Aircraft Accidents and Mismanagement, Part Two

“A bad manager can take a good staff and destroy it, causing the best employees to flee and the remainder to lose all motivation.”  Brigette Hyacinth, MBA Caribbean Organisation.  Ms. Hyacinth is a motivational speaker and educator.  There is iron in her words, especially for the employee who can’t leave.  There is nothing worse than working in a hostile or adversarial workplace, particularly one that is inescapable.  How does this type of work environment affect aviation safety?

Case One: Thirty years ago, I was a supervisor for an airline.  A new Director took over my line station, immediately rearranging the station’s work schedules to ‘streamline’ the workplace to the flight schedule; in reality, an experiment.  On paper, the new schedule made some sense, shuffling manpower around to address a minor future problem.  However, the old schedule worked just fine; the manpower met the needs of the flight schedule because, except for a few seasonal ad hoc flights supported by overtime, all the aircraft were worked.  Bottom line is, the Director decided to fix something that wasn’t broken.

Overnight, the workplace turned into a hostile environment: crew-to-crew tensions elevated; supervisor-to-mechanic relations deteriorated.  Meanwhile, the Director never showed his face, choosing to remain in his office to ‘let the dust settle on its own’; no meetings, no one-on-one chats, just silence.  This did nothing for workplace morale.

It wasn’t that the workforce was so opposed to a new schedule; despite the drastic changes, job actions were not the problem.  Instead, it was in the delivery: the quality of life needs of eighty-five mechanics were casually dismissed by the new Director.  Those who could transfer out, did; those with families were locked in or found other equally paying jobs in the area.  After several months, the more talented and experienced were reacting, taking the better shifts.  On-time reliability decreased with the reduction of experienced mechanics on more demanding shifts.  Other airports serviced by this station were beginning to be affected by the delays.

The workplace environment, increasingly hostile, ultimately resulted in Human Factor issues, e.g. sleep disruptions – workers were now having to drive long distances in congested rush hour traffic; family and financial tensions increased – spouses were expected to compensate for the mechanics’ new hours that intruded on every family responsibility, from Childcare to school sports; and the feeling of being trapped in a job with no escape.  These human factor issues played havoc with safety, not because of resentment, but from exhaustion, distracted attention, family problems, etc.

The Director was removed after one year; during that time, upper management threw all support behind him, that is, until reality set in and they realized the unnecessary schedule changes were costly and counterproductive.  However, the damage was done.  One bad manager destroyed a cohesive staff of professionals; productivity took forever to return, reliability suffered, the workplace environment and trust of management were irreparable, all because one bad manager wanted to prove his own worth.

Years later, when I worked aircraft accidents, my friend Evan, a Human Performance specialist, weaved human factors questions into each technician interview we conducted.  Why?  Because technicians, pilots and air traffic controllers are human.  We react – often intensely – to radical changes in, e.g. sleep patterns, temperature, financial difficulties, family influences, lighting, etc.  Even though conditions change, life goes on, whether we can handle it or not; it does not stop to ease life’s difficulties in.  This phenomenon was exemplified by the First Officer in the Colgan Air 3407 accident in Buffalo, February 2009.

Case Two: Air Midwest 5481 is a tragedy I refer to often, perhaps for the many lessons we can glean from that particular accident.  The 2003 Charlotte disaster would never have happened, but for the complete breakdown in management.  The failure at Air Midwest went from the top ranks to a frontline workforce of complete strangers with no loyalty to the airline.  However, the main difference between the breakdown at my former employer and Air Midwest was in the training; management allowed Air Midwest’s maintenance training to suffer to the point of irrelevance.

The level of inexperience at Air Midwest, especially at its Huntington, WV, facility, was stark; correct maintenance practices were ignored or misused.  The quality of technician training was absent; the workforce’s dedication was indifferent, while management’s attention was never on the workforce or the safety of work accomplished.  The Air Midwest supervisor worked Day shift and the contract workforce worked midnights; this meant the contractors employed to work the Air Midwest aircraft were unsupervised – by Air Midwest.  No one was assuring the airline’s best interests and safety were looked at.  The contractors, left to their own devices, never dedicated themselves to proper training.

