Aircraft Accidents and the FAA Compliance Philosophy, Part Two

Many write, e.g. books, articles, blogs, to pass on some experience or knowledge, while others push an agenda, either political or ideological.  I attempt to put common sense into words, employing what I have seen in my aviation career to support my views; I try not to be cynical, yet, sometimes, that does bleed through.  Every so often, disaster appears imminent; like an aviation Paul Revere, I must voice.

A friend of mine with a Doctorate in Human Factors praised the Federal Aviation Administration (FAA) for its Compliance Philosophy (FAACP).  He is a most qualified authority on Human Behavior; he works for the FAA and likes the less aggressive approach the FAA is taking to Enforcement, that the FAACP portrays a more ‘kinder, gentler FAA’.  In fairness, he never worked as an FAA aviation safety inspector (ASI); he is a subject matter expert (SME) on events after they have happened, like an accident or regulatory violation.  He praises the FAACP because FAA ASIs now focus on a Federal Aviation Regulation (FAR) violator’s Behavior, first, and the violator’s enforcement consequences, second.

When I investigated aircraft accidents for the National Transportation Safety Board, I often interviewed aircraft mechanics; I found a certificate holder’s Culture had much to do with the accident’s cause.  Tantamount to Culture being important were Human Behavior issues, e.g. loss of a spouse, sick child; and Human Factor issues, e.g. workplace lighting or sleep patterns.  Even though I had a Graduate Degree with a minor in Human Factors, I was never the authority my aforementioned friend is.  In all the interviews I conducted, I always followed the lead of accident investigators with Doctorates in Human Behavioral Studies for accuracy, knowledge and the right answers.

This is a critical point; in these interviews, my strength was in my familiarity with how aviation industry cultures worked.  Unearthing deep-rooted problems with Human Factors and Human Behavior issues did not fall to me; they were well beyond my capacity.  In the FAA’s adopted FAACP found at https://www.faa.gov/about/initiatives/cp/ Generally, if you are qualified and both willing and able to cooperate, FAA will resolve the issue with compliance tools, techniques, concepts, and programs. Only on discovery of behavior indicating an unwillingness or inability to comply, or evidence that, for example, supports an intentional deviation, reckless or criminal behavior, or other significant safety risk, does FAA consider an individual ineligible for a Compliance Action.”  This sounds like the FAA expects its ASIs to be Behavioral specialists, not enforcers of the regulations.  Are FAA ASIs being trained to recognize behavior issues?  If so, how are they being trained?  Why steer away from enforcement?

In reality, that’s not how FAA oversight works.  It requires experienced ASIs to conduct quality oversight, recognizing, then rooting out problems to avoid accidents, e.g. Cultural and Systemic Problems.  FAA ASIs are sworn to uphold strong principles; they take an oath to do their best to keep the skies safe.  FAA ASIs are not Behaviorists; their duty is to Safety, not psychoanalysis.

This well-intentioned Philosophy, the FAACP, is weighed down with three obvious problems.  First – the wording is ambiguous.  When does unacceptable behavior become so egregious as to reach the point of action?  How much must safety be compromised before the FAA Administrator approves action?

Second – as per https://www.law.cornell.edu/uscode/text/49/44701 the FAACP defies Law 49 of the United States Code 44701: (a) (2) (A):

(a) Promoting Safety.—The Administrator of the Federal Aviation Administration shall promote safe flight of civil aircraft in air commerce by prescribing

(2) Regulations and Minimum Standards in the interest of safety for—

(A) inspecting, servicing, and overhauling aircraftaircraft engines, propellers, and appliances”

And, (5) “Regulations and Minimum Standards for other practices, methods, and procedure the Administrator finds necessary for safety in air commerce and national security.”

Though the Law does not dictate how the regulations are to be enforced, the Law does not allow for anything less than Safety first, “The Administrator shall carry out this chapter in a way that best tends to reduce or eliminate the possibility or recurrence of accidents in air transportation.”

