Aircraft Accidents and Evacuation

Did you ever see a documentary on how an airliner is built, from drawing board to test flight?  Each new airliner must have an evacuation test performed to certify the number of passengers that can be safely evacuated in an emergency; a controlled simulation, employing test subjects who resemble Olympic athletes, instead of real-live passengers.  There’s the hundred-meter Dashers who can cover the distance from their seat to an exit like a gazelle; the sixty-meter Hurdlers leaping over other evacuees and the High Jumpers, clearing the seatbacks with little to no effort.  These employee-slash-test subjects can expedite out the various exits like water through a sieve.

What test subjects you don’t see are those that resemble the pregnant Mom with three children in tow; the Great-grandmother confined to a walker or the Sumo wrestler who barely fits into his Coach seat, much less the aisle … and, if you read last week’s article on Aircraft Accidents and the Survival Instinct, the untrained Emotional Support Animals getting caught up in the panic.  For such a simulation to accurately demonstrate what happens when an airliner evacuation is in crisis, one has to throw in lots of smoke, kill the lights, have everyone yelling simultaneously at the top of their lungs, some luggage from under the seats littering the aisles, children and the handicapped being trampled upon and the pushing/shoving/fighting that goes along with desperation.

And one more thing: add the selfish passenger trying to extricate his laptop or luggage out of the overhead bin, even while he is fighting the flow of traffic to get to it.

To those who read my columns, you would notice I do not agree with the National Transportation Safety Board (NTSB) that often.  However, in regards to this topic of overhead bins and unsafe passenger practices, I’m pleasantly surprised to see the NTSB come out on the side of common sense, leaving the Federal Aviation Administration (FAA) seriously wanting.  It isn’t that the issue hasn’t come up before; there are quite a few events that we know of that have had passengers demonstrate a complete lack of safety without any consequences for their actions.

To give perspective, to those of us who fly, for pleasure or business, all of us have witnessed the logjam that greets us every time we board a flight.  The logjam occurs because numerous passengers who boarded fifteen minutes before you, are still looking for an overhead bin.  Once found, they waste more time blocking other passengers while stuffing luggage twice the size of the overhead bin … into the overhead bin.  Then they bounce like a pinball, looking for another overhead bin to house their other pieces of luggage.

On February 2nd, Bloomberg ran an article:  This article followed the NTSB Investigatory Hearing into American Flight 383, the B767 that burned on an O’Hare runway following an uncontained engine fire on October 28, 2016.  One issue raised was the emergency evacuation interruptions by passengers, e.g. a woman passenger who ignored the flight crew’s orders to “drop her luggage”, thus holding up the egress of other passengers.  The luggage posed a threat to the inflatable escape slide, e.g. sharp corners, zippers.  She blocked the aisle to get her luggage, before lumbering down the aisle.  This could have had serious fatal consequences to numerous other passengers, many of whom couldn’t get their children around her in the narrow space.

On August 3, 2016, an Emirates airliner in Dubai found passengers desperately trying to liberate their luggage from overhead bins, even as Flight Attendants yelled to leave everything behind.  Other similar emergency evacuation problems, where passengers defy flight crew orders to ‘drop the luggage’ get lost in the hype behind the accident and accompanying investigation.  Meanwhile, aviation authorities shake their heads, saying “What to do? What to do?”

Common Sense should prevail.  However, in the world of accident investigation and regulation, common sense is lost.  Consider the tragedy of Germanwings 9525: in the wake of 9-11, we created a ‘fix’; a situation where the cockpit door was so secure, even the Captain couldn’t get back inside.  What if a similar event occurred that wasn’t a suicide?  What if the first officer did become incapacitated by stroke or heart attack.  Would the end result have been different?

Every self-proclaimed aviation expert looks for ‘new fixes’; untested, unnecessary and senseless ‘solutions’ to, in this case, the dangerous-passenger problem.  One ‘solution’ levied by our ‘aviation experts’ is to design overhead bins that lock in an emergency.  I can’t begin to list the problems that THAT ‘fix’ would present: How would the airplane’s computers know to lock the bins?  Is there going to be a ‘Lock-the-Bins’ switch installed in the cockpit?  Can the plane be dispatched with the overhead bin locks broken?  And then there’s the ultimate fly-in-the-ointment problem: what if the lock activates due to a relay problem, then can’t be released after landing?  What to do?  What to do?

