Aircraft Accidents and the Government Shutdown

This past week the Federal Government shut down; the politicians could not – refused to – find common ground in order to keep the government open.  It is not, for purposes of this article, important what the differences in opinion are; this is not a political argument.  What is important are the effects the shutdown has on any and all in our American society.

Let’s get one thing out of the way: politicians and bureaucrats act this way, not out of any noble cause; their reasons are selfish.  As citizens, we have all heard the arguments framed by politicians.  Responsibility for funding the necessities of government should not to be trivialized; Departments, e.g. Defense, are not Chess pieces for politicians to bargain and move.

The belief is that when the government shuts down, time stops.  However, there is no Bugs Bunny air brake handle drawn from out of nowhere; no suspended animation device as in a Twilight Zone episode.  Safety infractions continue to happen, whether people are looking or not.  In regards to aviation, Congress would have you believe that nothing of consequence happens during the time they are holding their breath and kicking their feet.  The truth is that airlines continue to fly, medical helicopters are being operated and aviators will violate the Federal Aviation Regulations, especially in the absence of inspectors.

The costs associated with a Shutdown far exceed the normal excesses of government.  The infamous $435 Hammer and $640 Toilet Seat are tame extravagances in comparison to the lost dollars from even one day of a Government Shutdown (GS).  In the aviation industry, these costs pale next to the safety challenges created by cancelled surveillances, lost safety meetings or the deferring of certifications.  But, to make my point, let’s look at a routine disruption Congressional game-playing causes, namely Training.

There are dozens of sub-departments in the President’s fifteen Cabinet Departments, e.g. Transportation, Defense, Labor, State, etc.; each sub-department is engaged in the work required for it by the American people.  For purposes of this article, let’s look at Training requirements at the Federal Aviation Administration (FAA), which is one part of the Department of Transportation (DOT); it is an easily measurable expense and open to public scrutiny.

An average FAA training class holds about fifteen to twenty people; these classes may be occupied by, e.g. FAA personnel, Industry technicians or International overseers.  There are usually eight to ten classes being run simultaneously, which places the number of students at about two hundred students at any given time.  Since a GS has no specific end date, the students must be sent home at a cost of about $500 per student for rebooked flights, penalties and future return flights.  Then there are per diem costs, e.g. food – $60/day; hotel costs – $95/day; baggage fees, rental cars, airport parking fees, airport transportation, the added cost per day of being held over a two-day weekend.  These costs are available for public viewing at the General Services Administration website.

After that, let’s not forget the cost of instructors; the fees above apply to each instructor, an average of two per class, for the entire training period missed.  For just the FAA, the Training costs for shutting down the Federal Government for just one day are in excess of $200,000.  This price does not include the costs leveled at the private businesses who sent their people from Industry and International sources to the FAA for training; costs that are not refundable.  The FAA is one Administration (sub-department) under the DOT; the DOT is one Department in the President’s Cabinet.  The point: perhaps millions of dollars, across the government, are wasted, just in rescheduling for required Training.

Training is one small cog in the daily responsibilities of a government department, e.g. the FAA.  However, the FAA’s responsibility to the aviation industry is to provide oversight; to assure certificate holders are conducting business safely, preventing accidents and providing American citizens safe passage in all modes of aviation.  The FAA’s other responsibilities include approving certifications, from approving a repair station for its certificate to operate, to approving runs for an airline’s new aircraft.  These are overwhelming responsibilities where industry aviators outman government overseers, several thousand to one.

Oversight is the FAA’s main function.  In order to assure the continued safety, the FAA must provide oversight of, e.g. an airline’s programs.  They accomplish this by employing Data Collection: proving that programs work by collecting information, e.g. engine monitoring, structural inspection findings; Risk Analysis: taking that information and analyzing it to prevent future safety issues and accidents; and On-site Surveillance: the personal viewing of goings on at the airline.

