Aircraft Accidents and Recognizing the Mentor

Dan Harper could be gruff, indifferent, and a practical joker.  He was also the best aircraft maintenance mentor I ever knew; a mechanical wizard, the likes of whom will never be seen again.  One time, he worked a B727 Flap problem that had plagued the airline, costing thousands of dollars in aircraft utilization: The Inboard Flaps would not align with the Outboard Flaps.  In one shift, with myself in tow, he ran the problem down to a bone-shaped input rod, two inches long, buried deep in the Flap Actuation system.  A sealed bearing, worth about twenty bucks, was corroded and preventing the proper feedback inputs to the Inboard Flap system.  What was so impressive was the problem had stumped dozens of mechanics and twice as many Boeing engineers for months.

Dan Harper retired in the 1990s.  The tenacity Dan taught young mechanics, like myself, stayed with us today, thirty years later.  These lessons were not easily earned; they required timing (being there when the job happened), being assigned to work with Dan that night and Dan making me an active part of the repair.

I am fortunate to have my younger son finishing trade school to get his Airframe and Powerplant maintenance certifications.  We get into some interesting conversations about the maintenance industry, his view coming into it – looking forward – while my view is as I’m phasing out – looking back.  A discussion we had made me think about both Dan Harper and my position as a Mentor.

In 1999, I was an Aircraft Line Maintenance Supervisor in Newark’s Liberty Airport.  One particular night, I assigned two senior mechanics, I’ll call ‘John’ and ‘Paul’ – who both had received the required MD-11 Systems classroom training – out to repair a coupling on an MD-11’s number two engine fuel line.  NOTE: McDonnell Douglas made great use of these couplings, while Boeing and Airbus did not.  John and Paul spent, what I believed to be, an excessive amount of time on the repair; time was running out; the plane was scheduled to push for an international red-eye flight at 03:30.  I drove out to the aircraft and made Paul get out of the Hi-Lift.  John and I then rode up.  As he shone his light, I separated the coupling – Zip-Zip – turned to John and said, “Now, fix it.”

Both John and Paul should have known better, right?  They both had received the proper training.  But, unlike Dan Harper’s mentoring of me, no one had ever demonstrated to John and Paul how to repair this particular coupling, one they had never worked on before.  This was in large part to the difference between heavy maintenance and line maintenance.  John and Paul were line mechanics (quick turn maintenance), while my background was in heavy (broken for days) maintenance.

When a mechanic receives training on an aircraft, it can come in four different ways: On-the-Job Training (OJT), Stand-up Instruction (SUI), Computer-based training and Web-based training.  Computer and web-based training is training by computer … period.  SUI requires an instructor, who is familiar with the aircraft, to teach the class all about the systems, engines, etc.  If there is an aircraft or simulator available, the students can be walked through the various parts of the aircraft.  The most effective training is OJT; it requires the mechanic to be guided through the various maintenance by a mentor, someone who can teach the ‘student’ how to do the task before signing him/her off as trained.  Where OJT exceeds SUI is that OJT teaches the task on the aircraft … every time; there are no ambiguous pictures or slides, the aircraft has to be on hand.

So why do I write this story?  Am I employing my readers as my confessors?  No, the point to be made here is, I was the only one out of ninety-one certificated mechanics who had ever repaired this particular type of coupling due to my heavy maintenance experience.  My concern with meeting a flight time prevented me from teaching John and Paul on something they had never done before.  This rare opportunity would have improved their knowledge and safety by my demonstration.

My actions frustrated a learning experience in two ways: my lack of patience prevented me from properly demonstrating what I should have exploited as a teaching moment, and, I discouraged them from turning to me in the future to learn and be safe.

Aviators, we are entering a dangerous time. Pilots, Mechanics, Air Traffic Controllers, Flight Attendants, technology is replacing you.  This is not an opinion or an emotional appeal.  These are facts that we, as professionals in an industry, must accept and, furthermore, understand.  It cannot be repeated enough.  The changes are gradual; one generation will not see the changes from the previous generation.  How the Airline Industry reacts to the Mechanic and Pilot shortages will be a far different long-term strategy than what the Aircraft Manufacturers are doing.  Manufacturers respond to the Operators’ long-term needs.  For example: Analog technologies have been replaced by more efficient Digital technologies – that’s a FACT. Bio-fuels will replace the standards of today, e.g. AvGas and Jet A – that’s a FACT.  Composite materials will replace, almost part-for-part, the metals aircraft have been built from for decades – that’s a FACT.  Operators demand the technology; Manufacturers will deliver the results.

Flight crews will eventually be downsized, if not eliminated altogether, in a short period of time.  The four-member flight crews of the Fifties were reduced to two-member crews in the Eighties; in thirty years the number of crew members were halved.  Thirty years later, where are we?  Already major manufacturers are researching and developing a one member or zero-member flight crew.  Unmanned aerial vehicle (UAV) technology has proven the concept’s feasibility.  Who will the flight crews of today mentor?  Who will mentor the pilots of tomorrow?  What will be done with the lost experience?