Maybe it’s the mechanic in me or my experience working at Risk Analysis, but perhaps we should start asking the question, ‘Why’ enough times until we find – – – THE ROOT CAUSE!  The ironic thing is, it only takes asking ‘Why’ five times before the answer presents itself; I know this because I’ve employed Risk Analysis in accident investigations, troubleshooting and inspections – ask ‘Why’ five times, that’s all it takes.  In my experience, the solution is simple and so in-your-face obvious.

One solution I would put forth is: start using civil penalties against passengers who defy flight crew instructions; you don’t even have to write them, they already exist.  According to FAA Order 2150.3B, ‘Interference with Cabin or Flight Crew’ carries a fine of $25,000 for the violation.  According to Title 14 of the Code of Federal Regulations (CFR) Part 13.301, (revised 01/01/2017), interfering with a cabin or flight crew [member] now carries a maximum fine of $34,172.  If enough people receive civil penalties requiring them to mortgage their house to pay for stupid actions that threaten the lives of others, then perhaps it will cease to be a problem.  That’s too tough?  Right.  And maybe we should allow people to continue driving drunk and performing other stupid acts without consequences.

What exactly does it mean: interfering with a cabin or flight crew?  It means – not suggests – that both a flight crew (pilot) and cabin crew (flight attendant) are the final authorities of the aircraft’s safety from passenger loading to passenger deplaning.  What it means is, if the flight attendant tells a passenger to “drop the bag” and get off the burning airplane, that the passenger doesn’t ignore said flight attendant or argue, but drops the bag, turns tail and runs out of the plane.

The reason this will not happen or will only occur under threat of FAA violation, is because the airline doesn’t want to ‘upset paying customers’, even the stupid ones; the airline is so busy apologizing for the event that the they won’t back the flight crews; instead they will defer to the crazy customer whose eyes rotate non-stop, in a counter-clockwise direction.

It also means that, unless the FAA pushes the issue – which they should, but won’t – the flight crews will have no teeth; they will be ignored as the guilty passenger thumbs his or her nose at them.  In this case, the NTSB should hold the FAA to task, by requiring the FAA to exercise the authority given to them by Congress to make the skies and people safer.  Come on NTSB, this is your moment to shine!

What else can solve the problem?  How about removing overhead bins or limiting their use to emergency equipment, e.g. bottled oxygen.  Wow, what a weight savings; less fuel burned, more profit.  Kaching!  Kaching!  The FAA isn’t in the Commerce business; outside of safety issues, it can’t tell an airline how to run its business.  But overhead bins are no longer a Commerce issue, they are a Safety issue with proven violations to support removing them.  Passengers have begun bringing carry-ons onboard because airlines charge for check-in luggage.  In the name of Safety, the FAA can require airlines to do away with the charge, thus depriving passengers of the reason to bring carry-ons onboard.  That’s what luggage compartments in the aircraft’s belly are for.

And here’s another reason, folks: while airlines are tricking passengers into hauling their own luggage upstairs, airlines charge for other customers to carry their cargo in the luggage compartments that passengers aren’t using.  Kaching!  Kaching!  Bottom line: passengers are being duped, not once, but twice.

Overhead bins were originally designed for small items, necessary items, e.g. medication, pillows – not a week’s worth of luggage.  What this means is another good idea that was turned into something it wasn’t intended for.  But what about misrouted luggage?  What about long waits for luggage?  That falls under the heading of Capitalism.  Let the consumer push the airline to perform as promised; allow the consumer to hold the airline’s feet to the fire.  Routed my bag to Singapore instead of Miami?  I’ll be returning on your competitor.  Can’t seem to get me my luggage in a timely manner?  I’ll be getting my flight miles somewhere else.  The airlines have built a system that makes passengers complacent, almost obedient and forgiving; unwilling to demand the services they pay for already, while placing their safety in jeopardy.

