Aircraft Accidents and Professional Standards

Not too long ago, there were ‘Stay Smart’ commercials that highlighted the advantage to staying at a Holiday Inn Express.  In one specific ad a man performed flawless surgery on a patient, impressing the surgical team.  When asked how he had managed the life-saving operation so coolly, he said he’s not a surgeon, but he had stayed at a Holiday Inn Express the previous night.

The point of these ads was to associate staying at a Holiday Inn Express with unlived experience; that unearned talent was bestowed on someone just because of his/her hotel choice.  Ironically, aviation safety has the same expertise qualifications.  There are those aviation website owners who never worked a single safety issue, yet they play aviation experts on nightly news shows.  Travel journalists pass themselves off as seasoned accident investigators, not solving cases of missing aircraft.  Then there are the countless senators and congressmen, bloviating nonsense, while getting in the way of safety. The common thread: they stay regularly at Holiday Inn Express.

What standards should aviation professionals aspire to?  Doesn’t the industry become unsafe when inexperience distracts us from safety?  In short, there should be a law that says: If you don’t know what you’re talking about, just … stop … talking!

For instance, there was an aviation website administrator who rejoiced on his website when pilots disregarded their approved de-ice programs by broom-sweeping ice off an airliner’s wing.  Is this website administrator aware of when Arrow Air 1285 crashed in Gander, Canada, on December 12, 1985?  When 248 U.S. Army personnel were killed as they flew home for Christmas?  The accident occurred due to inadequate de-icing; the pilots disregarded Arrow Air’s de-ice requirements.

What about the travel journalist who passed herself off as an aviation accident professional?  The journalist interviewed accident investigators, applied her inexperience to interpret the second-hand information incorrectly, then fed conjecture while distracting attention away from the real causes.

Representatives in Congress misdirect information regularly in order to garner support from their base instead of fixing the serious problems that plague all modes of transportation.

In all these cases, aviation safety suffers; accident lessons are lost; PEOPLE DIE!

And now, the Director for the Office of Aviation at the National Transportation Safety Board (NTSB) has been sharing his self-imposed professional experience to tell the aviation industry just how safe aviation is.  Aviation International News online (Ainonline) aviation journalist, Kerry Lynch, covered the 2018 Bombardier Safety Standdown in Wichita, Kansas; her two articles included reporting this NTSB Director’s speech.  The Director made comments about the air carrier industry accident rate and a Trans-Pacific Jets fatal accident in Teterboro airport last year.

This NTSB Director began with grandstanding; his misleading comments lacked professional integrity, indicative of the fact that attending accident meetings did not equate to understanding major issues in the investigation itself.  Words and terms discussed by the seasoned investigators were misunderstood by the NTSB Director, who grasped just enough of what the investigators examined to be dangerous.

The NTSB Director’s first comments were about Part 121 air carriers, an industry he should have a better grasp on, considering the fact he manages the investigators who conduct these accident investigations.  The NTSB Director’s comments about air carrier accidents, “is a very short conversation.  It’s the sound of crickets … they’re just not happening anymore in the U. S.  How did what was already the safest form of transportation become one in which accidents just got wiped off the map for nine and a half years?  A lot of things came together.”  And then, he says, “Are we realizing those gains in Part 91 and 135 jet operations?  Not yet.”

Apparently, the NTSB Director stayed at a Holiday Inn Express.  Aside from the fact that Part 91, 135 and 121 operations aren’t limited just to jet traffic, these claims are very irresponsible.

Part 121 refers to Title 14 Code of Federal Regulations (CFR) Part 121 air carriers, aka airlines: Operating Requirements for Domestic, Flag and Supplemental Operations.  The NTSB Director was pushing for CFR Part 91: General Operating and Flight Rules and Part 135: Commuter and On Demand Operators, to be the next on the list for accident-free NTSB assistance.