Third – the FAA ASIs are not certified in Human Behavioral Studies; most have never taken Psychology or Behavioral Studies courses … period.  FAA ASIs do not practice Psychology.  The reason why is because FAA ASIs are professional aviation people, whether Airworthiness, Operations, Flight Attendants, Air Traffic Controllers, etc. with years of aviation experience and training.  Their specialty is aviation, not people’s feelings or intentions.

Furthermore, the FAA does NOT provide training in these specialties; this is the most important point to be made regarding the FAACP.  The average FAA ASI’s strength lies in familiarity with the Aviation Industry and the professionals’ responsibilities who work in that industry.  The FAA ASI’s priority is not always WHY the mechanic, pilot, etc. is unsafe; the FAA ASI answers the question of HOW the mechanic, pilot, etc. is unsafe.  Isn’t intent a question for a lawyer; a question best answered by a Human Performance, Human Factors or Psychologist SME who has been trained to look for these answers?

In 2005, Northwest Airlines experienced a strike by its aircraft mechanics and cleaners.  The FAA reacted by increasing on-site surveillance and auditing, assuring safety was not compromised, that no one took advantage of the job action.  FAA Order 8900.1 Volume 3, Chapter 28, Section 1, speaks to reasons for the FAA increasing surveillance, e.g. significant employee turnover, financial problems, mergers and strikes.  The increased oversight did not question the integrity of the airline or the union members; it never asked ‘Why’ (though the why was obvious).  The FAA’s response displayed confidence in its ASIs to prevent any unsafe acts by anyone at Northwest – for any reason – that would disrupt aviation safety.  Each individual ASI had the professional experience to recognize anything out of place, to prevent unsafe activities and to PROTECT the travelling public.

Last week I underscored a fact: the average FAA ASI is outnumbered by the aviation professionals it oversees, sometimes by more than one hundred to one.  Because of this disparity, many of the accidents, both major and ‘minor’, were not prevented due, in part, to an overwhelming number of certificate assignments.  We will never know how many accidents have been prevented by alert FAA ASIs conducting quality surveillance, noting what was out of compliance and effectively overseeing the operation … not each individual mechanic’s, pilot’s, etc. behavior.

When with the FAA’s Flight Standards Division, I got into a conversation with two lawyers concerning an air carrier’s refusal to follow its own approved weight and balance program.  Both lawyers supported the FAACP’s ‘Behavioral’ direction.  “How bad can it get,” one asked, somewhat arrogantly, “when an air carrier doesn’t follow its own procedures?”  I showed them pictures of National Airlines flight 102 B747, as it slammed into the ground in the Bagram Airfield in Afghanistan.  The B747 aircraft suffered from a load shift before crashing.  A Finding: the airline did not follow its own weight and balance procedures.

“That’s only one instance,” he replied.  I pulled up accident reports for Fine Air 101, April 7, 1997, in Miami, FL; Air Midwest 5481, January 8, 2003, in Charlotte, NC, and other operators’ aircraft accidents, each caused by a failure to follow weight and balance procedures.  “These,” I said, “were the ones that didn’t get away.  There are others – unreported – that could have been just as tragic.  Finally, there are many more that the FAA ASIs’ experience prevented.”

Weight and Balance procedures are a small slice of the Aviation Safety pie; there are Operations procedures, Maintenance procedures, contractor oversight, Repair Station Quality Control Manuals, Training, Fueling procedures, Parachute rigging procedures, testing qualifications, etc.  FAA ASIs must rely on their experience to pull many situations back from the brink; they must recognize tragedy in the making; they must use their knowledge and experience against overwhelming opposing numbers to protect the travelling public.  To redirect their efforts into dead end directions, e.g. behavior, is a waste of resources and a recipe for disaster.

Somebody must be benefiting from the FAACP, I do not know who.  Enforcements against violators of the FARs, whether intentionally or unintentionally, is an effective deterrent to repeat offenders.  Making FAA ASIs into psychoanalysts defeats their purpose.  The FAA ASI will become ineffective as a regulator and a safety advocate.  And, the aviation industry?  It becomes a danger to itself, unsafe, until someone reverses the direction.  Then the decades-long effort begins where the FAA must undo what it has done … and corrects itself.