Mechanics are, likewise, being cut back.  Since the early Nineties, the airliners themselves have been instrumental in troubleshooting aircraft problems.  Instead of two mechanics fixing an aircraft, the numbers drop to one mechanic and the aircraft’s computer.  The technical mental muscles we so frequently exercised with troubleshooting will be replaced by master computer diagnostics, employing sensors to locate the problem.  Without input from the mechanic the aircraft will order the part, spit out the maintenance paperwork and run the system test.  The mechanic?  He or she will assist the computer, replace the part and stand by to return the aircraft to service.  What will happen to those years of troubleshooting experience?  Who will be the mentor: the mechanic or the computer?

Air Traffic Controllers are welcoming in the servant to their future, Next Gen, or the latest version.  Computer run traffic control for our air lanes; little to no human intervention.  Computers on the aircraft talk to computers in air traffic control; very little verbal back-and-forth.  All route or altitude changes are done automatically by the aircraft’s system computers.

In the last two decades I investigated aircraft accidents that amounted to simple mistakes; dozens of lives were lost because of fundamental blunders in training, troubleshooting and familiarization.  Incorrect applications of procedures and the extinction of common safety knowledge prevented those without mentors from doing their job right and to the best of their ability.  And the irony is: we as an industry will never know how easily disaster could have been averted.  In a few years we will not even remember how to ask the question: “What could we have done to prevent this?”  Why?  Because there won’t be anyone in the industry who will remember how to do things according to ‘The Old Ways’.

It is up to us to keep the lessons of yesterday alive into the future.  I am here, recognizing my mentor, one mechanic who taught me how to do things right and safe.  He shared with me techniques no one uses anymore.  Why not?  Because the computer will fix it; that’s why not.  To all those mentors, whether Mechanic, Pilot, Air Traffic Control and Flight Attendant, we recognize you and will remember you.  That is, for as long as we’re around.

Aircraft Accidents and 60 Minutes

Paul Harvey passed away in 2009; he embodied common sense when journalism was still impartial.  He is remembered for such quotes, “If ‘pro’ is the opposite of ‘con’, what is the opposite of ‘progress’?”.  My age group best remembers him for The Rest of the Story, a series of stories … about stories; they delved deeper into a narrative than was originally reported, giving both humorous or dramatic information that made a great story so much greater.  He remains the Master.

Steve Kroft of 60 Minutes recently reported a story about Allegiant Air called Flying Under the Radar; he hoped to highlight Allegiant’s safety violation problems and any Federal Aviation Administration (FAA) oversight.  Mister Kroft’s investigative reporting was questionable.  Does Allegiant have safety issues?  Yes.  Do all airlines have safety issues?  Again, yes.  Is the FAA broken?  Absolutely.  Do we trust the Federal Government for its experience; can its objectivity and integrity be believed?  No … just, no.

It is never okay to yell ‘FIRE’ in a crowded movie house.  Safety and lives are compromised as people scramble for the safest exit.  Such is the way with aviation safety; one does not call what’s ‘UNBROKEN’, ‘BROKEN’, while ignoring what is actually broken.  Southwest Airlines flight 1380’s recent mid-air, uncontained engine failure accident; will it get the much needed attention?  With Southwest flight 3461’s diversion to Panama City and Steve Kroft’s Allegiant Air drama muddying the waters, will Southwest 1380’s urgency get lost in the minutiae, the danger left unaddressed for days?

The 60 Minutes webpage: https://www.cbsnews.com/news/allegiant-air-the-budget-airline-flying-under-the-radar/, provided a transcript.  First off, Steve Kroft is not an aviator; he would not know a Turbine Engine from a Ram Air Turbine.  It is arrogant for a celebrity to advise the aviation industry on how to police its own.  He is a reporter who relies on his own skills to tell ‘Steve Kroft’s story’.  His team possesses trade secrets on setting up interviews, e.g. the proper backdrop; artificial lighting versus sunlight; shadow use; make-up application; takes and retakes for capturing the ‘proper reaction’, etc.  Then, employing these skills, Mister Kroft interviewed former passengers.  What linked them?  Being on terrifying Allegiant flights.  They are not aviators, but that fact is never a prerequisite for being afraid.

The first was a young woman who tearfully relayed her fear of never seeing her daughter again after the right engine on her Allegiant flight caught fire.  Seeing flames exit the rear of an engine is scary, no doubt; it also begs the question: Why didn’t the pilot just stop the aircraft after the engine vomited flames?  Two facts could have allayed this woman’s fears.  First fact, all two-engine airliners are designed to fly on one engine in just such an emergency.  Title 14 Code of Federal Regulations (CFR) Part 25.121 Climb: One-Engine Inoperative speaks to these designs.  In other words, the passengers were not in danger.  Mister Kroft ignored this fact; instead, he exploited the woman’s crying.  Second, the airliner could not be stopped.  Simply put, once the airliner’s take-off roll passes a ‘point of no return’ – Rotation Speed – the airliner is committed to flight.  If the pilots slammed the nose down to stop, the outcome could have been disastrous, resulting in multiple fatalities, thus the need for 14 CFR Part 25.121.