For all the accidents I’ve investigated or certificate holders I’ve inspected, training is the common thread of abuse.  Padded training hours, inexperienced instructors, ‘pencil-whipping’ and over-crediting of hours are common ways any organization hides their employees’ lack of qualification.  Air Midwest had all these and more, including a large turnover of technicians.

Air Midwest gave no structure for the contract maintenance people to follow; management was unconcerned, so the technicians felt no loyalty to stay.  The revolving door of technicians made completing the necessary training and cultivating experience on the aircraft, impossible.  Management was untouchable, inaccessible and apathetic.  Furthermore, management was irresponsible.

In both cases, similar results occurred, e.g. a large turnover of employees.  In Case Two, with only eight mechanics per shift, a consistent turnover of employees is glaring in this situation.  All eight had cycled out over a period of several weeks, and then the replacements cycled out.  Upper management didn’t disregard the problems, they just didn’t care.

In Case One, the effects were less obvious, except over time.  The increasing percentage of people transferring out or ‘jumping ship’ was spread out over months; senior, more qualified mechanics moved around internally, leaving the less experienced to the shifts that demanded experience.  The signs were ignored by upper management, even justified as the consequences of necessary change or dismissed as disgruntled mechanics resistant to change.

With improper Training, the trail is easy to prove; training records are tangible, one can see the abuses in documented training hours.  Human Factors issues are not so easily identifiable; the negative effects are felt over a longer period of time, sometimes over several seasons, e.g. increases in driving times the workers experienced could be discounted as an increase in Christmas travelers or beach goers.  These issues are lost in analysis.

The common factor in both cases was Management, or the absence of good management.  It’s important to note, these are not isolated incidents, but examples of greater problems.  Front line and upper managers are supposed to be filters between the bean-counters and the workforce; they’re not meant to become bean-counters themselves.  Upper management should become increasingly concerned, not so much with what happens outside the company, but what effect their decisions have on the inside of the company.  Upper management should rely on the analysis of Quality Control and not on lower management’s often sycophantic opinion.

Today’s managers are in a rapidly changing environment, each trying to make their niche, claw their way to the top, oftentimes at the expense of the group they’re managing; this fact is not debatable.  But the workers are what’s important: consumers don’t purchase goods and services that managers make possible, they purchase these items from what the workforce provides, assuming there is a workforce to provide.

And safety isn’t something that can be managed, it has to be committed to by each employee.  To do so, each employee must receive the training and tools they need to be safe, work safe and think safe.  To do that, managers have to get back to supporting their workforce, not destroying it.

Aircraft Accidents and Mismanagement, Part One

In 2015, Victor Lipman wrote an article for Forbes, titled: People Leave Managers, Not Companies.  In the article, Lipman makes the point: “In short, the central relationship between manager and employee plays a critical role,” in employee disengagement.  This may sound like a trivial problem, not rising to the level of concern.  However, in safety-sensitive environments, e.g. aviation, employee engagement is not an option; attention to detail is critical to not just the health and hazard of the employee, but to the security of those engaged in safety of flight.

Two things that I try to incorporate heavily when instructing my classes are: Culture and the Five Whys.  The Culture of an organization is the single most important aspect of an organization; it is a major factor when conducting Risk Analysis to fix systemic problems.  The Five Whys dictates that, when deconstructing any accident, it is crucial to go backwards from the accident, asking ‘Why’ at least five times; each answer generates another ‘Why’ until the conclusion solves the mystery; it guarantees discovering the root cause of the accident.  I’ve found that a major culprit in both cultural problems and accident root causes stems from concerns with Management, or, to be more precise, Mismanagement.

Management – either middle or front-line – controls communication between upper executives and the workforce; their persuasions influence executives in making life changing decisions, for good or bad, on the workforce.  Since there exists, especially in the larger companies, communication divides between executive management and the Workforce, inept management is almost impossible to filter out, resulting in workforce frustrations.