Let’s be clear: the Part 121 industry is not now, nor will it ever be, accident free.  The absence of destroyed airframes and dead passengers does not mean that serious problems don’t exist.  It is naïve to even suggest that air carriers have cleared some imaginary hurdle, e.g. accident-free status, especially from someone representing the NTSB.  Has the NTSB Director ever worked in the air carrier industry?  No?  Then the NTSB Director does not understand how the air carrier industry works.  He should refrain from making absurd comments until he understands what the safety consequences of his words are.

Congress and the media listen to NTSB managers, though no aviation professional knows why.  Anyone who has ever dealt with bean counters knows that the purse can snap shut without the benefit of facts.  It is Congress that decides the budget for the Federal Aviation Administration (FAA).  Presently understaffed, the FAA manpower cannot meet the demands of the current aviation industry.  With increasing future responsibilities of oversight and surveillance, e.g. an increasingly global industry, unmanned aerial vehicles and NEXTGEN, the FAA is undermanned; serious stuff, here people!  With the number of Part 121 operators increasing their footprints internationally and their growing fleets of aircraft, can the limited number of FAA inspectors keep up?  Can the NTSB Director’s ramblings about airliner accidents ring true, that, “they’re just not happening anymore in the U. S.”?  With the FAA’s senior workforce retiring, can their experience be translated to the next generation of inspectors?

In the second article, the NTSB Director spoke about a Trans-Pacific Jets’ Learjet 35A accident that is under investigation; the aircraft crashed in Teterboro, NJ, on May 15, 2017.  In the Bombardier Safety Standdown, the NTSB Director shared with the audience certain particulars of the cockpit voice recorder (CVR) recordings that should not have been shared publicly and so flippantly.

The NTSB Director stated, “This captain would say things like: What the bleep; we’re a bleeping Learjet; get us bleeping higher; …”  The NTSB Director questioned the Captain’s motives; the captain’s request for a cruise altitude of 27,000 feet during a repositioning flight.  The NTSB Director mocked the second-in-command (SIC) flying, “… a training flight for an SIC who is not ready to fly the airplane.”  When, but in a training flight, is a pilot supposed to train?

These particular CVR recordings are part of an active investigation; their contents are not open for public viewing.  Elements of professional confidentiality should have stayed within the confines of the accident report – and only the accident report – where transcripts can be correctly translated, expletives and all, in the order they happened.  Although written transcripts do not capture the urgency or the speaker’s tone, the words and actions must be accurately recorded.

I have had the unhappy experience of listening to CVR crash recordings; I say ‘unhappy’ because you realize that the persons recorded are deceased; that you are listening to their final moments, often in stressful situations.  To treat such CVR recordings as a point of entertainment is unprofessional.

To question the Captain’s intentions or the SIC’s qualifications without a point of reference is also unprofessional.  Did the NTSB Director have access to Trans-Pacific Jets’ Operations Training Manual; how do they conduct training flights?  Is the Director a former Chief Pilot?  Did he have experience in choosing altitudes?  If the Captain’s methods were unorthodox, what experience did the NTSB Director draw those conclusions from?  How long has it been since the NTSB Director investigated a major accident; what discipline was he investigating under, e.g. engineering, maintenance, etc.?

In today’s world of instant social media access, nothing can be done about rogue aviation website administrators; writers can’t be stopped from penning second hand hearsay; government administrators should employ discretion and common sense.  A fancy job title has as much to do with aviation safety as sleeping in a Holiday Inn Express.  Both have nothing to do with professional standards.

Aircraft Accidents and Lessons Unlearned XIX: Fine Air 101

On August 7, 1997, a clear day in Miami, Florida, Fine Air flight 101, a Douglas DC-8-61 cargo plane, crashed while taking off from Miami International Airport’s runway 27-Right.  The aircraft rotated to approximately seventy degrees with relation to the ground (per witnesses in the tower) and impacted beyond the airport perimeter.