A second passenger told a story about smoke in the cabin.  Mister Kroft makes a comment that the cabin filled with hydraulic fluid fumes from Skydrol, an oily hydraulic fluid.  Why weren’t the oxygen masks dropped?  The fact is that Oxygen, in pure form – as from an oxygen mask – reacts violently to airborne lubricants and oils.  Skydrol would not burn; Oxygen, however, would, causing burns to faces and lungs.  Since the aircraft was on the ground, why not open the four overwing exit window plugs or the entry door, get fresh air circulating throughout the cabin?  If I was choking, I would have forgone permission and removed the overwing exits myself.  In this event, the airline’s emergency procedures must be rewritten.  However, not dropping the Oxygen masks was a good call.

Mister Kroft interviewed John Duncan, Executive Director of FAA’s Flight Standards Division.  This was a mistake on so many levels.  If Mister Kroft really wanted hard answers about why enforcements against Allegiant were not followed through; if Mister Kroft was really serious about fixing safety mismanagement, John Duncan was not the person to ask.  To be clear: Mister Kroft can ask Mister Duncan about anything; Mister Duncan should have been better prepared for any and all questions, but John Duncan was not the person with that enforcement information or that duty.  The FAA’s Office of the Chief Counsel (OCC) – the FAA’s Legal Division – is responsible for enforcements; it is the FAA OCC’s decision not to pursue safety violation prosecutions.  Mister Kroft edited in a few ‘gotcha’ questions, but the interview’s ‘search for answers’ was a waste of Mister Duncan’s time and the viewer’s time.

Much in Mister Kroft’s report was made about the Tampa Bay Times (TBT) reporting on Allegiant’s safety issues from January 2015(?) – or, was it December 2015(?) – to January 2016.  In April 2016, TBT’s investigative reporting concluded that, the FAA found no deficiencies and that Allegiant was re-certified for five more yearsWha-a-at?  Air carrier certificates do not expire!  They are valid until surrendered, revoked or suspended.  Unless there are records of these actions, there would be no recertification.  TBT conducted an investigatory report in an unknown timeframe; they then reported a recertification that did not happen.  The TBT is to be commended for pursuing the story, but it is not read by FAA management in Washington, DC.  Furthermore, the Certificate Management Office for Allegiant is in Nevada, not Florida; the Principal Inspectors for Allegiant are in Nevada.  If the TBT wants to alert the FAA about safety, they need to communicate to Washington, DC and Nevada where the people who can actually affect change are located.

Since Mister Kroft does not have aviation experience, he acquired two experts.  His aim was to use qualified people to express the opinions he wants expressed.  Enter former NTSB Board Member, John Goglia and former FAA Attorney, Loretta Alkalay.  Before introducing his experts, Kroft points to Service Difficulty Reports (SDR) that, “we have been scrutinizing”.  Who are Mister Kroft’s ‘we’ people?

It is John Goglia’s interview that stands out; he demonstrates that political prowess he’s lorded over reporters for decades, saying one thing while subliminally winking at the camera.  Vague questions are answered with vague opinions, e.g. “we’ve seen that in airlines”.  Where?  What airlines?  “I try to push Allegiant to clean up their operation.”  Did Mister Goglia really review Allegiant’s operations?  Of course not, but Mister Kroft is sold, eagerly accepting this feedback at face value.  He’s been played by the best.

Mister Goglia’s most telling reveal, however, is his statement about SDRs, “Well, just the service difficulty reports say that– somebody’s not paying attention.”  Again, John Goglia knows.  By definition, an SDR means someone is paying attention; that 14 CFR Parts 121.703, 135.415 and 145.221 Service Difficulty Reports dictate to all certificate holders to report serious failures and malfunctions.  Allegiant filed SDRs, but do they point to one particular aircraft?  To one particular fleet?  To one component?  To one flight control?  To one instrument system?  Why were the SDRs written?  Mister Kroft cannot provide answers.  Mister Kroft’s ambiguity casts doubt on his report’s accuracy; he sacrifices truth for unsubstantiated allegations, like when he is concerned with the “antiquated, gas-guzzling” MD-80.  Two other major airlines still fly the MD-80.  Should the flying public be running from the airports?

Mister Goglia, again, tries to spoon feed issues Mister Kroft is missing.  “We’ve seen some problems with the contractors that they’ve used.”  Who is this phantom ‘we’ group Mister Goglia refers to?  Mister Kroft misses it.  More importantly, Allegiant’s contract maintenance providers don’t solely work on Allegiant aircraft.  Big Repair Stations (maintenance providers) have multiple big Operator clients.  John Goglia knows this; he really tries to open Mister Kroft’s eyes to a bigger picture of the industry.  Instead, Steve Kroft glazes over as the facts elude him.  Points to John Goglia for at least trying.