The point is that solutions are easy; breaking out of our comfort zones, not so much.  But we must break this safety violation cycle brought about by dangerous passengers; ignore those ‘experts’ with silly solutions; don’t trust the documentary, but see what really happens.  Then use common sense and root cause risk analysis to completely fix problems.  For instance, another thing that came up this week was about the dog in the overhead … aaahh, I don’t have time to discuss how ridiculous ALL the parties were in THAT conundrum, from the dog’s owners to the airline.  I’ll save that Darwin Award for another article.

Aircraft Accidents and Survival Instinct

Survival Instincts are learned early in life.  One doesn’t have to build up the instinct, like an anti-body, it is often learned at a time when we develop our fundamental curiosity.  A child, who barely understands the word ‘No’, can feel the pain of a hot stove; the memory is stored in the Brain’s sensory cortex; when the child comes upon the stove again, he understands the danger, intuitively knowing to exercise caution or be burned.  Most animals have this same reflex to pain, warning them to all types of dangers.

In the world of aviation, dangers are so plain, so stark, that they qualify as common sense.  I have seen blatantly ridiculous displays of counter-common sense, executed by many airmen, so as to meet the requirements of the Darwin Awards.  But one aspect of aviation (and there are quite a few) challenges common sense on everyday flights on an airline near you, dismissing the safety of lives, health and the sound judgment to separate logic from utter silliness.

An article by D. Koenig, an airline writer, threw some light on an incident in Phoenix, February 21, 2018.  An emotional support dog sitting with its owner in the passenger cabin of a Southwest Airlines aircraft, bit a seven-year old girl who went to pet it.  The owner stated that, “he warned the young girl not to approach his dog.”  An earlier incident on a Delta flight in June, a seventy-pound dog bit another passenger on the face, requiring the unfortunate passenger to be hospitalized from the wound.  In similar circumstances, airlines are quick to defend the rights, not of the wounded passenger, but of the Emotional Support Animal.

What is an Emotional Support animal?  They are animals that provide emotional support for their owners during high stress situations, e.g. flying.  The term was born from the Americans with Disabilities Act of 1990 (ADA), which recognizes the rights of the valid handicapped to receive non-discriminatory treatment for various situations, e.g. housing, jobs and service animals.  What is the difference between a Service Animal and an Emotional Support Animal?  In a word: Training.  Service animals are extensively trained to deal with emergencies, assuring their owner’s safety in all types of crises.

An Emotional Support Animal (ESA) isn’t required to be trained; they will act as any animal would in a crisis, albeit in conditions that include humans in the same danger.  The only requirement to bringing an ESA into the aircraft cabin is a note from a human physician stating that the doctor – not necessarily a mental health doctor – supports the psychological attachment of the human to the animal.

Let’s look back at the ESA that bit the little girl; the owner says something telling about the incident; he said that, “he warned the young girl not to approach his dog.”  The child may not have developed the instinct that says a dog can be dangerous; indeed, the child may own a dog, a similar dog at that.  Walking down the aisle in a narrow-body metal tube, there isn’t much room for a child to be steered away from a dog or cat.  Close proximity is a given; a child’s affectionate nature, an absolute.

There is, however, a greater problem that aviation’s common sense is ignoring: Survival Instinct.  Since no one can foresee an inflight or ground emergency on any flight, what happens when an untrained animal, such as this, is introduced into a traumatizing situation, e.g. an emergency evacuation? 

I’ve participated in Emergency Evacuation Drills.  These simulations are comprised of trained flight attendants, trained inspectors, blinding smoke obscuring which way to turn.  It’s a sobering lesson requiring seconds to escape, or ‘die’ in a controlled mockup.

Navigating through an actual smoke-filled aircraft is the definition of desperation, chaos, especially on a full aircraft.  Many passengers are crawling on the floor, those standing are pushing and shoving, all are disoriented.  Passengers are unable to see, choking on fumes.  Flight crew members are shouting orders over passengers, who are shouting names, crying or screaming.  The cabin temperature is in the triple-digits and climbing, it’s hard to breathe and one can’t open their eyes.

