seeing the forest for the trees.  I asked the Quality Control manager a question during his interview in Dayton, Ohio; I asked him, “Do you fleet in on a Federal Holiday?”  This question made no sense to the other fifteen people in the room; it, however, made perfect sense to the Quality Control manager and myself.  He did not want to answer my question.

A cargo airline does not operate like a passenger airline; passenger airlines operate twenty-four hours a day, seven days a week.  A cargo airline – especially in 1999 – only operates when domestic businesses are open.  Businesses in the United States do not open on Federal Holidays; therefore, the cargo airlines do not fly on Federal Holidays; they fly the day before and the day after.  The night before a Federal Holiday a cargo airline conducts a ‘fleet in’.  This is where all the inbound flights are held over for the entire Federal Holiday and released the next night.

November 25, 1999, was Thanksgiving Day.  N8079U arrived in Dayton, Ohio, at 10:00 PM on November 24th and departed 3:00 AM on November 26th.  This gave the maintenance crews, not two hours to work the elevator as originally believed, but twenty-seven hours to work the elevator tab attach bolt; enough time to remove it, replace it … but not secure it.

Emery’s management tried to conceal the true cause of the accident; instead, they attempted to divert unwanted attention and unnecessary blame on the Repair Station, TTS.

Unfortunately, the NTSB learned nothing from the deception; they ignored the fact that Emery was not only responsible for circumstances leading up to the accident, but that Emery’s management thumbed their noses at the NTSB, exploiting the NTSB’s apparent lack of cargo airline cultural familiarity.

The cause of the accident was the bolt falling out, making the elevator uncontrollable; what caused the accident was Emery not following its own approved procedures.  DC-8s are one of the dinosaurs of commercial aviation; no one flies them domestically anymore.  But cargo airlines do fly Boeings, e.g. B737s, B757s, B777s, and Airbus aircraft, e.g. A300s; as do the passenger airlines … all the passenger airlines.  The arrogance of ignoring a cargo airline based on the body count means that important factors affecting the safety of a cargo airliner will be missed; therefore, the same factors affecting the safety of a passenger airliner flying the same type airliner and utilizing the same repair stations will be missed. This puts passenger airliners in the same jeopardy experienced by the cargo airliner, with more devastating results as far as body count.

Joe Yingst learned valuable lessons about how to survive in his industry following his airline’s loss of certification.  As for me, this was the first lesson unlearned I experienced as a new accident investigator.  It would govern how I conducted accident investigations in the future; to trust no one and to look beyond the accident to the real cause.