Loretta Alkalay, former FAA Legal representative from the FAA OCC, also makes vague comments based on hearsay.  This dialog, however, is very disappointing.  Ms. Alkalay condemns the FAA’s legal actions, attacking her former colleagues’ decisions based on her reading of one letter supplied by … Mister Kroft?  Did she speak to Allegiant’s FAA Principal Operations Inspector?  Did she call Allegiant’s Chief Pilot?  Mister Kroft misses another opportunity to see the bigger picture.

Noting another FAA ‘failure’, Ms. Alkalay states that Allegiant received a ‘slap on the wrist’.  After an FAA Inspector pushed for harsher enforcement action, the violation was reduced to a Letter of Correction because of the FAA’s new Compliance Philosophy.  Ms. Alkalay calls this decision, “basically nothing.”  Where did the FAA’s new Compliance Philosophy come from?  Answer: The FAA Legal Department, the OCC; they are the final word on enforcements.  Ms. Alkalay and her former colleagues wrote the new Compliance Philosophy she is now condemning.  If Mister Kroft interviewed the FAA’s Chief Counsel, and not Mister Duncan, he would have gotten answers to his questions.

Let’s recap.  Steve Kroft’s 60 Minutes story focused on: (1) an engine fire that was not life-threatening.  (2) Smoke in a cabin where possible injury was averted by Allegiant’s flight crew.  (3) Tampa Bay Times’ stories where the obscure newspaper misdirected its coverage.  (4) Re-certifications that did not happen.  (5) A Compliance Philosophy criticized by a person who helped write it.  (6) Unfounded concerns about contract maintenance; misunderstanding the purpose of SDRs; an interview with the wrong FAA official; unanswered questions; ambiguous reporting; opinions in place of facts; no expert solutions and misinformation about safety items.  Now, three US Senators are crying for investigations into, what amounts to, the wrong problems and irresponsible sensationalism.

Paul Harvey’s integrity is truly gone.  Mister Kroft wasted an opportunity to make a positive impact on Allegiant’s safety culture.  There were no revelations here; no lessons learned.  Should the FAA be scrutinized?  Yes.  Investigate Allegiant Airlines?  Make it happen.  But let the findings be fact-based, with real solutions.  Do not let important safety items fall victim to ignorance and emotion.

Aircraft Accidents and Being Motivated by Passion

Most people’s favorite It’s a Wonderful Life moment is George Bailey being rescued by his neighbors and friends.  I disagree.  The pivotal scene is where there is a rush on the banks.  Here George becomes more than a friend; he becomes the leader the citizens of Bedford Falls need.  “Think!  Don’t you see what’s happening here?”  Against the background of the 1929 Stock Market Crash, George desperately tries to subdue his friends’ panic; that if they surrender to their fears, motivated by passion, the movie’s antagonist, Mister Potter, will exploit the citizens’ hysteria and put them in poverty.  By allowing emotions to feed despair, Bedford Falls would become Pottersville.

Redolent of Oscar Wilde’s quote, “Life imitates Art far more than Art imitates Life,” the aviation industry has, for many years, been motivated by passion – not common sense – to bring about change and safety.  We barely acclimate ourselves to the ‘new ways’ before we are loaded onboard for another rollercoaster ride back into the future.

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Like a single or pilotless cockpit, for instance.  In 1957, the Boeing B707 first flew; it became an original transatlantic jetliner requiring a four-pilot flight crew.  In 1981 (Twenty-four years later) the commercial industry was introduced to the Boeing B767, an airliner that in 1985 became the next generation transatlantic jetliner, cutting its flight crew complement in half to two pilots.  Since 1981, for thirty-seven years and millions of flown miles, the aviation community has perfected the two-pilot cockpit and the digital technology.  In terms of high-tech, we are where we should be … perhaps.  But, is the commercial aviation industry ready to turn the corner; convey this much responsibility to computers?  The scientific know-how is inevitable.  We have not, however, learned to tame the automation; it still confounds us, leaving us astonished as a result of our arrogance.

So, why do we put our caution aside?  Simply, a threat is made to our way of life.  If we can’t find pilots, our ability to go on that vacation, business trip or delivery of an overnight package is threatened.  With the decreasing pilot population smaller connection routes will be discontinued, regional operator contracts won’t be renewed, smaller airlines will go under and you, the travelling public, will have to travel hundreds of miles to catch a flight.  Available seating will be non-existent.  Pilots will exceed their rest periods, leading to labor problems and government violations.  Pilots will be hired without the qualifying flight hours, requiring Federal Aviation Administration (FAA) policy changes.  Recommendations related to National Transportation Safety Board (NTSB) investigations and special interest groups will be shelved.  Passions will overcome common sense for, well …  the sake of the flying public.