Now, introduce into the mayhem, Fido, the confused dog, his own Survival Instinct kicking in full throttle.  Is Fido the size of a Chihuahua or a Great Dane?  It doesn’t matter; the untrained animal loses it, confused at the turmoil going on around him.  Whether fighting for its own survival or the survival of its owner, Fido now contributes to the mayhem.  Like falling pins on a bowling lane, passengers stumble, trip over Fido.  Sensing attack, the dog bites in his desperation.  Other passengers, resembling dominoes, also start to fall over the fallen.  The escape route is blocked; people die from heat exhaustion and smoke inhalation, inches from the Exit.

Do I exaggerate?  Fido isn’t a Service Animal; he isn’t trained to remain calm in stressful situations.  The ADA was aimed at Service Animals whose service to blind or deaf humans guarantees the survival of their owner, while not contributing to the injury or death of others.  What the presence of an ESA does amounts to putting the lives of many in jeopardy.  Are there legitimate ESAs?  Yes, but these require specific training to handle genuine human limitations, e.g. post traumatic stress disorder (PTSD) suffered by military personnel exposed to combat, a legitimate condition.

It is, however, difficult to imagine an eight-year old girl, traveling with her family, possesses the emotional need of an ESA.  Furthermore, if pressed, the girl could not name or explain the condition that requires the ESA to sit on her lap through a flight; she could not answer the question: what does the emotional support animal do for you?  The reason for this is because the qualifications for an ESA amount to procuring a note from a doctor – not necessarily a mental health doctor, but, e.g. a pediatrician.  Thus, the fallacy of the ESA: that nothing more than a family pediatrician’s ‘prescription’ introduces an ‘ESA’ into an environment that can endanger a planeload full of people.  Many of the airlines are now beefing up their ESA requirements, albeit years too late, to discourage the growing numbers of ESAs being boarded.

A blind man can present proof of a Service Animal’s qualifications, training and need.  This blind man is the true intended recipient of the ADA’s benefits; he isn’t abusing the ADA; he employs it to supplement what his handicap deprives him of.  Another misapplication of a law is the Air Carrier Access Act, which further drops the restrictions of ESAs, yet increases the need for proper documentation.

An example of the lack of common sense displayed with ESAs was exhibited on January 28th when a woman tried boarding a United flight from Newark to Los Angeles with her six-foot ESA, Dexter the Peacock; United denied the boarding for obvious reasons.  In January 2016, a man boarded a Delta flight with a full-sized live turkey, which was given its own seat.  Would, in an emergency, a turkey or peacock not employ those talons if it felt threatened, its survival instinct engaged?  Other ‘ESAs’ have included full-grown pigs and Shetland ponies.  When does common sense kick in?

This is an abuse of the ADA; it was not the intention of the Act to be used so arbitrarily.  The numerous people taking advantage of the Act’s objective belittles the purpose, while trivializing the needs of those sincerely disabled.

The concerns with these abuses go further than the trivializing of Law and the safety of passengers; it has to do with the inconvenience of travelers and the unnecessary costs to airlines.  Allergies are a reality, one that could affect multiple passengers in one flight.  Untrained animals cannot control their bodily functions as well as a child who has been potty-trained.  Animal feces and urine present an unexpected problem for the airline as well as the passengers.  Maybe the little girl took her ESA dog for a walk before flight.  Very considerate, but did she or her family anticipate gate holds, unforeseen maintenance, that their airliner would be sequenced into a holding pattern or weather delays/re-routes?  All these events and more add time to a flight, with pet walking areas hours away.

Animal waste can be a bio-hazard and/or an airborne pathogen, within the airtight cabin.  The foul odors and mess aside, if not cleaned up quickly, the waste can cause corrosion on the aircraft or the transmitting of disease among the human passengers.  When an animal defecates or urinates inside a gate-held airliner, the flight could be canceled or indefinitely delayed, resulting in costly re-bookings, airline scheduling nightmares, passengers missing flights and flight re-routings.  Airlines could lose hundreds of thousands of dollars in maintenance costs, pilot and flight attendant rescheduling, aircraft swaps, unexpected aircraft movements, jet fuel used, overtime for gate agents, landing fees, etc.

