Aircraft Accidents and Misdirection, Part Two

In 1826, James Fenimore Cooper’s protagonist in his Leatherstocking series, Nathaniel ‘Natty’ Bumppo returned in The Last of the Mohicans.  Natty was a modest character, a fearless warrior, fearless friend and marksman; a quiet and unassuming man.  In 1992, Director Michael Mann and actor Daniel Day Lewis managed to ruin the character because they wanted to give the audience their interpretation of what Cooper was saying 166 years before.  The character was changed without any good reason why, ruining the story.

Three weeks ago, the National Transportation Safety Board (NTSB) Chairman’s ‘Message From the Chairman’ embarked on shining light on a minor problem without any clear reason why:

https://www.linkedin.com/feed/update/urn:li:activity:6440565827719741440

As written two weeks ago concerning a fatal ballooning accident in Lockhart, Texas, the Chairman is changing the conversation, redirecting attention from the true issues, resulting in confusion and misdirection.  This Chairman’s venue is being misused, making incorrect recommendations outside of the NTSB accident report.

The Chairman’s Blog and the accident report are not the means to second guess the decisions of those involved, nor is this article.  Indeed, American 383’s crew should be praised, not criticized, for handling an absolutely unique experience with professionalism.

The travelling public needs to understand this.  The public has no choice but to trust the Department of Transportation and all its divisions, e.g. the Federal Aviation Administration and NTSB, to provide factual information.  Instead, the public hears the NTSB Chairman – a Presidential Appointee – writing in his Blog: Message From Chairman, “If you design something with enough complexity, don’t be surprised if someone can’t use it when they really need it.”  Then, when the Chairman ‘gets the fix wrong’, it results in recommendations that are ambiguous, at best.

The Blog posting was about American 383, a Boeing B767 with a number two engine fire during takeoff roll on October 28, 2016.  Chairman Sumwalt’s concern: during the emergency, a flight attendant (FA) could not contact the flight crew (FC) through the newly designed interphone system receiver as the cabin filled with smoke.  This accident was so unique, it is extremely confusing why the Chairman overstates the importance of an interphone system modification, while ignoring the more critical issues that he should have focused on in his Blog instead.  This accident was unique, but not surprising.

American 383 was on its takeoff roll, when the number two engine’s second stage high-pressure turbine (HPT) disc failed, breaking into several pieces.  With the engine at takeoff power, a large section of the HPT disc, weighing 57 pounds, was launched through the engine casing, subsequently penetrated the lower and upper wing sections before being propelled a half mile away, where it broke through the roof of a warehouse.

As American 383’s emergency progressed, the pilots – who were made aware of the emergency with the cockpit’s flashing lights and aural warnings – had to abort the takeoff while running through the emergency shutdown checklist, a high stress process with the airplane on fire.  Meanwhile, the passenger cabin filled with smoke.  Passengers left their seats; one passenger deployed the over wing escape slide directly behind the number one engine.  He was seriously hurt by the engine’s jet blast.

The Chairman’s concern is for a redesigned interphone handset’s confusing complexity; that the FAs were not properly trained on the new handset; that the mix-up directly resulted in the passenger’s injury.

What?!

To fully understand the situation, it is necessary to explain the scenario from the flight deck.  While smoke is entering the cabin, the FC is focused on making the airliner safe – NOW.  The fire MUST BE extinguished to allow for a safe evacuation from at least two of the eight exits, possibly one – all while preventing an explosion.  After the number two engine failed, the aircraft was braking to a stop.  Why not shut down the number one engine?  The number one engine generator was the only guaranteed source of power for emergency evacuation lighting, fire protection and radios.  The Auxiliary Power Unit was shut down, no jet stream to power the Ram Air Turbine.  The number one engine was the only means of power until the number two engine fire was put out.  The number one engine was kept running for a full minute after the aircraft came to a stop.