With a pending pilot shortage and technology that suggests superiority in the air, we will again be driving an emotional rollercoaster – to fast track pilotless airliners.  Slowly the First Officer (second pilot) will be replaced; he or she labeled ‘redundant’, unnecessary for safety of flight.  Drones, Space X launch vehicles and satellites prove our ability; eventually, technology will dictate that we don’t even need onboard pilots.  Computers will evolve to the point they can handle everything.  At first, a human ‘pilot’ will ‘fly’ the airliner virtually, from the safety of a room at the airline’s headquarters.  In short order, that need will cease to be.

“Think!  Don’t you see what’s happening here?”

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Climate Change, aka Global Warming, infamous perpetrator of alleged consequences, e.g. greenhouse gases and ocean acidification, is a hot topic.  Without convincing data to support pro or con on the subject, nations have been blindly moved to take sides, motivated by their citizens’ passions.  Rash decisions will be made; studies begun with questionable findings.  As an industry, the aviation community asks the question: What can we do to Save the World?  The answer: Bio-fuels.  In record time, the industry is developing and testing bio-fuels in real situations.  Eventually, airliners will be flying revenue flights, crossing the United States and the Oceans, hours away from the nearest field.

However, are we properly vetting these fuels?  Are we putting the engines through the full collection of environmental conditions?  How about the fuel systems?  Do we know for sure that fuel components will survive exposure to these bio-fuels under all operating pressures?  Will the new bio-fuel blends reduce any component’s useful life and what happens if they do?  Will components have to be re-engineered or re-approved?  What effect will be seen on an operator’s engine maintenance program?  What new fuel microbes will be introduced and will they affect safe operation?

“Think!  Don’t you see what’s happening here?”

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A recent misconception is that as the accident rate goes down, aviation safety is achieved.  This drop in fatalities represents a ball-spiking moment for the NTSB and the FAA, but more so for many prominent politicians who work on various transportation or aviation sub-committees responsible for funding the FAA and NTSB.  In this instance, the bully pulpit, normally reserved for a President, is employed liberally in an effort to take credit for what many hard-working aviators’ lives and deaths made possible.  The reality: aviation safety is only made possible through the conscious efforts of safety-minded aviators; it is a privilege, bought at great cost.

Politicians and bureaucrats would have us believe that safety is their gift to the traveling public, that without their guidance and leadership we would be in fear of flying.  In discounting that fear, the politicians perform the greatest disservice to the public, by deluding us into a comfort zone they cannot support.  Their actions, motivated by passion, are self-praise and job security, not aviation safety.

To bolster this myth, this fairytale of aviation safety, the FAA and the NTSB are throttled back.  After all, why support agencies that have performed their jobs so well, their methods, analysis and purposes are almost obsolete?  Instead, politicians determine there must be a cheaper, less invasive way to conduct oversight and perform surveillance, two methods employed to get the skies safe to begin with.  One way is to re-organize.

So, the FAA rebrands.  Is the strategy to employ people familiar with aviation to conduct the oversight and surveillance?  Has the FAA-to-Industry relationship changed; is the FAA becoming a partner with the Industry and less the administrator of the Industry?  Is safety to be delegated to blind trust?  Are FAA inspectors checking off question responses as opposed to visually checking on the goings on?  What if the FAA inspectors are being taught to drive a laptop instead of driving a government car?  Is the FAA foregoing the five Whys of Root Cause Analysis for the two Whys of Safety Assurance?

If the answer to any of these questions is ‘Yes’, then the aviation industry is looking at a return Swing of the Pendulum.  The Myth of the No-Accident Safety Record becomes painfully clear: There is no such thing as a No-Accident Safety Record.  There are all types of responses to this revelation; the passionate Media will call it “A Tragedy!”  Politicians and Bureaucrats will say, “It’s not our fault; we’ve been betrayed.”  And the cynical will only refer it as, “The Smoking Hole.”

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And a voice, strangely reminiscent of Jimmy Stewart, will whisper in the wind, “Think!  Don’t you see what’s happening here?”

Aircraft Accidents and Lessons Unlearned XII: Liberty Helicopters N350LH

As I’ve stated before, the most tragic result of a fatal accident of any kind, is NOT learning from a previous accident what could have prevented it.  The last few weeks, I have been discussing a complete lack of common sense in aviation.  I avoid recent accidents because they are still in investigation, i.e. the report has not been signed.  My weekly articles are often aimed at the obvious accidents; those that affect the airline industry, therefore the accidents that are noticed by the flying public because of the victim count being tallied by the media on a daily basis.  However, to ignore accidents involving General Aviation and Air Tours (Part 91) operators flying nine-or-less passengers would be to ignore a diverse group of aviators, a great disservice to us all.

Helicopter tour accidents are numerous; more occur than the general public knows about, simply because low fatality count accidents ‘fly’ below the media’s radar.  The first accident I investigated for the National Transportation Safety Board (NTSB) in 2001 was a tour helicopter where six perished and one was critically injured.  Since there was no definitive probable cause to the accident, no final word speaking to how the accident occurred and therefore how to prevent a repeat incident.  Air tour certificate holders continue to enjoy relaxed oversight by overwhelmed Federal Aviation Administration (FAA) inspectors.