Interruptions in the daily routine of oversight can impact the airline directly.  In some cases, FAA visits planned weeks in advance would be canceled due to a GS; planned maintenance or flight operations would have to be rescheduled so as to reroute equipment in or until another aircraft is slotted for a phase check.  These costs include fuel to relocate an airliner; the costs of pulling that airliner out of service; and lost revenue from dissatisfied customers resenting the inconvenience.  Costs for cancellations, rescheduling or, even, shuffling aircraft and flight crews, would run into the tens-of-thousands of dollars in costs to the airline and its contract maintenance facility.  According to the length of the GS, the FAA might have to put off surveillance for weeks, which dominoes into months, affecting the very safety of the airline and the contract maintenance facility under surveillance.  Result: safety is negatively affected for the flying public.

Businesses, like Repair Stations, are required to undergo a strict certification process.  This process can take months, arranging demonstrations for approval or waiting for revision approvals to manuals and procedures.  Even a short GS could put these certification milestones off for weeks, costing the Repair Station a lot of money in start-up costs and lost business.

Since oversight and surveillance are an ongoing process all over the United States, rescheduling these events costs money; airlines and other travel organizations do charge for cancellations or re-ticketing fees.  The expense of moving aircraft around for inspections; lost time for a grounded aircraft; overtime wasted covering a cancelled event; these are expenses that can hurt the certificate holder for circumstances beyond their control.  The costs are then passed onto the customer, whether the air carrier flies passengers or boxes.

The European Aviation Safety Agency (EASA) and the Department of Defense conduct mandatory inspections and audits of FAA regulated certificate holders.  EASA has to cancel appointments when the FAA is on GS, incurring more expense for the FAA.  These expenses – both industry-wide and world-wide – run in the millions.  Again, these costs are for one sub-department answering to one Department in the President’s Cabinet.

It’s been said that the cost to government is minimal due to a government shutdown.  Maybe it’s true the average government employee doesn’t feel the impact of the costs.  That is not to say they aren’t aware of the impact, just that they are helpless to stop it.  In the 1972 movie, The Godfather, Peter Clemenza tells Michael Corleone, “These things gotta happen every five years or so, ten years.  Helps to get rid of the bad blood.”  Government Shutdowns aren’t like that; they don’t ‘gotta happen’; they are unnecessary.  Shutdowns put the very safety of the American public at risk.

Aircraft Accidents and the Code of Conduct

It has been reported lately that 2017 was the safest year ever recorded, with zero commercial aviation fatalities.  Politicians and bureaucrats on both sides of the aisle were standing in line to take credit for the milestone, convincing the public that this is a sign of the future; we stand on the brink of a brighter tomorrow; we have fixed aviation safety for good.  Break out the champagne!  All we have to do is conduct ourselves as we have the last twelve months and we … are … Golden.

In the words of Killer, the Vulture, “Uh, no, no, no … uh, nope.”  When I hear that we have achieved such a record, that’s when I start looking up with fear at the sky; I pop open my Wile E. Coyote Acme umbrella in anticipation of becoming clobbered from above.

Such historic landmarks are illusions, non-existent; there are no assurances that each time an aircraft takes off, it will be an uneventful flight.  Each flight is the continuing efforts of multiple individuals contributing to its safety, e.g. pilots, mechanics, flight attendants, etc.; an ongoing effort of being safe.

When I worked the aircraft line in 1987, one of my fellow mechanics signed off the logbook with the words, “Another every day, non-eventful post-flight accomplished on N*****.”  My coworker was given something to remember this by in his personnel file and a re-post-flight was accomplished.  As trivial as he found walking around an aircraft to be, it is not a mundane task … not in the least.  One can find many safety anomalies during a post-flight walkaround, e.g. bird strikes, metal kicked up from the runway and embedded in a wing fuel tank (saw that one myself), tires missing restraining hardware, hot brakes, etc.  Each finding represents a threat to man and machine.

Each flight must be treated as a unique event; not one of a group of events, but in a class by itself.  To think otherwise tempts fate; it allows us to fall into a comfortable position that breeds complacency.  I’ve had the opportunity to listen to several cockpit voice recordings of the last minutes of a flight.  Never did anyone on those tapes believe that their soon-to-be accident flight would be anything but be uneventful.

The Titanic took the term ‘Unsinkable’ quite to heart, enough so, to race carelessly through an iceberg field.  Someone convinced the Shuttle Program astronauts that, “a tragedy on the scale of the Challenger disaster would never happen again, so whose up for flying STS-107 in Columbia?”  I’m convinced that the flight crew for Asiana Airlines 214 felt that the airliner’s technology would not let them crash.  National 102, Air Midwest 5481, Colgan 9446, Valujet 592, complacency, complacency, complacency.  Can it be more obvious?