Aircraft Accidents and the FAA Compliance Philosophy, Part One

The Foucault (Foo-koh) pendulum’s continuous motion depends on two things: the Earth’s rotation and magnets at the pivot point.  Magnets maintain energy lost due to gravity, while the Earth’s rotation shifts the pendulum’s direction by a few degrees per hour as referenced to the floor.  At the pendulum’s lowest arc point, kinetic energy (energy in motion) is greatest.  However, at the arc’s end, potential energy (energy at rest) is greatest; this is also the exact point where direction changes due to influence from the Earth’s rotation.

I use this analogy to explain a greater issue, not one as subtle as the gentle nudging of Earth’s rotation.  Over the years, the Federal Aviation Administration (FAA) has made changes in direction, some in response to negligible variations in the industry, e.g. response to some Safety Recommendations.  Other times the FAA makes grand gestures that define its overall mission, e.g. its Compliance Philosophy (CP).  This viewpoint outlines how the FAA conducts business, overseeing the aviation industry while maintaining safety.

The FAA Compliance Philosophy is the FAA’s Culture.

In 2015, the FAA adopted a new Compliance Philosophy, one that involves a ‘just culture’ that “has both an expectation of, and an appreciation for, self-disclosure of errors.”  The FAAST Team website: www.FAASafety.gov lays out the FAA’s CP, as, “Simply put, the goal of the Compliance Philosophy is to identify safety issues that underlie deviations from standards and correct them as effectively as possible.  To do this, the Compliance Philosophy embraces self-disclosure of errors.”

To be clear, self-disclosure is a tool the FAA employs with all that fall under its surveillance and Oversight.  It is a part of the safety process, not THE safety process.

To give perspective, one must analyze what the FAA faces in its day-to-day mission.  In the General Aviation world alone, hundreds of US FAA inspectors are responsible for several hundred thousand FAA designees, private pilots, air taxi operations, FAA-approved repair stations, mechanics, avionics technicians, medical helicopter operators, repairmen, designee engineers, fixed base operators, crop dusters, pilot schools, mechanic schools, balloonists, glider pilots, unmanned aerial vehicle operators and experimental aircraft operators around the world.

In the Air Carrier world, the numbers are just as skewed.  For instance, in 1982, an airline had 62 aircraft.  The FAA Certification management office (CMO) overseeing the airline had sixty inspectors in the three modes: Operations (Pilots), Airworthiness (Maintenance) and Avionics.  Since the airline was not flying international – at the time – the airplanes routed regularly into the hub airport.  Here the FAA could observe all the airplanes within a few days, while speaking to most, if not all, pilots and mechanics.

Today, thirty-six years later, the same airline has a fleet of hundreds of different model aircraft spread all around the world, flying 24/7, 365 days a year.  The FAA’s CMO has about eighty inspectors divided between management and the three specialties.  Access to all the aircraft is limited at best.  Operations, Airworthiness and Avionics inspectors cannot possibly see every one of the thousands of FAA-certified workers within a year’s time.  Notwithstanding, the thousands of contract maintenance personnel, their management teams, manuals and procedures responsible for performing maintenance on that one airline’s aircraft throughout the world are not even included in that number.

The FAA’s limits include time and distance.  The FAA’s efficiency is limited by the scheduled hours the inspectors can work – the Department of Transportation does not pay overtime.  Budgeting for international trips is cut to the bare minimum, even domestic trips are limited.  Available manpower is inadequate, e.g. in the aforementioned CMO, only twenty Airworthiness inspectors are responsible for thousands of mechanics and their training, manuals, spot checks, engineering modifications, aircraft damage, support personnel, enforcement misdemeanors, accident investigations and paperwork.  The average FAA-inspector works a Monday through Friday schedule, 8:00 to 4:30 in its respective time zone.  Some FAA-inspectors drive hundreds of miles to conduct surveillance on their certificate holders.  Add sick time, vacations, training, holidays and all the risk analysis reports that the inspectors are required to file and track.