When businessmen miss important meetings, suddenly Fido’s doe-eyed gaze isn’t so cute.  When packages traveling on passenger airlines don’t arrive or families lose time and money on their vacation, the support for supposed ‘ESAs’ evaporates.  These disruptions are real; these disruptions have happened.  And the airline is not required to compensate for the inconvenience.

As mentioned, the airlines are finally getting in front of this situation.  They have incorporated some common sense restrictions, yet their progress could be hampered by lawyers representing ESA owners everywhere.  In an effort to appease some people, they have allowed these selfish passengers to dictate how the airline operates.  Unfortunately, these airlines may find, it may be financially too late for their own survival instinct to kick in.

Aircraft Accidents and Military Investigations

My brother and I were in a play together in high school.  My brother asked my parents if we could host a cast party at the house, “a few people since it was a small cast”.  Closing night, everyone is pumped; my brother, taking a bow, announces to a sold-out audience of 300 that “the cast party is at my house.”  Half of Nassau County, New York’s teenage population descended on my parent’s house, clogging every street within a half-mile circle.  My father glared at me, but I said, “I didn’t invite them to the party.”

In aircraft accident investigation, the term ‘party’ is used, e. g. “a group gathered for a special purpose or task”, not as a social get-together.  The National Transportation Safety Board (NTSB) parties are limited to manufacturers, the Federal Aviation Administration (FAA), the air operator, etc.; these people are committed to finding probable cause(s).

My good friend asked me why the NTSB isn’t involved in Military accident investigations.  It’s a good question; both the NTSB and the Military investigate accidents involving similar aircraft models and they are both branches of the Federal government.  Or are they?

The Military operates differently when it comes to air transportation, not only for how they transport, but what and who.  What is a ‘Military aviation accident investigation’ (MAAI)?  Would an NTSB and a Military accident be different?  In my opinion, there are three types of Military aircraft: Helicopter, Fixed-Wing, e.g. fighter jet, propeller-driven cargo hauler, trainer, etc. and the unmanned aerial vehicle (UAV).  An MAAI would be one where a Military aircraft is destroyed or damaged, by itself or with another Military aircraft.

What about accidents like National Airlines Flight 102 in Afghanistan?  That accident, and others like it, involved civil aircraft contracted to the Military.  These accidents are investigated by both the NTSB and the Military, albeit not jointly.  The Department of Defense (DoD) investigates why the Military passengers were killed and/or cargo was destroyed; the NTSB and FAA investigate the aircraft and the air operator.  The two investigations may investigate simultaneously or separately, according to time and available resources.  In a case like National 102, however, since the accident occurred on a Military base, the DoD should have been a party to the NTSB investigation for many reasons.  The DoD’s absence resulted in egregious mistakes in the accident report, with important facts overlooked.

Among the reasons the NTSB doesn’t get involved in MAAIs would be: Federal versus State, Cultural Differences, Number of Available Experts, Taxpayer Cost and Military Confidentiality.


Federal versus State:  The Military (Army, Navy, Marines, Air Force and Coast Guard) is considered a Federal entity.  However, the National Guard is not; they are funded by each individual State; they fall under the authority of the State’s Governor.  Because of this distinction, they are not automatically included in the term, ‘Federal Military’.  Would the NTSB be obligated to respond to a State supported branch?  The NTSB’s involvement would be on a case-by-case basis, but they are not required to act as an investigation party.  Any State could request the NTSB take the lead in investigating or ask the NTSB’s assistance in the investigation. I, personally, never became involved in the decision-making to launch on a State-run aircraft accident, so my personal knowledge of these conditions is limited.

Cultural Differences:  The NTSB is dedicated to investigating civilian accidents.  General Aviation and Commercial Air Operators, e.g. airlines, charters, air taxis, medical helicopters and tourist flights, operate under the FAA’s oversight.  The different branches of the Military have their own aircraft accident investigation groups.  For example, according to his website, Chesley ‘Sully’ Sullenberger, the Captain of US Air Flight 1549, investigated accidents for the U.S. Air Force during his time in the Military.  As a civilian pilot, he was involved in an aircraft accident (US Air 1549), but he didn’t investigate civilian accidents.  An important distinction since there are procedural differences between how the Military and the NTSB investigate.