The moment the engine fire alarm went off in the cockpit, the Captain controlled the aircraft’s momentum; the First Officer probably armed the first Halon bottle and fired it while the number two engine was still spooling down.  When the fire extinguisher system was armed, the number two engine generator was disconnected, hydraulics and fuel to the number two engine were cut off.  As the Captain stopped the jet, the First Officer called ground control to alert them and get the aircraft rescue and firefighting trucks rolling.  This flurry of activity probably occurred before the plane came to a stop.

When the aircraft stopped, the pilots immediately ran through their approved emergency shutdown checklist: a series of verbal challenges that assured the pilots shut off systems that could make the emergency worse, disabled unnecessary components and enabled a safe path to evacuation.  It is crucial, in the pursuit of safety, that the FC be able to accomplish these tasks … without interruption.

NOTE: an accident of this type has never occurred before, one where the high-pressure turbine disc penetrated the twin-engine airliner’s wing fuel tanks, dousing the hot engine and main gear brakes with thousands of pounds of gravity-fed fuel migrating to the lowest point in the tank, causing an unquenchable fire.  In contrast, Delta 1288, the disc breached the MD-80’s tail section and United 232 the disc tore through the tail, but no fuel sources.  American 383’s fire, on and around the number two engine, was the main contributor to the flood of smoke entering the cabin.

Why is Member Sumwalt concerned about the interphone system?  Is it a complexity problem or a training issue?  It would most likely be a training issue since the Flight Attendants often talk with the Flight Crew during regular flights, e.g. informing the crew that the cabin is prepped for takeoff, when the FC needs the aisles blocked for a bathroom break, requests to raise or lower the cabin temperature.  The interphone is not an ‘Emergency Only’ device.  The FAs talk on the interphone to the cockpit all the time.

Was the FA’s inability to use the interphone the root cause of the passenger chaos?  Does Member Sumwalt suggest that the interphone was so complex as to be unusable in an emergency but not in normal use?  Does the report state why the flight attendants needed to contact the cockpit?  An interphone problem is a training issue that can be solved with a class, a video or a simple revision to the flight attendant manual.  Should the flight attendant have used the interphone to speak to the passengers instead of the flight crew?  What specific action would have stopped the passenger from deploying the slide or getting injured?

As the flight crew ran through their priority checklist, they would not likely have answered the phone; it would have been a distraction to the pilots’ priority of keeping the emergency from progressing.  So, the question stands: Why did the FA use the interphone to call the crew?  Did the FA need, e.g. the Captain to drop the O2 masks?  Did the FA need advice on which emergency slides to deploy?  The flight attendants had better eyes on the situation, e.g. how the fire was progressing or which slides were safe to deploy.  The flight crew had a limited view of the wings, even when not previously occupied.

However, if the Chairman is going to suggest a safety risk, then he or she should spell out what the risk is and employ root cause analysis to suggest a solution.  Recommendations are teaching moments, not preaching moments.  Besides, there is one more solution they missed; one more possible scenario to look at:

What if the interphone became damaged and did not work at all?

Aircraft Accidents and the Novelties

Albert Einstein was once quoted as saying, “The only source of knowledge is experience.”  I thought of this as I read an article a few months back about two EasyJet A320 pilots in Great Britain.  The female Captain was twenty-six years of age, while the male First Officer was nineteen.  I am sure I’ll be labeled a youth-aphobe (or something like that), but it seems to me we are constantly throwing caution to the wind these days and settling for novelties.  The Captain is young; it’s unlikely she has a lot of jet aircraft experience.  The First Officer was seven years younger, just old enough to drive and here he is flying 220-plus passengers 35,000 feet in the air.

These two young people are novelties, like the first all-female flight crews or first brother and sister flight crews.  They appear to have more to do with the Guinness records than accomplishments.  Common sense dictates that these milestones are irrelevant, perhaps counterproductive, when focusing on safety.  At what point does the novelty get too preposterous?  Perhaps when the first legally blind, all Octogenarian flight crew to land an A380 on an aircraft carrier will be the breaking point.  I hope it stops before that.