This is an accurate view of how the FAA/Industry relationship works.  This is not to garner sympathy for the FAA Inspector – no, no, no.  Instead, it paints a picture of how the numbers play out, how disproportionate the relationship truly is.

As per FAA NOTICE 8900.323, the role of the FAA aviation safety inspector (ASI) was changed; the ASI’s responsibility went from a regulator to a behaviorist.  Adopted as FAA policy in September 2015 and superseded by FAA ORDER 8900.323, the FAA ASI ends up not enforcing the regulations each ASI has sworn to uphold.  Instead, each ASI has been tasked with analyzing each aviator’s behavior and judge their safety violations by their objective, whether intentional or ignorant.  The average FAA ASI is no longer a safety advocate, an enforcer of the regulations.  The average FAA ASI is now a psychologist; analysts of might be, not enforcers of must be.

The FAAST Team website goes on, “[The CP] involves collaborating with the aviation community to share information about safety issues that underlie deviations from standards.  Errors must be identified, reported and analyzed in a non-blaming manner so that appropriate remedial or system-wide corrective action can be taken based on the specific facts and circumstances of each case.”

It is common sense: FAA-inspectors must move away from the laptop, put down the checklist and do what they do best: observe … and when something is wrong, take action; hard action, if need be.  The FAA inspectors must be empowered to act with integrity for the safety of the flying public.  In the world of aviation safety, the term: ‘non-blaming manner’ makes zero sense.  It is a politically correct buzz-word that has no place in the proactive action of saving lives.  By abiding by this word salad of seemingly impressive terms, the FAA makes itself irrelevant.

In every industry there are the ‘mistake makers’, those who unintentionally act unsafely, who would benefit from extra training or a wrist-slapping.  On the other hand, there are many parties in aviation who know the system very well; they know how to avoid the cameras, can outrun the regulators and know how to hide their transgressions in plain sight.  In an industry that carried 965 million passengers last year, this is not a trivial point.  It is a fact that this is a problem; it cannot be stopped without constructive oversight, surveillance and legitimate – firm, but fair – consequences for violators.

Inspectors are spread thin today, as demonstrated by the above paragraphs.  They need cooperation from industry with a ‘trust yet validate’ relationship.  Opportunities to find safety issues are limited.  My classes are populated with stories by former inspectors/instructors about the successful landing that could have been a disaster; how months of investigating brought down a safety violator providing bad parts to airlines; concerning the accidents that required deeper analysis for the true cause.

Isn’t treating every safety event as an ‘unintentional error’ or a ‘behavioral issue’ trivializing the incredible safety dangers the flying public is being subjected to?  By turning repeat offenders of the Federal Aviation Regulations into truant children in need of a time-out, won’t the unseen safety violations soon outnumber the findings?  By tying the hands of ASIs and limiting their ability to conduct valuable oversight and surveillance, then enforcing what they find, aren’t we, in our complacency, heading for aviation safety upsets to eclipse anything in the past?

This is the change in direction the FAA has taken.  The swing of the pendulum determines whether the aviation industry either moves forward or slides backward, nudged by influential forces.  Next week we will look deeper into the FAA’s Compliance Philosophy and the true effect in and on the Aviation Industry.

Aircraft Accidents and NOTICE 8900.463

A quote from inspirational speaker, Jay Kristoff, starts off with the words, “An avalanche starts with one pebble …”  It is not wise to take quotes out of turn, but Mister Kristoff makes a good point with just these six words.  Articles have been written about how the Federal Aviation Administration (FAA) is an evolving part of the government; they have changed with the times, acclimating themselves to the transformations the aviation industry goes through.  This is a true statement, for the most part.  However, there are changes, e.g. NOTICE 8900.463, that are adopted whose long-term effects may not reflect the original intent.