By comparison, I have investigated many commercial accidents.  Would that qualify me to investigate Military accidents?  No, because I haven’t been exposed to that culture.  Sully could have been investigating commercial accidents for years had he pursued that field because he worked in the commercial aviation industry as a pilot for US Air.  He also could have been investigating Air Force accidents, but not necessarily an accident involving an Army Helicopter or a fighter jet that crashed on a Carrier deck.  Why?  Because each Military branch has its own culture; their own way of doing business; their own procedures that make their missions unique.

The NTSB would not investigate Military accidents, no matter the Branch.  Just as each certificate holder, whether an airline, repair station, aviation school, has a culture, each Military Branch has its own culture.  The values of each organization being investigated plays a pivotal role in fact-finding.  Another important dynamic would be Human Factors issues, again, unique to each certificate holder, as well as each Military Branch.

Number of Available Experts:  The NTSB has a limited number of resources.  Most likely, Military accidents would involve a modest crew.  The NTSB’s major accident investigation groups don’t have numerous investigators standing by, just waiting to launch on a major accident.  Major commercial accidents I’ve worked for the NTSB, those involving two or three pilots, were provided with a minimum number of investigators, even if they were a major airline’s two-pilot, wide-body, cargo aircraft, e.g. Emery Flight 17.

In accidents employing two or three pilots, the NTSB usually assigns a local investigator, one with a heavy workload.  They investigate numerous accidents and write many reports per month.  In that respect, whether commercial or Military, the investigation’s quality would be questionable, the recommendations ineffective.

Taxpayer Cost:  All the NTSB’s expenses are paid by the taxpayer.  This includes travel expenses, e.g. airfare, rental car, fuel, food and hotels; testing components or engine tear-downs at the manufacturer’s facility; interviews and on-site inspections; and the man-hours needed to prepare the final report.  If this service is already being conducted by the Military investigators, the redundancy is unproductive.  The NTSB would not be able to contribute any information to the final reports that would benefit safety.

Military Confidentiality:  This is probably the most decisive argument for why the NTSB does not conduct Military accidents.  Even though the Military operate similar aircraft, albeit the Military version, e.g. a DC-10 is a KC-10 or a B747 is an E-5, that is where the similarity ends.  Much of the aircraft flown by the Military are equipped with avionics and components that aid the aircraft in its mission.  Missile defensive systems, such as composition decoy flares are installed in secrecy; investigating aircraft with these systems may require a security clearance; certainly, the instructions for maintenance or operation are not made public knowledge.  For security reasons alone, the NTSB would be kept away from a Military accident.

Let’s assume an NTSB accident investigator stumbles upon a Military aircraft accident.  The danger to the investigator – or anyone – should not be trivialized.  Unexploded ordinance or pyrotechnic composition decoy flares could cause death and injury to unqualified persons navigating around the wreckage.

The NTSB has earned a place as a leader in accident investigation technologies and procedures.  However, their mission isn’t to direct every accident investigation, indeed, even be a part of every accident investigation.  It’s understandable that they would not, where the Military is concerned, be invited to be a party.

Aircraft Accidents and Lessons Unlearned XI: Eastern Flight 66

How did it get so late so soon?”  This quote, credited to the late Theodor Geisel, aka Doctor Seuss, can be the lament of most accidents of old.  As mentioned before, the true tragedy of an aircraft disaster is the lessons we do not learn, those we forget or … take too long to correct.  Such is the lesson of many smaller accidents, where accident findings move down the list of problems to amend.  In that case, it would be better to quote J.R.R. Tolkien when he wrote, “All we have to decide is what to do with the time that is given us.”

In aviation safety, we must do all we can in ‘the time that is given to us’.