Aviation safety isn’t brain surgery; it’s a culmination of years of accident investigation, ongoing inspections, record reviews, internal auditing, quality control, quality assurance, surveillance, etc.  Aviation safety boils down to using tools, e.g. a simple list of rules that, if followed, will guarantee one satisfies his or her own place in a safe flight’s chain.  The Aviators Code Initiative (ACI) provides Codes of Conduct that span many aviation disciplines, e.g. Aviators, Flight Instructors, Helicopter Pilots, Student Pilots, Seaplane Pilots, Light Sport Aviators, Glider Aviators, and Aviation Maintenance Technicians, each found at:

http://www.secureav.com

The site also provides guidance for Unmanned Aerial System Pilots and Manned Aircraft Operating Near Drones.  For example, here is the Code of Conduct list for Aircraft Maintenance Technicians from the above website:

The Code of Conduct has seven sections, each containing Principles and Sample Recommended Practices.

  1. General Responsibilities of Aviation Maintenance Technicians
  2. Third-Party Safety

III.           Training and Proficiency

  1. Security
  2. Environmental Issues
  3. Use of Technology

VII.         Advancement and Promotion of Aviation Maintenance

Each section breaks down into its own rules of safe habits.  These rules for safe habits are, fundamentally, work ethics and best practices that we all should follow.  I feel work ethics have taken a large hit in this new world of reliable technologies; work ethics suffer from a lack of common sense, relying on the machine to police the safety, leaving the aviator free to attend to unnecessary distractions that have nothing to do with safety.

A concern of mine: work areas that display signs, such as: (#) Days Since the Last Accident, are posting excuses for complacency.  These signs should be replaced with signs that say: Are You Going to Have an Accident Today?  Make people worry less about being rewarded for doing their job with pizza parties and more about not being rushed to the hospital or losing one’s sight; that would be an incentive to be careful.  People don’t need to be reminded of what they’ve already achieved; they need to be aware of what they haven’t.

We will never be accident-free.  We need to remind ourselves every day about the consequences of inaction, what happens when we break discipline, not just to ourselves, but to those we are charged with transporting safely every day.  It’s in our benefit to conduct ourselves to the highest level; anything less is just not good enough.

Aircraft Accidents and Discipline

On September 17, 1908, Lt. Thomas Selfridge flew into history; he became the first recorded fixed wing aircraft accident fatality.  Selfridge was taking a test flight for the Army, flying as a passenger with Orville Wright.  As Wright entered into a right turn, the aircraft engine failed; the plane made a shallow dive into the ground.  Wright survived, but Selfridge was pinned under the engine, receiving fatal injuries.

Obviously, this tragic event was, for the available technology and aviation knowledge at the time, unpreventable; there was no previous experience for Orville Wright to benefit from to avoid the disaster.  One only has to look at later tragedies in space flight, the next frontier, e.g. Apollo One, Challenger and Columbia, to see that even learning curves can spark disaster caused by unknown elements or, in the case of both Space Shuttles, arrogance and complacency.  But we can’t escape that excuse these days, especially with standard flight knowledge.

Since 2003, I have been critical of individuals who tweak hard-earned privileges to their advantage; rights merited by more qualified professionals.  These persons ride the coattails of experts in their field or hide in the shadows of more competent individuals.  There is no discipline in acquiring these privileges; no knowledge went into the privileges; no responsibility is taken for use of the privileges.

For instance, people who abuse the Americans with Disabilities Act suffer no consequences for their arrogance; they’ll carry anything from a cat to a full-grown turkey onboard a passenger flight without regard for others’ safety or comfort.  The privileges acquired by, e.g. the Association for Unmanned Vehicle Systems International (UVSI), are damaged by those amateurs who use drones with absolute disdain for the safety and privacy of others.  These amateurs amount to a very small percentage of the specific community, yet they draw the most attention – mostly negative.