At first glance, National Policy letter, NOTICE 8900.463, is tame by policy standards; it’s innocuous, yet an example of the FAA’s empathy for the upcoming pilot shortage.  The purpose of NOTICE 8900.463 is to provide financial relief from using a complex airplane for qualifying a pilot for a commercial pilot certificate.  The monetary burden on both the pilot and/or a flight instructor to provide a complex airplane is felt due to complex airplane availability and the cost to maintain such an airplane.  It is in the Notice’s vagueness that the problem lies; that, and in both the future abuse of such a policy, and the lack of pursuit of alternative means to prevent such abuses.

NOTICE 8900.463 was made effective on April 24, 2018.  The purpose of the NOTICE: “Specifically, it outlines the policy which no longer requires applicants for a commercial pilot certificate with an airplane single-engine rating to provide a complex or turbine-powered airplane for the associated practical test and no longer requires applicants for a flight instructor certificate with an airplane single-engine rating to provide a complex airplane for the practical test.”  The FAA assures the reader of NOTICE 8900.463 that, “… the FAA finds that no longer requiring an applicant to provide a complex airplane … will not result in a decreased level of safety.”  It is hard to avoid cynicism with this statement, especially when one can derive little comfort from these words as the ground is racing up to meet you.

What is a complex airplane?  Per Title 14 of the Code of Federal Regulations (CFR) Part 61.1 – in short – an airplane that has, e.g. retractable landing gear, flaps, a controllable pitch propeller and is equipped with a digital computer and associated accessories for controlling the engine and the propeller.  One of the requirements for a commercial pilot certificate, per 14 CFR 61.125 (b) (5), is the “Safe and efficient operation of aircraft,” specifically complex aircraft, in addition to flight proficiency.

To the non-aviator, this caveat has little to no meaning; aside from the obvious differences of two aircraft, e g. a helicopter and a fixed wing aircraft, the dissimilarities between a complex aircraft and a non-complex aircraft may not seem important.  After all, don’t all fixed wing aircraft have landing gear?  Don’t most, if not all fixed wing aircraft employ flaps as secondary flight controls?  It is in the operation of these systems that the true distinction lies.  A Cessna 150 with non-retractable landing gear has a close resemblance to a Cessna 210 with retractable landing gear: both have a high wing, single propeller, etc.  Yet there are distinct differences that set them apart, e.g. the 210 has six seats to the 150’s two.  More importantly, because of the 210’s retractable landing gear, it qualifies as a complex aircraft.

The reasons for using a complex aircraft for commercial pilot certification is, not just in the pilot’s familiarity with the aircraft model, but in his or her familiarity with the aircraft’s equipment and systems, of which retractable landing gear is one.  Retractable gear becomes an issue during take-off and landing cycles; the gear represents an attention to tasks that must be part of the approach and departure, monitored and, if necessary, compensated for in an emergency.  What if the gear doesn’t extend?  What if two-gear extend, but one stays in the well?  Why is this important?  Because it is a required knowledge for a commercial pilot certificate, for a complex airplane.

What is a commercial pilot certificate?  The requirements are spelled out in 14 CFR 61.121, 61.123, 61.125, 61.127, 61.129, 61.131, and 61.133.  In short, it certifies the holder of the commercial certificate, that they can be – as per 14 CFR 61.133 (a) – a pilot in command for carrying persons and/or property for compensation or hire.  A commercial pilot can be paid for their flying skills … as a pilot.

It is more than just retractable landing gear that identifies a complex airplane; flaps must be also monitored and, if necessary, compensated for during approach and departure.  What if the flap system fails?  How does a pilot determine a flaps-up landing speed or control an asymmetry problem?  With turbine engines, can a six-cylinder combustion engine be used to simulate a turbine engine-out scenario?  How about analog technology; can it accurately mimic digital technology?

NOTICE 8900.463, like other policy changes, presents great concern; its danger is not in its details, but in its ambiguity.  Last week we spoke about Colgan 3407, the concerns with the pilots’ training.  NOTICE 8900.463 speaks to substituting inferior equipment for commercial certification.  If the intent is to save money by substituting one airplane for another, where does it end?  Who decides whether the qualifying training that might have saved Colgan 3407 can be substituted for?