On March 11, 2018, a Liberty Helicopters, Inc., a Eurocopter AS350B2, Registration number N350LH crashed into the East River off the shore of Manhattan (Accident number: ERA18MA099).  During an engine out event, the helicopter impacted the river’s surface and rolled inverted due to a failed inflation float.  In the commotion following the forced landing, the pilot escaped from the capsized helicopter, but five passengers perished while trying to escape their restraints.

As the NTSB continues its investigation into the events that led up to the accident, the obvious questions they ask will be ignored in this article:  Were the nitrogen bottles used for inflating the pontoons properly charged or maintained?  Did the pilot verify the pontoon bottles were reading correctly before flight?  Was the fuel cutoff switch properly guarded?  How much passenger movement was allowed in the cabin?

The major issue to be discussed in this Lessons Unlearned concerns, not the manufacturer’s installed restraints, e.g. seat belts, but the passenger harnesses installed as part of a Supplemental Type Certificate (STC).  An STC is a modification made to the aircraft, post-manufacture; it supplements the Type Certificate, which provides vital information pertinent to the equipment built into an airframe, engine or propeller.  The restraints were installed by the manufacturer; the harnesses were installed later.  The harnesses were part of a business decision to provide customers (passengers) the ability to see outside the helicopter for, e.g. photographing, without the side doors being in the way.  The harnesses also allowed the passengers mobility: movement inside the cabin.

Common sense can be a difficult concept; it becomes evident when looking at an Operator’s culture.  Allowing movement within a helicopter cabin subjects the passengers to several safety concerns; it also exposes the aircraft’s flight sensitive equipment to safety issues not present when passengers are restrained.

Let’s be clear: the helicopter in question: an AS350B2, has a small pilot/passenger area.  Movement by passengers in flight can pose multiple issues for aviation safety.  There are dangers, both internal and external, that demand passengers remain safely buckled in their seats; there are even better reasons for maintaining a safe distance between passengers and the helicopter pilot’s controls, from inadvertently manipulating flight critical devices.

The passengers are restrained two ways: seat belts and harnesses.  Since the door is off, the Operator deems the seat belts can be unbuckled to facilitate freedom of movement; the harnesses MUST be secured, yet allows the passenger to, e.g. hang their feet out the side or slide in a bench seat to enable changing one’s position from looking forward to facing the side.

Here lies the cause of the accident.

As reported in the NTSB Preliminary report for accident ERA18MA099 and the FAA Emergency Order of Prohibition Docket (EOPD) number: FAA-2018-0243, the surviving pilot reported, “when he reached down for the emergency fuel shutoff lever (FSOL), he realized that it was in the off position. He also noted that a portion of the front seat passenger’s [harness] tether was underneath the lever.”  Why the FSOL was not guarded against inadvertent actuation (such as the tether tripping it) is one MAJOR safety issue; this borders on utter recklessness; this point cannot be minimized.  The harness, however, is a concern in that very likely the fuel was shut off unintentionally and easily.  The harnesses, designed to give passengers freedom of movement, were the initial contributor to the tragedy.

One constant throughout aviation is that the pilot’s controls are off limits to non-flight crew persons, from the Cessna 150 to the Robinson R22 helicopter to the Airbus A380 to the Goodyear Blimp; no one – not one … single … person – aside from the pilots, should be able to influence the safe operation of any aircraft, deliberately or accidentally.  Not only did the STC’s installed harnesses allow the fuel to be shut off, but the pilot was unaware of the action until it was too late.

The harnesses, likely the accident’s cause, then became the instruments of the passengers’ deaths.

Before the flight, the pilot pointed out to the passengers that a knife was available to cut their harnesses in case of emergency.  Let me repeat that … A KNIFE WAS PROVIDED as a back-up to the normal releasing of the harness.  As described in the FAA EOPD, the harnesses’ lanyards are secured by screwing closed a locking carabiner, a locking loop, to the helicopter’s airframe.  The loop is inaccessible by the person wearing it because it is behind the person’s back.  The EOPD states, after the fact, that ‘A supplemental passenger restraint system [harness and carabiner] must not require the use of a knife to cut the restraint, the use of any additional tool or the assistance of any other person’.

This is how tragic the deaths were: a knife was provided to cut the restraints that were supposed to be quickly-released.  Not just one restraint, but all five.  How reckless!  In a cabin fire, the passengers would have burned to death.

Restraints, whether seat belts or harnesses used in, e.g. Coast Guard helicopters, are robust straps; they are designed to withstand heavy ‘G’ forces found in aircraft operations.  Under the best circumstances, they are hard to cut; under the threat of drowning, they are impossible for the average passenger holding their breath in freezing water.  Conclusion: the harness carabiner was inaccessible to the wearer; the strap was difficult to sever; the knife would have been up for grabs, if the wits of the drowning passengers even remembered to use it or they were conscious/injured to look for it or the knife hadn’t fallen to the river floor.  The water was dark, cold and situational awareness (inverted) worked against them.