People with real disabilities have worked hand-in-hand with the Federal Aviation Administration (FAA) and other like organizations, to promote safety in the air.  Their trained service animals won’t snap at other passengers, defecate from fear of jet noises (which cause major delays and cost the operator thousands of dollars) and are able to handle emergency situations, while aiding their owner during evacuations.  The UVSI works hard to eradicate real drone threats, trying to bring in line the amateurs who abuse the privileges of using the commercial airspace and who are the drone threats.

In the 1965 movie, Those Magnificent Men in Their Flying Machines, a group of men with the financial means to buy aircraft, race from London to Paris in 25 hours, 11 minutes.  Released almost 53 years ago, the movie is a classic example of how money does not represent experience.  Several ‘pilots’ play a dangerous game of learning to fly while preparing for the race.  The lyrics speak to their acquired skills: “They enchant all the ladies and steal all the scenes,” and “Up, down, flying around, looping the loop and defying the ground.”

In my first novel, The Air Crash Files: Jet Blast, my protagonist, Daniel Tenace, makes an off-handed comment about light-sport pilots in the air above Fauquier County, Virginia; he calls them ‘FDGs’ (Future Dead Guys).  The character states this, not as a citizen tired of, e.g. the ultralight engine’s ‘lawn mower’ noise – though at early morning hours, they are annoying.  He makes the remark because he and others have spent years training to work on and fly aircraft; that aviation is, like the sea, unpredictable and unforgiving.  One has to be prepared for anything.

This is not a reflection on the many people who are legitimate Light-Sport Pilots belonging to legitimate organizations, e.g. The United States Ultralight Association (USUA) from whom I expect to receive a strongly worded letter in the near future.  On the contrary, I find these organizations to be excellent advocates for their members, providing advice, regulatory support and a community that stands behind each member, because, let’s face it, Government Officials don’t know everything.

To better understand the requirements to operate as a Sports Pilot, review Title 14 of the Code of Federal Regulations (CFR) Subpart J, Parts 61.301 through 61.307; General Operating and Flight Rules are listed under 14 CFR Part 91.  14 CFR Part 61 Subpart J lays out all the hurdles and obligations a Sports Pilot needs to meet to obtain their certificate.  The issue I have is not my feelings on what qualifies a person to fly Sport Pilot; instead, it’s the discipline to continue flying successfully and safely in that unpredictable and unforgiving sky.

In 14 CFR Part 61.303, the requirements are given for operating a light-sport aircraft.  A person using a United States (US) driver’s license to operate a light-sport aircraft (LSA) must comply with restrictions and limitations of the US driver’s license and hold a valid FAA-qualified medical certificate, that it is in good standing and in the applicant’s possession.  An applicant must pass a knowledge test on aeronautical knowledge; they must pass a practical test on operations specified in 61.309 and 61.311.

Yet my concern remains: is possession of a US driver’s license as a requirement enough to apply for a light-sport aircraft certificate?  LSA pilots must pass familiarization training, yet I feel there isn’t incentive to be current; up, down, flying around looping the loop and defying the ground doesn’t qualify as being current or building experience.  Is there a time limit on recurrent training?  If the window of opportunity for LSA pilots is a month or two in a six-month period, how do they refresh their skills and what regulation requires it?  If they break a leg or have surgery during this missed window of opportunity, are they required to retest?

I spent three years in a trade school chasing my Airframe and Powerplant certificate; when I joined the airlines, that certificate only qualified me to train as a mechanic.  There was a time limit saying that: even though I had years of experience working, e.g. DC-10 maintenance, if I didn’t work on a DC-10 in a specific amount of time, then I had to retrain, start from scratch.

Private and commercial pilots are the same way; recurrent training is mandatory.  Recurrent training is not required as a gimmick or money-making scheme; it is dictated to assure the pilot or mechanic holds the highest level of safety first.  Toba Beta said, “Practice doesn’t make perfect.  Practice reduces the imperfection.”

The CFRs are ambiguous; they are written that way to assure some wiggle room in the regulations.  I may have missed a point of 14 CFR Part 61, but I don’t see how not being proficient is discipline.  To obtain any type of pilot certificate based initially on possession of a US driver’s license hardly seems to inspire one to build experience.  Is a desire to be a LSA pilot enough or does one have to go beyond a requirement; to take the initiative to be better by practice?