To allay any thoughts that I’m trashing Management, understand I’ve worked in Management, myself; I’ve been there and even got the T-shirt.  I supervised a major airline’s maintenance line station, consisting of eighty-five mechanics in an environment that would qualify as adversarial.  I would never do it again … no, no, no.  Not because I couldn’t do the job; not because of the combative environment; not even because I ran out of people to pay to start my car for me each night (it was a rea-eally adversarial environment).  Instead, it was the same Management people I knew before I became a supervisor versus those same Management people I knew after I became a supervisor.  Those people are the reasons I will never work in Management again.

Yes, Management is a thankless job.  It’s wearing the biggest target in a ‘Kick-Me’ contest, and everyone’s wearing golf shoes.  It’s also a job one volunteers for; specifically, one walks into a management interview with eyes open wide, knowing the responsibilities.  Still, one interviews anyway.  What does a manager do?  Does the employee work for the manager, or does the manager actually work for the worker?

When my employees depended on me to fight their battles, I often took the bullet for them, even when they weren’t in the right.  I stood toe-to-toe with condescending airline pilots, technical specialists, flight planners and other surly management types.  I suffered some bloody noses, received quite a few apologies, but always made my mechanics’ battles, my battle.  Written discipline was an absolute last resort.  My job was to support their efforts to do their job, which was to fix airplanes.  Why?  Because the pilots never said, “I had to disconnect the number two generator in flight.  Send out a manager.”  The First Officer never called over a manager to look at a hydraulic leak.  They always asked for the mechanic.

During accident investigations, it was my job to familiarize myself with different air operator cultures.  In these situations, I found Management could be the breaking point between safety and carelessness; indeed, Management dictated the very Corporate Culture.  Their actions or inactions affected morale, shift schedules, inter-shift relations, tooling, budgeting, overtime, training, vacations and safety.  Add a Union to a non-union shop and the Culture transforms into unrecognizable chaos with a short fuse.

Why is this important?  It speaks to the importance of Culture.  A management team’s competency or inclination to support their employees, dictates their employees’ successes and the workforce’s willingness to stay at the job for the long haul.  However, this same Management team can destroy morale, productivity … and safety.

With accidents, e.g. Air Midwest 5481, management had no presence; the site manager worked dayshift while the mechanics worked at night.  In the National Airlines flight 102 disaster, why wasn’t Management making the decisions on what loads were acceptable to carry?  The safety situation becomes more tenuous when employing contractors, workers who have no stake in the company’s success, beyond the paycheck.  The mindset: there’ll always be someone needing contractors.

Does this mean the Management-to-Workforce relationship has changed?  To me it does, because in my experience, Management no longer supports Staff; instead, Staff supports Management.  This is a dangerous idea.

Think about it: advances in technology and corporate practices are putting the workforce in a no-win position; these dramatic changes are being introduced subtly.  Robots are replacing food service employees and stock clerks.  Cashiers are being ousted by self-scanning registers.  Hotels reward customers for cutting back on maid service.  Aircraft manufacturers are investing in single-pilot and – eventually – pilotless technologies.

With this realization, the Culture shifts.  Management doesn’t need the employee because Executive Management provides the front-line manager with the toys to get the job done less expensively and more efficiently.  Management is moving into the driver’s seat; technology supports the manager; the workforce becomes expendable.

This seems like a dark situation right out of the book, 1984.  I have always worried that Safety and Common Sense are being quickly – too quickly – replaced by the security of technology.  How it will reconcile itself in the future is something no can foresee.  Is it true that People leave managers, not companies?  Perhaps.  I’m more concerned that there will come a time when the manager … and the company … just won’t care.

Aircraft Accidents and Forgetting the Past

There is a memorial in Forest Lawn East Cemetery, Weddington, North Carolina; it was dedicated (and still is) to the twenty-one victims of Air Midwest flight 5481.  It’s a proper monument to those who lost their lives that day: tranquil, respectful and a place to find peace.  The families even managed to extract an unprecedented apology from Air Midwest for the carelessness that led to the accident and the loss of so many lives.  Air Midwest’s President said, “We have taken substantial measures to prevent similar accidents and incidents in the future, so that your losses will not have been suffered in vain.”