The take-off roll appeared normal; the recorded cockpit conversations did not note any bouncing of the nose gear or any loss of steering control; this could suggest that the aircraft was within the normal center of gravity (CG) limits while in ground mode.  When the aircraft rotated (the nose came up) and transitioned into flight mode, but it did so dramatically.  The pilots became rapidly aware the stabilizer was out of trim; the climb rate became exaggerated, the nose rising to almost seventy degrees in reference to the ground.  Given the low altitude, low speed and aerodynamic stall experienced, the trim would have taken too long to correct; the pilots had no time to respond and rectify.  The aircraft fell like a rock.

The CG range (envelope) of an aircraft is determined by some version of Engineering, whether at the manufacturer, for aircraft manufactured as cargo aircraft; by the engineer who designed a passenger-to-cargo conversion or an engineer who certified a Combi-aircraft, which carries both passengers and cargo in the cabin area.  The extremes of a CG range (envelope) are allowable nose-heavy (Forward limit) or allowable tail heavy (Aft limit); the CG moves in between, according to how the aircraft is loaded for flight.  CG is critical information; the pilots set the proper stabilizer trim for weight distribution.  This is accomplished by adjusting the Horizontal (Trim) Stabilizer’s leading edge up or down.

Stabilizer trim affects the longitudinal attitude of the aircraft (nose up or down); the pilots set the takeoff trim prior to flight.  The weight and balance calculations – dependent on the distribution of weight in the fuselage – tell the pilot where center of gravity is, thus what degree the stabilizer trim is to be set at.  If the center of gravity calculations are erroneous, the trim setting is also wrong.  If trim is set incorrectly, the aircraft may rotate too early or too late during the takeoff cycle.

The accident report for Fine Air 101, AAR 98/02, references two events that suggest a problem; both, however, are non sequiturs.  First, two ‘THUMPs’ are picked up by the cockpit voice recorder (CVR) just as the aircraft’s nose comes up; it suggests movement of freight.  My experience flying on cargo airliners most of my career, freight moves within the limited confines of its cargo locks during attitude changes (rotation); this can be very loud.  It is impossible to discern from a CVR written transcript how loud or from how far back in the aircraft, the freight moves.

Second, witnesses say fire erupted from the two right wing engines (#3 and #4) suggesting the aircraft engines caught fire or were failing.  However, the aircraft’s longitudinal attitude was extreme – 70 degrees in reference to the ground – significantly interrupting the normal flow of air into the engines.  Each engine’s air-to-fuel ratio changes suddenly, resulting in compressor stalls as the engine tries to pull air into the inlet.  The burner can flames sometimes belch out the front and/or the back of the engine.

The cause of the accident was most likely communication problems between the air operator: Fine Air, who had operational control of the flight, and their contract customer, Aeromar, an air operator established in the Dominican Republic.  Aeromar contracted with Fine Air to carry its freight in what is called a ‘Wet’ Lease Agreement.  The wet lease meant Fine Air provided “airplane, [flight] crew, maintenance and insurance,” while Aeromar provided “fuel loading and unloading at all stops, landing fees … ground handling and all other flight-related expenses”.  Most importantly, the agreement states, “all flights covered under this Agreement shall be under the operational control of Fine Air.”  This means that Fine Air is not only responsible for everything that happens to that flight, but that Aeromar agrees to conduct business under Fine Air’s FAA-approved programs, e.g. the weight and balance program; Fine Air dictates how the aircraft is loaded, where the freight goes.  That is Operational Control.  However, Fine Air did not maintain operational control.


This accident report: AAR 98/02, is a good example of why the National Transportation Safety Board (NTSB) gets so close to the Probable Cause target … and then misses.  The two causes they wrote were: “(1) the failure of Fine Air to exercise operational control over the cargo loading process; and (2) the failure of Aeromar to load the airplane as specified by Fine Air.”  This is actually only one cause; exercising operational control means having load management.