Orville Wright lived until 1948.  He saw firsthand the advances made in aviation, launched from his and Wilbur’s dream.  Yet, I’m sure Orville lamented that Lt. Selfridge died because something happened outside of his control.  If Orville had anticipated the engine failure, the effect it would have on the aircraft’s stability could have been minimized; perhaps Lt. Selfridge would have lived a longer life.  Every life is full of what-ifs.  It’s important not to ask what-if all the way to the crash site.

Aircraft Accidents and Lessons Unlearned IX: United 232

On July 19, 1989, at 37,000 feet over northwest Iowa, United Airlines flight 232, a McDonnel-Douglas DC-10-10, suddenly lost hydraulic fluid to all three main hydraulic systems.  Hydraulics, being the lifeblood of an airliner, is used to actuate all primary and secondary flight controls, e.g. Ailerons, Flaps, Elevators; Hydraulics are required to lower and raise the landing gear, steer and brake the aircraft on the ground.  Despite the heroic efforts of the three pilots and an off-duty check airman, limping the airliner to Sioux City, Iowa airport, control of the aircraft was lost on Final approach.

United 232 suffered a catastrophic uncontained failure of the #2 engine’s Stage One Fan Disk, the center hub of the engine’s most forward fan section.  At rotational speeds of 1800 rotations per minute – any random fan blade of the eight-foot diameter fan section spins past the same point 1800 times per minute – the center hub came apart.  The separated sections’ centrifugal forces included enough energy to slice through the engine’s protective fan shroud, pierce the aircraft’s horizontal stabilizers and sever the #1 and #3 Hydraulic System lines routed inside the horizontal stabilizers; the #2 Hydraulic System was compromised at the #2 engine itself; thus, all three Hydraulic Systems failed.

In the case of United 232, the complete loss of Hydraulic System fluids was the cause of the accident.  It was, however, not what caused the accident.

Why did the #2 engine’s Fan Stage One Disk (FSOD) fail?  Per National Transportation Safety Board (NTSB) report AAR 90/06, the suspect FSOD was, at the time of the accident, seventeen years old; it had accumulated 41,009 flight hours and a total of 15, 503 flight cycles (one take-off through landing equals one flight cycle).  The year previously, it underwent its sixth Florescent Penetrant Inspection (FPI), a Non-Destructive Inspection (NDI) method.

Non-destructive Testing (NDT) and Non-Destructive Inspection (NDI) are a means for finding cracks, corrosion and other structural anomalies; NDI and NDT are used to test these components without having to destroy the component, part, structure, by destructive stress testing; the part can be reused if found to be structurally sound.  It’s the equivalent of X-rays versus exploratory surgery

The quality of the NDT process and materials is vital to accurately locating metal deformities and defects.  Without properly trained NDT personnel, NDI is completely ineffective.  Florescent Penetrant, Ultrasonic, Eddy Current, Magnetic Particle and X-ray inspections aren’t taught through common means; specialized training and qualifying to a high standard are critical to finding different types of defects; proper use of meters and equipment are imperative.

During the post-crash analysis of the recovered FSOD pieces, the metallurgical findings included radial cracks stemming from a ‘nitrogen-stabilized hard alpha inclusion’.  Per sciencedirect.com, ‘hard alpha inclusions (HAI) are low-density, hard, brittle regions of spuriously high nitrogen and oxygen that occur in titanium alloys;’ the HAI was introduced during the melting or forging process.  Titanium alloys become more brittle from the addition of nitrogen and/or oxygen, breaking down the integrity of the metal.  HAI is easily detectable by NDI as surface cracks and voids.  However, they are extremely difficult to detect when subsurface and require NDI that deals with magnetic fields to detect.

Still, though the Stage One Fan Disk separating so violently from the engine is the reason for the Hydraulic failures, the Fan Disk is an inanimate object; its integrity is dependent on outside influences; it can’t detect its own flaws nor repair them.  What initially caused the accident? We must go deeper by examining other similar accidents.