Eastern Airlines Flight 66 was a Boeing B727-225 (-200) that impacted Runway 22-Left’s approach lights at JFK Airport on June 24, 1975.  The airliner’s flight crew were more than qualified and properly trained, with each pilot having the necessary hours in the B727.  The aircraft was sound and airworthy; there was no conceivable reason for the airliner to crash.  However, the accident was a result of unfortunate circumstances in the form of windshear.

In those days we thought of windshear as a cruel tempest, illusive and misunderstood; an event that defied the logic of how air should move.  However, windshear is not irrational at all.  At the time of Eastern 66, it was next to impossible to study windshear because it was difficult to capture a windshear event with Seventies technology.

To understand the catastrophic effects of windshear, one point needs to be made clear: fixed-wing aircraft take off and land into the wind; coupled with the aircraft’s velocity, facing the wind adds to the lift that builds atop an aircraft’s wings.  The loss of the rapid air moving from forward to aft on an aircraft’s wing equals a loss of lift, resulting in the aircraft surrendering to gravity.

According to the Federal Aviation Administration, ‘Windshear is a change in wind speed and/or direction over a short distance.’  It can be horizontal or vertical, happen at high or low altitude; it is associated ‘with strong temperature inversions or density gradients’, as are found in thunderstorms.  There are also four types of original low-level windshear: Frontal Activity, Thunderstorms, Temperature Inversions and Surface Obstructions.

The science of windshear is more involved than can be related here; we’ll look at thunderstorm-caused low-level windshear at the fundamental level.  At an airport, a down draft towards the ground results in horizontal winds moving out and away from the storm’s center.  As the aircraft enters the storm cell’s perimeter, head winds increase, thus lift increases.  This false head wind forces the aircraft above the glide slope (approach angle); the pilot reduces engine power to recapture the approach angle, while altitude continually decreases.  When the aircraft recovers and dips below the approach angle, it is flying ‘lower and slower’; the wings are ‘dirty’, meaning the landing flaps and slats are extended; landing gear are down and locked; all inducing drag.  Closer to the ground, the aircraft enters the storm cell’s inner envelope where dwells the vertical down draft winds.  The pilot tries to power up, but the engines will take time to spool up to regain forward momentum.  With a decreased head wind, increased drag and low speed, the aircraft drops from a loss of lift.

In the day when Eastern 66 crashed, the only warning to a windshear event was from a Pilot Report, known as PIREP, or a verbal reporting from other pilots.  On June 24, 1975, Eastern Flight 902, an L-1011 aborted its landing shortly before Eastern 66’s approach; the L-1011 pilot responded to air traffic’s query, “Would you classify that (the event) as severe wind shift … correction, shear?”  Eastern 902 responded, “Affirmative.”

Ahead of Eastern 902, Flying Tiger Flight 161 “highly recommend that you change the runway …” and was more adamant when questioned by the air traffic controller, “I don’t care what you’re indicating; I’m telling you that there’s such a windshear on the final on that runway, you should change it to the northwest.”  Eastern 66 followed National Airlines Flight 1004 into JFK; National 1004 landed safely, but Eastern 66 was not so fortunate.

Eastern 66’s pilots were aware of the conditions from the radio communications; the First Officer, who was flying, anticipated any problems, even stating he would make the approach by keeping “a pretty healthy margin”.  Whether Eastern 66 continued the approach in error or Air Traffic Control (ATC) faulted by not closing the runway, the accident was a consequence of slow and uncertain information, plus a base-level of training for pilots and ATC.  In hindsight, what did we learn?

Between 1985 and 2000, after successfully tracking a tornado in 1973, Doppler radar joined improved weather radar networks to aid in the prediction of storm cells and their danger.  However, more sensitive tracking of strong winds and precipitation from thunderstorms, plus the suddenness of their appearance, was still in development.

On August 2, 1985, Delta Airlines Flight 191 was on final approach into Dallas/Fort Worth Airport, when it experienced a windshear just north of the airport; it crashed within sight of the landing runway, 17-Left.  The National Transportation Safety Board (NTSB) transcript stated that the Captain anticipated the problem thirty seconds before impact and told the First Officer, as the flying pilot, to “Push it up; push it way up”; this was followed by the sound of engines going to high rotations per minute (RPM).  Less than ten seconds before impact, a ground proximity warning goes off (due to a quicker than normal descent rate) and the Captain orders a Go-Around.