So, what happened?  This is indicative of Safety becoming irrelevant … and not just for the engineer who wrote the STC.  Many people dropped the ball.  Engineers who write STCs are not perfect; they only can see the modification from one perspective – an engineer’s.  It is exactly why I found that the NTSB primarily using engineers as accident investigators to be a short-sighted mistake.

I’ve worked STCs before; I’ve even questioned STCs before.  An engineer draws the STC on a ‘drawing board’, away from the aircraft.  The STC can be written and approved well before the aircraft is modified.  This is evident when working on aircraft, where, e.g. slat actuators cannot be maneuvered out of the aircraft’s wing.

In 2003, I worked an accident in Bogota, Colombia; an STC (the aircraft was leased from a US-based airline) written for a DC-9 aircraft by a qualified engineer, was discovered to be cause of the loss of aircraft and crew.  Briefly, the STC ignored the need for cargo restraints to translate the G-force loads into the aircraft’s structure.  The modification placed new cargo restraints onto positions that did not translate the loads into the structure, but into the flooring below.  During a turn, the floor failed, capturing the control cables for all flight controls and engines.  The aircraft crashed out of control.

Did Liberty’s pilots not question the passengers’ freedom of movement during flight?  Did the pilots not voice concerns over unexpected flight issues with open doors, e.g. bird strikes, weather, or turbulence?  Were the pilots not worried about mid-air upsets that could ‘push’ a passenger into the controls?  Did the pilot group have issue with the front passenger’s harness tether being too long, that it could get entangled with the main and tail rotor controls or the fuel shut-off, as it did?

What about the mechanic who installed the harness STC or the Inspection Authority inspector?  Did Maintenance not question the carabiner/harness system?  What about employing a knife as a means to cut the strap in an emergency?  Was the Maintenance provider worried that the slack in the front seat passenger harness could foul the helicopter’s controls; interfere with the pilot?

There is no separation between aviation specialties; Pilots, Maintenance and Engineering are in this one together; they each are the second set of eyes to each other’s work.  No one gets to walk away and say, “That’s not my job.”  The Lessons Unlearned take away this week was that: First, an engineer designed a reckless system that killed five passengers who had no hope of escape.  Two, those with experience, who should have said something, did not.  Each specialty owns a part of this tragedy.  It’s why pilots, mechanics and engineers must not forget this.  No air operator is too small to be diligent.

Aircraft Accidents and Using New Technologies

While investigating an aircraft accident, I interviewed a Required Inspection Item (RII) Inspector in Tennessee; an RII is the second set of eyes to the work performed by the aircraft mechanic, making sure the proper procedures are followed.  He said that part of his normal practice while performing each RII inspection was that he would grip the part’s safety material between his fingers, allowing the sharp safety wire or cotter pin to bite into his skin.  This was his way of dismissing self-doubt, that he had the painful reminder that the installation was properly completed; that the aircraft was safe.

Some mechanics have their own ‘pinch me’ method, a small routine that allows them the peace of mind so they can sleep well at night.  It’s human nature, as well as self-preservation, that drives mechanics to forego that moment forever, the one when an accident investigator shows up at their place of business to inform the mechanic that he may have contributed to the deaths of pilots and passengers by their lack of attention to detail.

Are we, in the maintenance industry, adopting practices that blurs the distinction between ‘being positive’ and ‘pretty sure’?  Although I’m impressed by growing industries, I want to caution mechanics, particularly those coming into the industry, to tread lightly when playing with new toys.

There are articles appearing in Fortune, Aviation Week, Aviation Pros, aka AMT Society and UAS Vision that speak to the new age inspection tool: the Drone.  For someone who conducted visual inspections the old way, let me be the first to say, “I knew it was coming,” and “Are you here to fix the pains of the old ways?”  Allow me to explain.

On April 28, 1988, Aloha Airlines flight 243 suffered a mid-flight departure of the aircraft’s upper crown, a section running width-wise from floor over the crown to the floor on the opposing side; from entry door to wing leading edge; 18.5 feet (5.6 meters) vanished over the ocean.  It was a pivotal moment for every Certificate Holder’s Aircraft Maintenance program and especially their Quality Control duties.  It also forced aircraft manufacturers to reevaluate airframe time limits, particularly for flight cycles.

After this accident/event, structural inspections went into overdrive.  All aircraft structures, especially older aging aircraft, suddenly required zonal inspections called SID (Special Inspection Document) inspections.  The older version of the SID inspection required mechanics to walk the fuselage’s crown from end to end, performing visual and tap inspections along the entire length.