Report AAR 98/02 gets bogged down in minutiae, e.g. the difference in the basic operating weight of the original aircraft N30UA and its replacement N27UA, saying “N27UA was a slightly heavier airplane”, which says nothing.  Is it five pounds heavier?  Five hundred pounds?  This ‘slightly’ term might not have made a difference in loading since the two aircraft had the exact same number of cargo positions (18) in the same body stations of the airplane.  If both aircraft were the same DC-8 series, they should have been part of Fine Air’s weight and balance control system incorporating fleet weights as per Title 14 Code of Federal Regulations Part 121.153 (b).  Were N27UA and N30UA the same series?  Did the NTSB Operations and Maintenance investigators understand these simple concepts and what they actually meant or were they taken in by the distractions?  Reading section 1.1.2 of the report, one is confused by what the NTSB said; most importantly, one is confused by who was calling the shots with the weight and balance.  What the NTSB desperately needed was an investigator who understood air cargo.  What they had was no investigator who understood air cargo.  They relied on Fine Air, who would not implicate itself.


In section 1.1.3, the report gets even more confusing.  Aeromar’s vice president “stated that the cargo weights listed on the pallet loading form did not include the weights of the metal pallets, netting or covering.”  WHAT?  Pallets weigh approximately 250 pounds each; netting and covers another 100 pounds … per pallet.  There were sixteen pallets.  If this is true, there was a 5600-pound discrepancy between what was reported as the cargo weight and what the cargo weight actually was.  If Aeromar’s culture results in inaccurate weights, then the problem wasn’t limited to Fine Air 101.


Conclusion 16 states, “The Aeromar cargo loading supervisor failed to ensure that the pallets were loaded according to an approved load plan and failed to confirm that the cargo was properly restrained.”  There are two errors here, yet the NTSB only mentions one.  (1) Fine Air did not maintain operational control by having a representative oversee the load to assure the aircraft positions used were correct.  (2) Fine Air should have had a representative overseeing the weighing of the freight in the warehouse to assure correct weights were documented, not weights that were 5600 pounds off.


The Probable Cause should point to the only cause of the accident; the NTSB then should have come up with recommendations that had teeth.  Instead, the NTSB wasted time criticizing the Federal Aviation Administration (FAA) while ignoring the bigger picture of how to prevent Fine Air 101 from happening again.  This fascination with hitting the FAA on the nose dilutes the urgency of the accident’s Findings.  This silly habit drew necessary attention away from what is the true cause: Operational Control.


The most frustrating aspect of this NTSB/FAA ‘relationship’ is that criticism of the FAA by the NTSB is seldom accurate since most NTSB investigators have no industry experience.  The majority of NTSB investigators are engineers and have never flown, repaired or worked with airliners … period; they don’t understand what is happening.  Because of this, even the industry does not take the NTSB seriously.

Important attention to contract issues in Fine Air 101 could have gone a long way in preventing later air disasters, e.g. Air Midwest 5481, National Airlines 102 and hundreds of unreported near-disasters.  The NTSB’s attention should have been on, not only what happened, but more importantly, how to prevent it from happening again.

From reading the report, a large part of the failure was on the Fine Air load supervisor.  This supervisor did not engage adequately with Aeromar’s people.  He also admitted to concentrating on making sure one cargo position was safe so as to draw the pilot’s attention away from the rest of the cargo positions.  This is crucial to the type of failure that led to the accident.  According to witnesses to the load, some say locks were not engaged while others say they were.  A pallet in position eighteen was way over the structural limits and could have thrown the CG off.  Yet, the NTSB seems unconcerned about its importance.

Every accident that teaches the Industry nothing, is demonstrative of the tragic side of accident investigation.  This accident should have led to industry-wide reforms; this should have been a red flag of the greatest importance.  Instead, the NTSB failed to inspire change; the spark that should have led to flame, fizzled out … again.