Who decides what non-complex aircraft can be substituted for a complex aircraft?  Is it the operator’s call?  Does the FAA aviation safety inspector (ASI) get an opinion, or does NOTICE 8900.463 prevent them from acting on the side of safety?  What data is used to support using one model of non-complex aircraft in place of a complex aircraft?  The ambiguity of NOTICE 8900.463 puts everyone at risk: the operator, the pilot, the FAA, but, most importantly, the passengers being carried and those who happen to be having lunch on the yet-to-be-determined accident site.

The abuses to this NOTICE are unlimited.  Since the FAA ties its ASI’s hands with NOTICE 8900.643, the operator is free to exploit the advantages.  The inability of the FAA to control this aspect of a commercial pilot certification means the operator can pursue, with little to no restriction, what’s best in terms of saving money, time or the building of a pilot’s flight hours.

Let’s look at how an airline can abuse a NOTICE similar to this.  When an airline conducts qualifying flights for Extended Twin-engine Operations (ETOPS) over water, the airline must prove that the aircraft can perform in real life scenarios in real time and that the airline’s procedures must compensate for such unexpected issues; the FAA gives them scenarios that give the airline opportunities to prove their ETOPS program works, e.g. an engine-out scenario.  In order to save time and money, the FAA might approve – through a Notice – the airline to perform the engine-out scenario … using a flight simulator, as opposed to an actual aircraft.  Don’t be fooled, this scenario doesn’t exist now, but it is coming where simulators will substitute for actual qualifying flights.  Flight simulator time is already counted as actual flight time, as it should be for pilot training in unique scenarios that cannot be duplicated safely, e.g. wind shear (Delta 191) or complete hydraulic system failure (United 232).  How long before the change is made where the focus is to save money instead of lives?

For NOTICE 8900.463, the frustrating fact is that there are alternate ways for approving the use of non-complex aircraft in place of complex aircraft: apply for exemptions.  This would guarantee that the FAA ASI remains an important part of the decision-making process of non-complex versus complex.  The FAA ASI is not so rigid as to ignore the logic of a good argument, especially when supported by tangible data showing the substitute aircraft will work.  In the same respect, the FAA ASI can prevent any abuse of NOTICE 8900.463 by its inclusion in the decisions to use non-complex versus complex.

When the FAA makes decisions based on financial or empathetic reasons – as opposed to fact-based – it is time to worry.  A Notice is meant to, in cases like this, give certain parts of the aviation industry relief from the rigidity of the Regulations.  The CFRs are hard to change for very good reasons; they often take a minimum of three years and three million dollars per rule change (not accounting for inflation).  If the regulations were easily rewritable then inexperienced and/or self-serving individuals would be making safety-sensitive decisions based on compassion, not fact; financial reason, not fact.

The few changes made in the wake of Colgan 3407 were made in compassion, not fact.  These empathetic changes resulted in ineffectual adjustments and short-term benefits.  Furthermore, making decisions based on compassion puts the aviation industry – all the aviation industry – into chaos.  Compassion has no place in safety; financial relief has no place in safety.

FAA Notices and other FAA policy letters, e.g. NOTICE 8900.463, certainly are the pebbles that begin an avalanche.  The consequences are undetectable at first, but the repercussions are long-term, growing and widening their effect, like the ripples in a pond.  Metaphors aside, this type of spontaneous regulating will prove questionable, leading to disastrous, in the future.  The aviation industry demands definitive regulation, not ambiguous placation.

Aircraft Accidents and Lessons Unlearned XIII: Colgan Air 3407

We get caught up in emotional circumstances; feelings can confuse cognitive reasoning – we lose perspective.  We elect officials, vote for laws, protest/support, e.g. Immigration, Gun Control, Tax Reform and many more emotion-packed topics.  Sarcasm and insults are indicative of how we talk; we have mastered the art of the ‘verbal drive-by shooting’.  As the Road to Hell is being paved with good Intentions, Passion becomes the enemy of Safety.