During interviews, the radar specialist in ATC, relying on weather information from Meteorology, said the storm reached a level 4: Very Strong with severe turbulence that stayed stationary.  Although the means to detect were more advanced, the reporting still relied on ‘ground truth’ reports: observances by people on the ground or in the air to the tracking reports.  The technology was still not fool-proof, yet pilots and ATC still put trust in it.

The NTSB Findings included ‘a lack of guidance, procedures, and training for avoiding and escaping from low-altitude windshear; and the lack of real-time windshear information.’  The technology, though improved since Eastern 66, still relied heavily on human observations instead of technological accuracy.  However, it’s the lack of training that stands out most from the time since Eastern 66.  After the accident, studying Delta 191’s flight data recorder allowed each airline’s training department to make use of real-time information for flight simulators across the industry.

On July 2, 1994, US Air Flight 1016, a DC-9-31, crashed during a missed approach go-around at Charlotte/Douglas Airport.  The NTSB determined that the flight crew continued with an approach into conditions that were conducive to a microburst; the flight crew’s recognition of the conditions and to act in time to avoid the accident.  Also blamed was ATC’s lack of procedures to inform and display the weather threat.

An interesting footnote to this accident is the windshear alerting system in the aircraft failed to detect the threat.  It did not fail as a detection device, but as it was programmed to detect.  The conditions with which it senses versus the settings the aircraft was operating at were not lined up, e.g. the flaps were retracted out of landing configuration – the windshear alerting sensors ‘turned off’ as they were programmed to do.  This equipment glitch, however, does not relieve the airline from providing the flight crew with the training needed to anticipate and avoid windshear.

On March 23, 2009, FedEx Flight 80, an MD-11F aircraft, crashed on the runway in Narita, Japan.  Although the MD-11’s windshear sensing equipment did not give an alert to windshear conditions, a Boeing B747 landed eight minutes earlier reporting that it had encountered a windshear.  The attitude of FedEx 80 was not a normal landing attitude (nose up); it then ‘bounced’ before touching down again, hard on the left gear.  The left wing struck the ground and broke free, resulting in the aircraft flipping.  NOTE: A bounce doesn’t guarantee the cause was windshear.  However, Delta 191 bounced off State Road 114; its flight attitude was similar to FedEx 80’s, before the final impact.

The referral to windshear might be merely coincidental in FedEx 80’s situation, but another driving factor is not: Training, or the lack thereof.  The Captain was on medical leave from October 2008 through February 2009; he received a successful proficiency training in February 2009.  One thing he did not receive was ‘bounce’ training for over two and half years.  As the accident unfolded, it is during the first touch down that he ‘bounces’ and the second touch down the wing breaks.  Was this ‘bounce’ brought on by windshear?  Possibly, but not provable.

The ‘bounce’ training was specific to the MD-11 and was being taught by FedEx after another FedEx MD-11, flipped in Newark/Liberty airport in 1997, an accident that was not a result of windshear.  However, training is still the common denominator.  Could enhanced training have saved any of these aircraft?  In at least three of the four, the enhanced training should have made a difference in decision making, whether to enter or not.  Proficiency training is not just a way to make pilots aware of situations, but to ensure they consistently refer to what they’ve learned to fly safely.  Otherwise, it’s just checking a box.

Doctor Seuss is also quoted as saying, “They say I’m old fashioned and live in the past, but sometimes I think progress progresses too fast!”  Progress will continue to progress too fast; humans will continue to fall behind the progress.  The technology and realism of flight simulators is incredible; they can simulate, with impressive accuracy, many inflight emergency events.  The correct employment of technology is necessary, it helps us to be safer.  But we, the humans, have to make the final decision in any circumstance; we still can’t rely on imperfect technology to save us.  When entering a situation, can we trust our training or should we trust the technology to pull us out?  It’s leaning towards trusting the technology.  I feel, if we can’t trust the training, maybe we should just go around.