In order to do this, the mechanic donned a harness with straps that wrapped around the chest, back and met at the upper thighs; the mechanic was protected from falling by attaching the harness to an inertial cable tether suspended from a reel on the hangar ceiling.  This tether had one foot of give before it stopped movement, snapping the harness into a zero acceleration (dead stop), thus preventing said mechanic from falling.  With the B727, the crown was accessed by a maintenance stand surrounding the number two engine inlet, two feet above the crown.  If the mechanic stepped down too quickly, the tether would SNAP … stopping downward movement, translating the sudden stop to the harness; the harness would, in opposition to gravity, dig into the mechanic in painful ways at crucial points on the mechanic’s body.  The mechanic would then dangle, suspended until the pain ebbed, thus prompting the title, ‘Dope-on-a-Rope’, hanging like a piñata for all to see.  Pained memories aside, safety is a concern anytime you have someone walking on a smooth surface fifteen to twenty feet off the ground, the chance to easily slip off the rounded crown.

Enter the drone, an independent unit that can hover over the aircraft, even to each side, with developed high-resolution cameras taking incredibly detailed photos.  The applications are endless.  In accident investigating, a drone would be invaluable, able to capture evidence in trees, caverns or cliff faces that would otherwise put humans in hazardous situations to work with.  Even if the drone becomes damaged or destroyed, the consequences are minimal compared to human harm.

Is this what we wish to commit to, locking ourselves into a reliance on drones for our inspection needs?  To me, this is the concern: We are going down a path that may bring us back to where we went off the rails in 1988.

I have been vocal about our industry’s overreliance on technology, to the exclusion of the ‘old ways’.  A drone, just like any tool, has limits to its effectiveness.  When I was a mechanic on the Line, the dawn of digital technology was providing us with a new tool in the way of digital cameras and transmitting the images via phone or computer.  This new tool was priceless; we transmitted pictures of hydraulic leaks or broken restraining hardware, zoomed in, added light or changed the view.  When I was in Tulsa, as part of the American 587 accident, investigators in New York requested I go to American’s hangar to take pictures of a sister A300 airliner’s vertical stabilizer mounts.  For accident investigating, a drone would reduce mistakes while assuring human safety.

What the drone cannot do, however, is hands-on inspecting.  The inspection mistakes leading up to Aloha 243 would have been hampered – not helped – by a drone-like version of inspecting.  In fact, the inspection methods at the time were evolving.  Today, we are suggesting that inspections be performed using technology that further separates the mechanic from the area to be scrutinized.

What does a mechanic look for that applies to a SID inspection?  What tools should he/she use?  The fuselage at Aloha 243’s failure points were considered Pressure Vessel (PV) areas.  PV structure areas are subject to heavy stresses, caused by the airliner skin’s expansion and contraction as the aircraft climbs and descends during each flight.  These large pressurization changes are causing the stresses.

During the time between heavy inspections, the best vantage point to detect these cracks is on the exposed outer skin, as opposed to the inner skin enclosed by the cabin’s furnishings; this is acceptable because the outer skin is exposed.  Even with paint covering the PV, the trained mechanic can detect cracks or corrosion, but it has to be direct eyes on skin, not eyes on drone’s display screens on skin.  There is a reason I say ‘eyes on skin’, as opposed to, say, ‘eyes on metal’.  It is because aircraft of all types are being built with more and more composite materials and, therefore, have different detection methods than metals.

A trained eye can identify subtle signs of metal corrosion below paint that a drone could not, taking into account light, shadows or closeness to the surface.  In addition, a mechanic can check for ‘oil-canning’, a symptom that metal is separating from the structural support members.  The subtle corrosion can bubble below the surface in almost invisible bumps.  To identify these cracks or corrosion, the mechanic must be able to touch the skin, push against the skin or feel the skin for the bumps below the surface.  A drone cannot do this.  The follow up to this discovery would be for Quality Control to perform a Non-destructive inspection method, e.g. Eddy Current, to determine the extent of the damage.

With composite materials, there is a possibility for composite sheet delamination caused by a break in the resin bonding.  A cavity builds between the plies; this then allows water to invade the space between the plies, whether directly by precipitation or by other sources, e.g. humidity.  The water then continues to build.  As the liquid freezes and melts from the extreme temperature variations the skin is exposed to, the composite delaminates further.  These anomalies, invisible to the naked eye (or drone camera) can be discovered using oil-canning inspections or by a tap-test, which identifies the cavity by the change in pitch of the taps made against the skin.  To further test, one would use a non-destructive testing method that would tell if the section should be replaced and how much to replace.

I realize my articles have earned me several titles: ‘Wet Blanket Guy’, ‘Party-pooper’ or ‘That old guy who keeps saying, “Hey, you kids, get off my Lawn.”’  However, I worry that all these new toys will completely replace the ‘old ways’.  Furthermore, the mechanics entering the industry have less access to the old ways as newer inspection methods replace better methods; in the world of cost-savings, newer is often cheaper and more likely to be adopted as adequate.  I’m an old ways guy; I like to touch the repair.  It’s how I know the plane is safe.  Then I can sleep at night.