Doogie Howser shouldn’t be performing surgery; Will Robinson shouldn’t fly airplanes.  It’s not that young geniuses aren’t talented (or perhaps they are just outfitted with good timing), it’s just that they haven’t enough real-world experience and the maturity born of practice and time, to be trusted with the lives of our families.  Novelties are only acceptable at circuses and on reality shows; there are no substitutes for skill born of time.  Experience and maturity enhance safety.

Experience is not quantifiable; one cannot measure experience, even when placed against maturity.  Once the novelty of flying a jet airliner has worn off, when it has been replaced with the harshness of pending disaster with the lives of others at stake, can the nineteen-year old pilot handle the responsibility?  Can he be honest with himself about his limitations or will he lock up?  Is he smart enough to trust his training, to turn off the technology if need be, swallow his pride and fly the airplane?  Do the passengers want to take that chance that he can?

I recently spoke with an aviation lawyer; he had some run-ins with a Federal Aviation Administration (FAA) aviation safety inspector (ASI) or two, concerning his client.  This gentleman (the client) was an upstanding aviator who only did what was right, 183% of the time; whose credentials were impeccable and morals beyond question.  Does this adequately paint the picture?

The question came up about experience, one where the attorney suspected the actions of an FAA ASI, calling him inexperienced, impulsive, unprofessional.  Furthermore, he said that the National Transportation Safety Board (NTSB) accident investigator (AI) consistently showed more professionalism, experience and empathy, as compared to the FAA ASIs the attorney had dealt with.  My first thought was, ‘Hmm, I wonder if this attorney moonlights as a First Officer on an EasyJet A320?’

To be clear, this wasn’t a discussion limited to ASIs conducting surveillance on air operators, but to all general aviation folks, as well, to which his client was one.  This particular discussion started out focused on post-accident investigations and their aftermath and segued into the aforementioned ASI’s contentious actions.

I am a former NTSB AI and a former FAA ASI for the FAA’s Flight Standards division; I should have been put on the defensive, felt honored or both.  At first, I felt the blood rise in my face and got my back up (whatever that means); I wanted to go all New Yorker on the attorney.  Instead, I tried reverting back to my instructor mode, hoping to make a teaching moment out of the comment.  A dozen famous sayings ran through my head: “Don’t judge, lest you …”; “Walk a mile in a person’s moccasins …”; “People in glass houses …”; each of which would have been an acceptable comeback, which would have put an end to it, while at the same time concluding the ability to further the discussion.

This attorney saw the world of aviation through a certain prism.  His client wears a halo; his client is without fault; the FAA is a big arrogant meanie who doesn’t play nice.  However, my past experience as an FAA ASI taught me that there are no halo-wearing clients; that I could tell the attorney true stories about other attorneys’ clients whose misdemeanors resulted in injury, destruction and/or death, mainly because the FAA ASI didn’t stop them in time.  All the attorney would have to do is accept his client’s human nature to understand why the FAA is full of arrogant meanies, that every FAA ASI has had his or her share of attorney’s clients thumbing their noses at the ASI before climbing into their aircraft for an afternoon of death and destruction with, e.g. a lack of helicopter familiarization training, packing too many parachutists into the jump plane or flying without the proper instrumentation; that the arrogant FAA ASI meanie has seen these types of client misdemeanors … A LOT.

Once that fact is understood, then the discussion can be elevated to discover why the FAA ASIs are meanies; HINT: they have to be; it’s their job to oversee safety.

It can also be made clear why the NTSB AI is so nice.  HINT: it’s because NTSB AIs do not enforce the regulations.  Heck, the average NTSB AI doesn’t even have to know the regulations and therefore doesn’t have to know when the client has declined to wear his or her halo.

Are there inexperienced FAA ASIs?  Absolutely, there are many.  Why are there FAA ASIs who shoot from the hip, are too inflexible, or are hard to talk to?  Most often, it’s due to a lack of opportunity to learn from a like event; that the event that is being mishandled can be turned into a learning moment and thus give the ASI a chance to learn from his/her mistake.  If the ASI refuses to budge, there is an opportunity for the attorney to be professional and address the issue with FAA Legal Counsel or even the ASI’s front line management to reconcile the problem.  Any which way, it can turn into a learning moment for the ASI, the client, and, yes, even the attorney, who may be reminded that there are three sides to any argument: Side A, Side B and the Truth.