Air Midwest was one of several airlines that operated under Mesa Airlines.  When Air Midwest ceased operations, the promises Air Midwest’s management made to those families were not transferred to Mesa; they simply no longer existed.

The memorial remains; it continues to provide solace to anyone who visits it.  However, like with all memorials, my impression of the after effect is one of cynicism, perhaps because people soon forget; it is unintentional, yet so human.

I personally affirm that we tend to overlook too much.  Yes, we remember the loved ones, but we forget and/or bury the reckless events that killed them.  We should try, perhaps, to maintain some semblance of the horror, just so we don’t completely lose our anger, thus our focus.  Though time heals all wounds, there are some wounds that should never close completely, lest we forget the lessons learned.

In a related story, an article this week from the website: MRO-Network: a certificated Repair Station is providing mechanics to airlines and Maintenance, Repair and Overhaul (MRO) facilities.  It’s a Temporary Service Provider of certificated aircraft mechanics and technicians.

When Repair Stations are certificated, they must have structure; workers must not be confused about whose maintenance program they are following.  They must follow the regulations outlined in Title 14 of the Code of Federal Regulations, Part 145, meaning: they must maintain a Repair Station Manual that describes the Repair Station’s facility, organizational breakdown and a description of the repair station’s operations.  The repair station must maintain a Quality Control Manual that describes how the repair station maintains quality of work.  Mechanics and technicians must be capable of working independently within the repair station, not be an interim replacement for vacation coverage or a striking workforce.

I have nothing against temporary services.  However, I believe temporary workers cannot fill slots that require the specialized training and accumulation of experience found in today’s aircraft mechanics and technicians.  I’ve seen this Temporary Service Provider concept employed before; it led to disastrous results.  It happened so long ago – a winter day, fifteen years ago.  People forgot what went wrong, if they even realized it to begin with.

I can’t forget.  I know so well what went wrong.

On January 8, 2003, Air Midwest 5481 crashed due to numerous irresponsible mistakes made by Air Midwest, egregiously preventable errors that formed a perfect storm.  Two of the main causes of the accident were a tail-heavy aircraft and no elevator authority to recover.  The tail-heavy problem was a result of procedural problems at the Charlotte ramp, for no one knows how long.  The other regional carriers for US Air at the time, did not learn from the accident, even though they used the same load crews and procedures.

It was the lack of elevator authority that really hits home; an elevator mis-rigging that was a direct result of training policy abuses by Air Midwest and its repair station.  When 5481’s pilots realized that the aircraft was going into a stall – a flight attitude that has no ability to generate lift – they pushed forward on the yokes against the mechanical stops, but were rewarded with no ‘nose-down’ ability (authority) to achieve level flight; the elevators would not move past a few degrees of zero degrees level, which was not enough to recover.

Air Midwest (AM) had contracted their maintenance to a repair station: Raytheon Aerospace (RA); RA needed manpower so they used a Temporary Service Provider for aircraft mechanics.  Temporary mechanics were rotated through RA, almost on a weekly basis; one mechanic would cycle into the hangar and another would cycle out.  No lasting experience, no regular training.

And here’s where the problems began: the large amount of mechanic turnover contributed to a workforce that was unfamiliar with the aircraft.  Initial training was accomplished every night and for three to four (out of a crew of six) mechanics at a time.  The qualifications of the trainer even came under question, concerning whether his lack of experience and knowledge of the aircraft qualified him to even instruct others.

I have full confidence in Contract Maintenance Providers; they are found all over the world.  Contract Providers most likely worked on the aircraft you flew yesterday or will fly tomorrow.  There is, however, an expansive difference between a Contract Provider and a Temporary Service Provider.  Contractors employ their own people; they follow their own procedures; mechanics and technicians know where they will be working tomorrow, next week or next year.

