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.”

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