How long does it take to become experienced?  For some, it may take weeks while for others it takes an entire career.  For some, like me, my career never stopped being a learning experience.  During my years in FAA’s Flight Standards, I saw dozens of senior ASIs retire, their experience and knowledge lost forever.  Twenty years – the average for a career – is not a long period of time; that becomes evident as we get older and time moves rapidly.  In aviation, a career passes quickly; twenty years is nothing.  Before you know it, it’s your retirement party, the cake is consumed and as you walk out the door, coworkers’ memories of you last as long as it takes for the door to close behind you.

Yet, no matter what your occupation, your experience never leaves you, even after retirement.  The only restriction you have is the one you place on yourself to know your limits, accept your ignorance and respect your elder coworkers for what they can teach you, that knowledge you can glean from them.

Is nineteen too young to fly an airliner?  Yes, I think so.  Is nineteen too young to be an FAA ASI?  Double yes.  Is nineteen too young to be an NTSB AI?  Again, yes.  Not because people aren’t smart at nineteen.  It’s because at nineteen one is just way too young to have enough experience. 

Aircraft Accidents and Misdirection, Part One

When Samuel Clemens, aka Mark Twain, worked for his brother, Orion’s publication, The Hannibal Journal, he wrote light verse under the pseudonym, W. Epaminondas Adrastus Blab.  In one headline he described a shocking news story that never happened; the issue sold out due to this written sleight of hand.  Clemens used misdirection: a sort of promotion ploy that worked well in his case.

Two recent postings from the NTSB Chairman’s blog Message From the Chairman are particularly bothersome.  One dealt with an AVweb article about a 2016 balloon crash.  The second was American Airlines 383’s engine fire in Chicago.  In these cases, it’s obvious that misdirection should never be employed to exploit tragedy.  To do so only ramps up the emotions of those who don’t know better, those easily misled; meanwhile false hope is generated for victims’ families.

AVweb, on August 29, 2018, printed the Chairman’s Blog as an article concerning NTSB Accident Report AAR 17/03, an accident where a sightseeing balloon struck powerlines near Lockhart, Texas, and crashed on July 30, 2016.  The Chairman made an emotional plea for change in the article headline: NTSB Chair: “The FAA Should Act”, Member Sumwalt said, “Two years after the Lockhart tragedy, and nearly 10 months after we [the NTSB] issued this recommendation, we still haven’t received any indication that the FAA plans to require commercial pilot medical certificates.  The FAA should act.  The victims of this horrible accident and their families deserve nothing less and future balloon passengers deserve better.”  The purpose, as this writer perceives it, is for the NTSB to profit politically from shouting out to the ‘families’ and ‘victims’.  Nothing pulls at the emotional heartstrings like gesturing towards the victims’ families, while nothing confuses the issue more.

While at the NTSB, I met with victims’ family members from Emery 17 and Air Midwest 5481; each were eager to understand just what went wrong, what exactly we had found.  The last thing one should do is suggest that the NTSB has the ability to control what it cannot, e.g. the industry, the FAA or influence any transportation authorities the NTSB is involved with.  The NTSB cannot tell the FAA how to fix problems nor give them a deadline to meet; the NTSB lacks the experience and authority to do so.

Is Member Sumwalt trying to foster public outrage at the FAA, demanding immediate regulation changes for balloonists?  Well then, why shouldn’t the FAA “Act Now”?  Because, simply put, the FAA can’t.  The FAA moves at a pace to stay in front of the industry.  The recommendations the Chairman proposes are reactive; change occurs slowly to assure rash decisions are filtered out.  In addition, regulations, e.g. for unmanned aerial vehicles, and quality control work on NextGen systems are the safety priorities presently; the FAA’s available resources are being consumed by these vital programs.