Temporary Service Providers, that I have seen, are in a different class.  When I investigated the Air Midwest accident, RA hid the fact they had hired temporary workers for weeks.  RA managers were moved or retired without notice.  By the time of the Hearing, temporary mechanics went from being employed by the Temporary Provider to being employed by RA and back again.  Most important: throughout the investigation, we learned that the training the temporary mechanics received was almost non-existent; they had no experience on any specific type of aircraft; the training that led to the mis-rigging of the elevators was grossly inadequate.

Why are temporary service mechanics considered unworthy supplements in aircraft maintenance?  Temporary, aka Temp, workforces come in many forms, e.g. office administrators; these Temps are using universal skills, e.g. a complete knowledge of Microsoft Suite.  Skills that are transferrable to every customer they serve, albeit with adjusting these skills to address needs that are indigenous to each customer.

Airlines and MROs are invested in equipment and services that are not universal.  Some airlines have turbofan engines while others have combustion engines; some have analog aircraft while others have digital; over the last twenty-five years more composite materials make up airframes.  Working with these technologies demands experience and knowledge; a technician cannot gain this experience in weeklong assignments.

This is why Temps for aircraft maintenance is not only unadvisable, but dangerous.  When Air Midwest crashed, the problems that led to the accident were to be corrected; training was to be improved, that the concerns with Temps would be addressed.  However, Air Midwest surrendered its certificate; the promises made to rectify training troubles no longer applied.

It is possible that Temp services, such as the one mentioned in MRO-Network’s article, are businesses of high integrity; that they plan to work within the regulations; their people will be the best trained, at least, in the beginning.  But, I’d be remiss if I didn’t remind the industry about the lessons of Air Midwest flight 5481.

Both Air Midwest and Raytheon Aerospace also began with reliable policies; they became certified because of their approved and accepted procedures.  They started out right.  Whether through complacency or laziness, their operations became unsafe.  And because of that, twenty-one people died.

‘We will never forget’ isn’t just a catchy phrase; it’s a promise; a commitment to make sure the failings of the past are not repeated.  ‘We will never forget’ says the apology and promise made to the families of Air Midwest’s victims must … must … must, ring true: “… so that your losses will not have been suffered in vain.”

Aircraft Accidents and Lessons Unlearned X: BOAC Flight 781

On January 10, 1954, British Overseas Airways Corporation (BOAC) Flight 781, a de Havilland Comet, crashed into the Mediterranean Sea following an inflight breakup.  It was the second of three fatal Comet accidents in less than a year; the third accident, Flight 201, could not be recovered, yet displayed similar characteristics to Flight 781.  Both accidents were investigated by Great Britain’s Ministry of Transport and Civil Aviation (MTCA), who authored the report.

Even though Flight 781 had come apart over the sea, a large portion of the aircraft was salvageable; the investigatory board re-assembled most of the pieces.  Early on, the investigation focused on evidence of a mid-air fire.  Modifications were made to the aircraft and, within a month, the Comet was back in commercial service.  Three months later, Flight 201 crashed, ending the Comet’s career.

The first and second accidents were unalike; the countries where they occurred were far apart.  In 1954, with the Jet Age in its infancy, accident investigation techniques were non-existent; inspection techniques were being developed.  Pre-WWII aircraft that survived the war were not capable of the speeds, altitudes, ranges, or pressurization capabilities of the new jet-age aircraft.  There were no baselines for the MTCA to compare Flight 781’s circumstances to.

The MTCA report claimed in its Conclusions that the aircraft crashed due to “failure of the cabin structure, owing to metal fatigue.”  Stress cracks emanating from an Automatic Direction Finder Window provided the ‘weakest link’ point for the original break-up, the window corners particularly.

With modern aircraft windows, stress flows freely around curved edges; it isn’t concentrated.  However, with the Comets’ squarish windows, stress cannot smoothly flow around the abrupt corners; the corners develop stress concentrations, which occur in a restricted area, because the stresses are higher than the surrounding areas.  The window frames’ squarish shape provided a point for cracks to start.