On July 6, 1996, a Delta Airlines MD-88, flight 1288, suffered an uncontained engine failure on take-off roll in Pensacola, Florida.  Engine debris from the #1 pod (left) engine’s Fan Hub, exited the engine’s shroud before penetrating the fuselage.  Delta 1288’s Fan Hub’s failure began during manufacturing; the drilling and boring of holes caused radial crack damage.  The crucial defect: hard alpha inclusions (HAI), this time involving Oxygen contamination, not Nitrogen.  The titanium alloy was overheated and exposed to oxygen during machining.  Drill bit chips, not removed during the drilling process, may have made micro-cuts in the holes.

On October 28, 2016, American Airlines flight 383, a Boeing B767, experienced an uncontained engine failure during takeoff roll in O’Hare airport in Chicago, IL.  The engine’s High-Pressure Turbine Stage 2 Disk broke into three large fragments, plus several smaller fragments; the second largest fragment, weighing fifty-eight pounds, punched through the right wing and soared a half-mile onto a warehouse’s roof.  Though the final report hasn’t been approved, the investigation is leaning towards defects in the High-Pressure Turbine Disk’s manufacturing.

The Lessons Unlearned from these three investigations should focus, not only on improving non-destructive inspection methods, but in how well they are being applied.  In United 232, it is easy to find fault with limited NDI technologies.  But, the eight years between United 232 and Delta 1288 saw improvements in Florescent Penetrant Inspection (FPI) technologies.  Why would the defects not be found?

Per NTSB accident report AAR-98/01, during post-accident inspections at Delta’s Atlanta facility, Federal Aviation Administration (FAA) inspectors found that Delta’s FPI testing area for components and parts was ineffective, e.g. the integrity of FPI materials were corrupted by contamination and improper housekeeping methods; FPI personnel training was deficient; inadequate quality controls; all led to seven violations that could have each contributed to insufficient inspections.

This problem is cultural; it points to multiple abuses in an airline’s culture, from cost-cutting attempts to manipulating the mechanic seniority system.  The NDI technology is there, but the air operator ignores the benefits.  The NTSB cannot dictate culture changes; an air operator’s philosophy can’t be changed by a Recommendation or put to rights by an Airworthiness Directive.  A culture must be fixed from within.

The twenty years between Delta 1288 and American 383, saw a rise in Eddy Current Inspections (ECI), a different type of NDT.  ECI improved the detection of sub-surface defects, e.g. cracks or cavities.  In time, Amplitude Analysis, an older version of ECI, was being overshadowed by a more sensitive ECI, Phase Analysis.

Culture was not a strong contributor to American 383; the technology was there; American made use of it.  But what industry changes took place in the years between 1996 and 2016?

In November 2001, while investigating the American 587 (NTSB Report AAR-04/04) accident, I flew to Tulsa, Oklahoma, to look at American Airline’s maintenance facility.  The Tulsa facility was representative of a vanishing maintenance norm; an era where airlines conducted their own maintenance, in-house, e.g. heavy inspections, component rebuilding; practically everything done to keep an airliner airworthy was accomplished by the airline itself.

Through the late 1900s, as the passenger and cargo airline industries continued to expanded overseas – slowly at first, but rapidly increasing their flights – maintenance and inspections were contracted out to other airlines and Repair Stations in Europe, East Asia, the Middle East and South America.  This saved money, e.g. labor and facility costs, and prevented unnecessary movement of the airliner just to accomplish maintenance.  As a result, airlines e.g. American, began downsizing their maintenance facilities and contracting out important inspections, e.g. Non-destructive testing.  Although the quality of inspections did not suffer during the transition, the airlines began to turn over control of their inspection programs and processes to a third party; oversight went from first-hand (single level) oversight to multi-level oversight.

This represents major changes in the control of: training, personnel, inspector pay scale, types of NDI offered, timeframes for work accomplished, etc.; a major transformation of the aviation industry with regard to the quality control of inspections, e.g. who performs inspections and who oversees them.

These changes are beyond the NTSB’s abilities to recommend safety.  Few in the industry could have foreseen airline industry milestones, e.g. Deregulation, Hub-and-Spoke, Regional Airlines, International Contractors, that are commonplace today.  We should go back to the early accident reports to assure safety measures applied then when the industry was different, still apply today; perhaps to learn lessons unlearned.  If not, American 383 may not be the end of the line of such accidents, a line that should have stopped almost thirty years ago with United 232.