Title 14 of the Code of Federal Regulations (CFR) Part 61, section 61.23 (b) Operators not requiring a medical certificate, like all regulations, take years to change.  It takes, on average, three to five years and over three million dollars to change, even a word, in a regulation – not ten months.  The earliest the NTSB recommendation might be changed is 2022.  In addition, the rule change would include medical certificate (MC) requirements be changed for: student pilots, glider pilots, sport pilots, flight instructors and check airmen; each of these different pilot groups would be affected by these changes.

Besides, the Title 14 CFR 61.23 rewrite was not the FAA’s doing; it was rewritten the way it is by pilot groups, the same workgroup whose integrity is now under fire because of the balloon accident.  In August 1962, Title 14 CFRs listed MCs under Part 67; at that time, balloon (then called ‘lighter-than-air’) pilots were required to have a MC.  Between 1962 and 1997, MC requirements moved from Part 67 to Part 61.23.  Why were the MC requirements changed?  Between 1994 and 1997, the Experimental Aircraft Association (EAA) successfully lobbied to have the rule changed to allow balloon pilots be exempt from MC requirements, even though balloons were/are passenger carrying aircraft.  It took four years, but EAA, with majority pilot support, got Title 14 CFR 61.23 changed to its present wording.

There is something else at issue here: the NTSB, indeed the Chairman, needs to be reminded of the NTSB’s purpose.  During this last week we have witnessed fact-finding events in the Senate gone amok, a spectacle that would make Jerry Springer jealous.  Senators from both sides of the aisle proved they are more concerned with personal career advancement than giving the American people what they want; what the Senators’ jobs dictate they do.  These circuses demonstrate the problem: the NTSB – like the Senate – has sunk into the same type of grandiose display of the ‘Look-At-Me’ mentality.

To clarify, NTSB Hearings, Sunshine meetings and all that spring from them are not political playgrounds; they are fact-finding events that support the NTSB’s Findings, Recommendations and Probable Cause … PERIOD.  NTSB inquiries are not designed for offering false hopes or giving substance to misinformed demands for change that is out of the NTSB’s control.  Instead, the Message From The Chairman blogs are saying to industry that the politically appointed NTSB Board Members don’t understand how the aviation regulatory process works and they are therefore ignorant of the regulatory processes for the other four disciplines: Highway, Rail, Marine and Pipeline.

In 2001, I was an NTSB technical specialist for aircraft maintenance.  During one Hearing, a Board Member said, “We’ve found cancer” in reference to an airline’s quality control system.  At a Sunshine Meeting, a former Chairman asked me, “Would you say that the airline has a lousy maintenance program?”  My response was, “I am not in a position to say,” so he took it upon himself to voice his opinion, on the record and for the two large video screens to either side of the Board Members’ table.  I did not refuse to comment out of humility; I didn’t comment because, even though I, personally, had spent months investigating the airline, I had seen only a snapshot of their maintenance organization.  With my years of experience, I was in a much better position to comment on the topic than the former Chairman.  It is just that I refused to.  And the inexperienced Board members should also refuse the temptation to make offhanded remarks because making offhanded remarks is not their jobs.

The NTSB Hearing and Sunshine Meeting are not court proceedings; there are no lawyers asking questions, just those persons who can answer to technical specialties.  The five Board Members are not transportation experts or litigators– they are Presidential Appointees – nothing more.  This is important to understand: the NTSB does not find guilt and has no authority to demand anything, much less that the FAA ‘Act Now’.  Instead, the NTSB’s task is to determine ‘Probable Cause’; Merriam-Webster defines ‘probable’ as “supported by evidence strong enough to establish presumption, but not proof”.  The NTSB then analyzes the facts that support recommendations that all five disciplines use to improve safety.  Again, recommendations, not instructions or demands.

I proudly served on NTSB Hearings and Sunshine Meetings, but it was easy to get caught up in the arrogance of the Board Members’ grandstanding, making inconsequential political points for the record full of ‘gotcha’ statements and lectures.  The NTSB Hearings and Sunshine Meetings have since descended further into a shadow of their original purpose, which is the promotion of safety.  Instead, the NTSB is relying heavily on sarcasm and table-banging as their purpose becomes confused.  As a result, the transportation industry suffers.