Between internal air pressures and temperature differentials, fatigue easily weakened the metal.  What does that mean?  How can metal fail so catastrophically?  To put in perspective: a total of 10.9 pounds per square inch of pressure (PSI) is placed on the hull at 27,000 feet of altitude; this is the altitude where Flight 781 came apart, climbing into extreme temperature variations.  That’s 10.9 pounds … persquareinch of pressure forcing out, with next to no pressure pushing in.  Consider that pressurizing an aircraft is like inflating a metal balloon.  Every time the aircraft climbs results in pressure pushing out on the skin and joints; each time it descends, the skin and joints flex inward.  The metal skin attaching hardware, e.g. rivets, screws, attempts to hold the balloon together while 10.9 psi is acting to force it apart.  The balloon eventually fails at the weakest point.  If this point is at a pre-established crack, the pressure rips the fuselage open with explosive force, tearing the metal like tissue paper, continuing unimpeded over the length and width of the fuselage; to quote the MTCA report, “like a 500-pound bomb.”

Investigators were slowly coming to understand that flight cycles and flight hours were two separate factors, especially when considering pressurization.  Manufacturers were concerned with the lifetime flight hours, i.e. the number of hours an airliner is flying, NOT flight cycles.

A flight cycle is vastly different from a flight hour; each time an aircraft takes off and lands is one cycle.  During this time, the aircraft is pressurized and depressurized one time.  By comparison, an A320 flying directly Fort Lauderdale to Boston may use three flight hours, but log only one flight cycle.  An identical A320 may fly Fort Lauderdale to Dallas, stopping off in Tampa and New Orleans; this aircraft logs three flight hours, but it also logs three flight cycles during that same three-hour period; three pressurizations/depressurizations.

What is interesting about the MTCA report is the statement, “During the period 1949 to 1951, there had been growing among all aircraft designers and users, a realization that the life of the essential structure is not unlimited.”  This statement is incredible: MTCA’s report suggests engineers in 1951 were aware of structural limitations.  Ignoring these concerns is indicative of an industry today that did not learn from the past.

Move ahead 34 years; in 1988, Aloha 243, a B737 flying between the Hawaiian Islands, experienced a catastrophic structural failure when the fuselage’s crown peeled off in mid-flight.  Boeing had overestimated the B737 airframe’s lifetime, forecasting a longer life without realistically studying the effects of flight cycles on the structure.  Following this accident, all manufacturers were forced to re-evaluate the life limits of all their products.

In many ways, Aloha 243 was unique; it stood separate from other B737 models flown by many US operators.  Aloha employed its B737s in short-range, ‘up-and-down’ island hops in a very hostile environment: humid air over a salty ocean; a great combination to aid corrosion.  Did Aloha and Boeing ignore the lessons of BOAC 781?  The consequences should have been obvious: inflating an overstressed and abused fuselage should have either dictated a more robust inspection program or limited the number of flight cycles in the corrosive environment.

But what changed in that 34-year gap?  For one, the engineers who designed the Comet, the B707 and the DC-8 were gone, replaced with engineers ignorant of the past.  Second, the same arrogance that doomed the Titanic and the Challenger was present, a culture that felt they could not fail.  Third, the industry was captivated by new technologies, fooled into complacency by trusting too much to new sciences.

This type of failure played out again fourteen years later when a rapid decompression destroyed China Air 611 on May 25, 2002.  A repair that was not tracked for reinspection turned into a deep crack; the end of the new crack in the B747 passed the repair’s perimeter; the fuselage tore open killing all 225 aboard.  China Air 611 came at a time when lessons from other events, added to breakthroughs in non-destructive inspection technologies were commonplace.  The fact that it was a different country is irrelevant; China Air 611 should never have happened, while Aloha 243 could have been prevented.

The takeaway of Lessons Unlearned from these accidents’ findings is that we are never ‘too advanced’ to learn from history.  Thirty years of technological advances and improved inspection techniques between the Comet accidents and Aloha 243 did not prevent the outcome: the structure, aided by enormous internal air pressures, failed in flight.  As we continue moving quickly into the Composite Age, we should review what we learned – and failed to learn – the last times; search for anomalies that could replay disasters of the past.  Armed with this knowledge, we can prevent the preventable next time.