Colgan Air (doing business as (dba) Continental Express), flight 3407, crashed near Buffalo, New York (NY), on February 12, 2009.  The Bombardier DHC-8-400 suffered an aerodynamic stall while on instrument approach into Buffalo Niagara International Airport, crashing into a house in Clarence, NY, increasing the death toll.  Accident investigations, e.g. Colgan 3407 and American flight 587, become highly charged, emotionally, when additional lives are lost on the ground; the media exploits the tragedy of added lives, weaving the facts into readily available 24/7 coverage.  This corrupts the environment surrounding the investigation, heightening the urgency for answers, which in turn, result in fixes that are short-term only.  For these reasons, the solutions must come from the head, not the heart.

Political representative Senator Chuck Schumer (NY) and safety advocate Chesley ‘Sully’ Sullenberger, stood with the Families of Continental Flight 3407 as they pushed for passage of the Airline Safety and Federal Aviation Administration Extension Act (ASFAAEA) of 2010.  The tragedy of this Act’s ratification was not limited to the accident that brought it to fruition.  It was what it did not do: fix major culture problems.  The ASFAAEA gave emotional responses to real problems, solving very little.

It must be understood, that the aviation industry is chock full of ‘experts’, including those who will tell you that they are experts if you didn’t know it already.  The Danish Physicist Niels Bohr stated, “An expert is a man [person] who has made all the mistakes which can be made in a very narrow field,” (Italics added).  By Mister Bohr’s standards, no one qualifies as an expert in aircraft accident investigation; it is an inexact science, at best.  That assessment is true because aviation is diverse.  Airlines differ from General Aviation; crop dusters are unlike air taxis, whose operations do not resemble medical helicopter operations.  Each of these separate aviation cultures cannot be captured by one mindset.  FedEx is as different from UPS as is United from American.

Investigators are passionate … about their jobs, but not the accident.  They cannot misuse their passions that cloud their search for answers.  Factual reports funnel Facts into Analysis, which leads to smart and effective recommendations and fixes.  Accident investigators must have a deep understanding of what the industry is about, how it works, how it does not work and how to fix it – to really fix it.

What is alarming from the Colgan 3407 Accident Report AAR 10/01 is what was missed.  FINDING number 11 states: The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.  It is understandable for this miss because ‘startle and confusion’ can only be credited to analysis – not fact.  However, these points cannot be ignored.  Analysis of a cockpit voice recorder, married to flight control movements found on the flight data recorder, is as close as investigators familiar with the aircraft, the pilots’ training and the flight conditions before the accident, can get to the facts.  The NTSB’s Human Performance specialists, who investigate human behavior, are incredibly talented; I’ve worked with them on several occasions; they know their stuff.  This statement describes the do-or-die moment, the pivotal juncture in Colgan 3407’s disaster; it is the point in time that the Captain’s training – or lack, thereof – failed to kick in; when he should have aborted the approach and gone around.  It is the moment when the pilots should have recognized their limitations.

However, this FINDING ends up being a throw-away; its impact is passed over in favor of ‘flight hour calculations’ and other events.  Total flight hour calculations are never a true indicator of experience and talent.  I doubt any commercial pilot would suggest that all flight crew members with more than, e.g. 1500 flight hours are indisputably competent; no airline crew member would make that fantastic suggestion.  Experience cannot be measured by yoke time.  My feeling is, it is better measured by competent training; in this case, training to understand one’s limitations.

The Captain of Colgan 3407 should have given himself both time and altitude, simply because he could.  His plane was not on fire, his fuel was adequate, the flight was not in immediate danger.  Instead he and the co-pilot allowed themselves to be dragged into confusion.  Is this the first-time Colgan flight crewmembers were paralyzed by astonishment?  It is not.  If only the NTSB recognized that this event had happened on another Colgan flight, a mere six years earlier.