The Chairman is in a position to make positive change.  His attempts to tie emotion and agenda to common sense destroys all the benefits of the investigation’s factual findings, exploits the victims’ families and gives no closure to their suffering.  It just provides more misdirection.

Aircraft Accidents and Lessons Unlearned XVII: Ryan Air Service 103

On November 23, 1987, Ryan Air Service flight 103 crashed on approach into Homer airport in Homer, Alaska; the Beech 1900C, registration number N401RA, was operating as a regularly scheduled Title 14 Code of Federal Regulations (CFR) Part 135 flight operation from Kodiak, Alaska to Homer.  The aircraft was not equipped with a flight data recorder or a cockpit voice recorder.

There were many reasons the flight crashed, but the most obvious factor was never addressed: Culture.  Even less attention was devoted to useful recommendations.

NOTE: When speaking of both weight and balance (W&B) or center of gravity (CG), the basics need to be understood.  Every aircraft has a CG envelope for flight, a specific range at the wings; it has a forward limit and an aft limit.  Any CG that falls forward of the envelope’s forward limit causes an imbalance resulting in a ‘nose heavy’ condition instability; any CG that falls aft of the envelope’s aft limit causes an imbalance resulting in a ‘tail heavy’ condition instability.  The calculated CG for any flight MUST fall between the forward and aft CG limits – for the entire flight – to maintain stability.

W&B is how one determines the flight’s CG; since every flight is different, every W&B calculation varies, while the envelope stays the same.  Where weights, e.g. passengers, fuel, baggage, are placed along the longitudinal and lateral axis of the aircraft to establish where the CG is for takeoff and where it ends up at the end of the flight.  The difference between Takeoff Gross Weight (TOGW) and Landing Weight, is the usable fuel that the aircraft burns as it flies.  In most aircraft, e.g. the Beech 1900C, as fuel is burned off, the CG moves aft because the used fuel at departure had brought the CG forward.

The National Transportation Safety Board (NTSB) found:

3/8 inch of ice had accumulated on the wings’ leading edges: It is unclear how ice thickness was determined; the aircraft descended quickly in a flat attitude, impacted terrain before sliding to a stop on its belly; there was no fire; although conditions favored icing, the impact would have affected the amount of ice clinging to the wings.  As to flight characteristics, the manufacturer recommended that from one to one-and-a-half inches of ice was allowed to accumulate before inflating the deice boots.  It was not reported whether the manufacturer advised this profile during the landing cycle, but icing was determined to not be a contributing factor.

600 pounds of more freight was loaded, above what the first officer requested: Per AAR 88-11 the NTSB gave two scenarios of weight and balance calculations. For simplicity, this article will use the greater calculated CG, though the lesser also exceeded the CG envelope’s aft limits by 8.43 inches.

NTSB report AAR 88/11, page 13, Subsection 1.16.2 Flight 103 Weight and Balance, the flight was launched with 2,283.7 LBS of freight onboard.  The distribution was: 82.5 Nose Cargo; 250 LBS Forward Cabin Baggage; Aft Baggage/Forward Section 1353.0 LBS and Aft Baggage Aft Section 451.0 LBS for a total of 2283.7 LBS of cargo.

NOTE: The Aft Baggage/Forward Section’s structural limits were exceeded by 473 LBS and the total manufacturer’s allowable cargo for the aircraft was exceeded by 373.7 LBS.

AAR 88/11 is vague as to the first officer’s request about weight loaded.  Instead, as per witnesses, e.g. Kodiak’s ramp cargo loadmaster (LM), the first officer (FO) did not understand the difference between weight and volume.  The LM stated that the FO requested the plane be “loaded with 1500 LBS of cargo”.  However, both pilots helped load the aircraft; they should have known how much weight was put onboard.  The LM said the FO told her, “Before we could get the 1500 LBS on board, it would bulk out.”

NOTE: Witness statements are not ‘factual information’; they cannot be used as a Finding nor construed as such in an accident report.  The LM’s statements were Hearsay; no one else could corroborate what was said since both pilots died due to the accident.

Assuming the LM was being truthful (no one alive could refute her), the FO demonstrated poor training.  Furthermore, the LM observed the aircraft’s tail sank low and did not caution the crew.  This is the first cultural issue: the LM suspected the cargo’s weight was excessive and did not alert the crew.

The center of gravity was eight to eleven inches behind the allowable aft limit: The landing limits of flight 103 “was calculated at 184.3 pounds over the maximum allowable landing weight with a CG located 11.20 inches aft of the (aft CG) limit (311.1 inches aft of both takeoff and landing aft limit of 299.9 inches)”.

As the airliner flew the route from Kodiak to Homer, it burned off fuel; result: the CG moved further aft, behind the envelope’s aft limit.  When landing flaps were extended and speed was decreased, the aircraft became unstable.  With the low altitude and throttles set at approach power, the aircraft became uncontrollable, could not recover and crashed.

The flight crew did not comply with Ryan Air and FAA procedures on computing CG: As mentioned, the NTSB came up with two W&B scenarios.  Per AAR 88/11, Ryan W&B procedures required, “The CG will be determined by the flight crew prior to departure of each leg of each flight.  In multi-engine aircraft, it must be recorded on forms provided by the company and held for thirty days at the home base”.  During this time, Ryan crewmembers wrote information on plastic cards with easily erasable grease pencil.  Report AAR 88/11 stated that, per Title 14 CFR Part 135 regulations, duplicate copies of W&B information were not required to be kept by the company.  However, the company policy clearly dictated that duplicates be kept for thirty days.  This is indicative of Ryan’s Operations department not assuring flight crewmembers followed policy, a cultural issue.

Another issue from the investigation was an unorthodox Kodiak ramp practice of ‘memorizing’ weights during hunting season and utilizing informal (unapproved) worksheets instead of writing them on each individual baggage tag in the baggage load calculations.  The cultural issues here are that Ryan Air’s Kodiak ramp came up with some unusual ways of doing business and that the FO had an distorted method of loading an airplane.  The FO, if not the Captain as well, was unfamiliar with some of the flight characteristics of the Beech 1900C, a plane he was charged with carrying passengers on.

The NTSB in 1988 mentioned the preceding four FINDINGS.  The NSTB determined that the LM became confused by the FO’s comment about bulking the cargo bay out.  This finding is absurd; the LM is in a position of responsibility; she should have been certain of her facts.  Furthermore, the lone two recommendations Board Members James Kolstad (Acting Chairman), John Lauber, Joseph Nall, Lemoine Dickinson and Jim Burnett, signed off on were ineffective:

A-88-158: “Expedite the rulemaking project to provide for dynamic testing of seat/restraint systems for airplanes in the commuter category”

A-88-159: “Expedite the publication and dissemination of information on airplane access points … for airplanes with 10 or more seats.”

The recommendations did not address the bizarre practices employed by Ryan’s Kodiak ramp, weight and balance training for the LM and the pilot workforce.  The NTSB did not entertain any truth behind the LM’s statements; indeed, the NTSB did not generate recommendations to ‘fix’ the serious problem at the Kodiak ramp and the entire Ryan Air Operations system.  If one LM is misinformed, then it is a good chance the entire LM group is misinformed.  The same goes for the pilots.

The NTSB report’s omission of important problems in Ryan Air’s W&B program and, thus, the careless exclusion of necessary solutions, e.g. training, as answers to the air carrier’s myriad of problems, unfortunately, did not end with Ryan Air 103.  These investigatory blunders surfaced again in Fine Air 101, ValuJet 592 and Air Midwest 5481, among others; each of these NTSB accident reports could have driven FAA inspectors to expand their surveillance to include other ramp operations that were not mentioned in the accident report and contractors’ training.

The most tragic thing about an accident is the lessons unlearned; when the industry is given an opportunity to prevent future similar events with some common sense and attention to detail, but fail.  Ryan Air Service 103 is just such an accident.