In 2003, I investigated both Air Midwest 5481 and Colgan 9446, both, dba, US Air Express; I investigated several other regional airlines flying those colors since, as well.  I found multiple problems with the Express carriers that differed from the US Air mainline operator.  The Operations investigators’ findings in 2003 were that Colgan 9446 accident’s probable cause was similar to Colgan 3407’s in 2009: pilot fixation on a problem.  In Colgan 9446’s case it was a reverse elevator trim; their problem-solving was limited by paralyzing confusion and restricted by a low altitude.  It had nothing to do with the pilots’ accumulated flight hours, which were more than adequate.  9446’s flight crew didn’t fly out of the situation; instead they fought the aircraft all the way to the scene of the accident.  If the NTSB compared these two Colgan (Regional) accidents, they would have found more than coincidence.  Both Colgan flight crews, despite which Regional name they flew under, became fixated at low altitudes.

Another astonishing element about the Colgan 3407 accident report was what was not a Finding, namely: What effect does the mainline airline, e.g. Continental Airlines, have on its Regional support airline’s operations, e.g. Continental Express, aka Colgan?  Himself, a former mainline pilot for US Air, Captain Sullenberger would agree that there are vast cultural differences between mainline Operators and their Regionals in regards to: pilot training, flight schedules, hiring practices, employee turnover, training contractor utilization; all of which may have played an important part in, not only Colgan 3407, but also Colgan 9446 and Air Midwest 5481.

Accident report AAR 10/01 boasts twenty-seven Recommendations; perhaps two or three have any teeth or even sound like fixes.  NTSB Board Members shared their ‘expert’ opinions, views that amount to bureaucratic myopia.  Chuck Schumer’s heartfelt support for the ASFAAEA managed to boost his political standing.  Meanwhile emotions ran high; the aviation industry did not benefit in the short term; it gained less in the long term.

In fact, matters are worse.  The ASFAAEA was intended to right the interpreted wrongs that were cherry-picked from the Colgan 3407 accident report, AAR 10/01.  The motivations by the Families of Continental Flight 3407 and, I believe, public figures, like Captain Sullenberger, were in earnest.  They, driven by passion, worked hard to right a wrong; their integrity cannot be challenged.  The ASFAAEA was designed to prevent the hiring of unqualified flight crewmembers (pilots); blocking them from sitting at the controls minus the adequate experience.  But, can ‘adequate experience’ levels be accurately measured?  If so, how?  Is it better to focus on an ambiguous quantity (hours) as opposed to focusing on quality (all training)?

This is how the political game is played on both sides of the aisle: play for time; distract with sidebars; allow those, like the Families of Continental Flight 3407, to claim victory.  Then, after an adequate period of time, give them a chance to forget.  Cynical?  Absolutely, even bordering on conspiracy theory.

Enter – very quietly – Department of Transportation/FAA NOTICE N8900.463, which is now, as of April 24, 2018, National Policy.  The Subject of this NOTICE is: Use of a Complex Airplane During a Commercial Pilot or Flight Instructor Practical Test.  The purpose of this NOTICE is to supplement a commercial pilot’s training requirements using equipment that is not, technically, up to the previous standard.  Is this a break from the intention of the ASFAAEA?  In a time that training needs to be improved, is the FAA lowering the bar, instead of raising it?  Is this a policy letter that the Chuck Schumers and Chesley Sullenbergers should be aware of?

What path to safety are we taking?  We have allowed ourselves to be lulled into a false security, focusing on a narrative that’s based in complacency.  It has been reported that these have been aviation’s safest years, that Major accidents are a thing of the past; we have figured this safety-thing out, folks.  No need to worry.  Time to move onto the next best idea.  Hey, is that a squirrel?

The Lessons Unlearned this month are: pay attention to all the Findings in an accident report; learn all you can from history; pay better attention to the Culture and wait, no matter how long it takes, for the other shoe to drop.  The time is past when we should be reacting to problems; we must instead be proactive.  However, if all the industry can do is react, then safety cannot bog down in passion; it must be driven by facts.  Otherwise, aviators become drowning persons who can’t swim; we flail our arms and exhaust ourselves, before slowly slipping below the surface.  Then, all we manage to continue being … are victims.