Aircraft Accidents and the Rule of Law

I really dislike social media; it’s ridiculously political, unnecessarily sarcastic and lacking in common sense.  Consequently, as an author, I have to maintain a presence in social media, while trying to remain apolitical.  But sometimes it just gets silly.  I read an aviation tweet strongly condemning the President for misspelling the word ‘hamburger’.  To me, that is very silly.  In a moment of uncharacteristic exasperation, I responded: “With the dangers facing aviation in the government shutdown, we’re reduced to condemning the President’s spelling?”  This prompted a critic, someone else, who questioned my morals; he condemned me for being unfeeling towards illegal immigrants (I still don’t get that stretch).  His question, which he insisted I answer: “What are you [meaning me] so afraid of?”

Ah, the emotional argument.  At this point the corner had been turned; my common sense kicked in and I recognized the pointless argument.  Shaking my head, I ‘walked’ away and turned off my cell phone.

However, I would like to answer my critic who questioned my morals because, the truth is, I really am afraid.  What I’m so afraid of is Ignorance, specifically ignorance of the Rule of Law.  And, as a young aviation enthusiast, my critic should be worried too … so very worried.

As I’ve mentioned earlier, my grandparents arrived in the United States around 1910; they didn’t cross the Rio Grande River, they crossed the Atlantic Ocean, before processing in through Ellis Island.  As poor and desperate as they were, they followed the Law.  They walked into the United States’ immigration process with their eyes wide open, voluntarily, gladly and without regret.

Ignorance of – or the flat-out dismissal of – the principle that “law should govern a nation” drives a breakdown in society.  The United States is a nation governed by laws; that’s a Fact.  We always have been and always will be.  To convince a specific population, e.g. illegal immigrants, to ignore the Rule of Law, to repeatedly reenter the United States illegally, suggests that they will ignore all Laws, even a Sanctuary City’s Laws.  This disrespect for Law promotes offenses against innocence, like Kate Steinle’s murder.  What happens when the illegal aliens’ entitled disrespect for the Law reaches that fevered pitch, making senseless murders, like Kate Steinle, to become the norm, not the exception?

The Rule of Law applies across all departments of government: Commerce, Justice, State, Defense, Transportation, Interior, Labor, Homeland Security, Veterans Affairs, etc.  These departments all have their Laws, which we call Regulations.  They define what is fair, guaranteeing the safety of the people.  The continuous involvement of government employees in the affairs of the United States guarantees no foreign or domestic threat can interrupt the United States’ citizens’ integrity and safety.

However, these departments’ effectiveness is being neutralized by this shutdown, major interruptions that are due to ‘issues of the heart’ not the head; of opinion, not fact.  What are the fundamental factual arguments behind these furloughs?  What will the long-term effects be as a result of these lost weeks?

An aviation investigation took place several months ago … or weeks … or years; WHEN and WHERE are not important, but an aviation repair station (RS) was caught by the FAA intentionally conducting repairs unsafely, overhauling aircraft components against the manufacturer’s recommended instructions.  This had been going on for years.  The RS charged $2000 to overhaul a component unsafely, on hundreds of like components, annually.  Over the years their profits equaled hundreds of thousands of dollars just on that one component model … and they were approved to repair hundreds of other component models.  The Federal Aviation Administration (FAA), through time consuming research of records, caught the RS only once; the RS received one monetary fine of $5000.  Why did the RS defy the Law?  The RS found it cost-effective to defy the Regulations they were certified under.  The RS felt it was cheaper to pay the fine than obey the Law.  And these violators of the Law were not the exception.

In this case, the faulty overhaul did not result in an aircraft accident.  But other similarly operated repair stations did cause aviation accidents, with numerous fatalities. Would it matter how many Democrats were killed? Or Republicans? How about Socialists, Independents and Constitutionalists, would it matter? If the RS was in a largely Israeli/Jewish neighborhood in Brooklyn, should the FAA be called antisemitic or Nazis for investigating?  No, because aviation safety is not about matters of nationality.  If the RS was in Salt Lake City, should the FAA be called anti-Mormon or immoral?  No, because aviation safety is not about matters of faith.  If the RS was in a Cuban neighborhood in Miami, would the FAA be racist?  No, because aviation safety is not about matters of ethnicity. Their job is safety … period.

I’ve been researching aviation accidents for decades now.  Except for some weather-related accidents, I have found that the number of aviation accidents due to human negligence are almost at 100%.  ‘Almost’ was due to technical reasons: human error inputs into the airframe or powerplant designs, i.e. someone did not follow Title 14 of the Code of Federal Regulations (CFR) Parts 21, 23, 25, 26, 27 and/or 29.  The other 99.99% of accidents were due to someone not following the Law, aka, the CFRs.  This means that each accident’s root cause was due to deliberate violations of the CFRs by a mechanic, pilot, quality control inspector, flight planner, maintenance planner, air traffic controller, load master or manager.  Hundreds of travelers, perhaps thousands, since the 1960s, have died tragically because someone disregarded or was ignorant of Aviation Law.  A hard, true, unfeeling and impartial Fact.

These accidents occurred despite the direct oversight of overwhelmed FAA inspectors, who were also understaffed.  No, this isn’t an excuse for the FAA; it is another fact, that many FAA inspectors oversee as many as thirty-five Part 135 operators, twenty or more Part 145 certificate holders scattered across hundreds of miles; that Certificate Management Offices for major global 24/7 airlines with thousands of pilots and mechanics, only employ around eighty to one hundred FAA inspectors to oversee them all.  If past accidents are any reflection on the airline industry cultures, the desire to ignore Aviation Law will continue, especially when the FAA inspectors are absent during the government shutdown.

The Government Shutdown; how inconvenient.  As of this writing, the January 2019 government shutdown is now in week four.  The Department of Transportation, particularly (for this article) the FAA, has furloughed hundreds of inspectors who are not conducting surveillance, not visiting training facilities, not performing safety audits, not reviewing manuals and not overseeing ramp activities.  These duties keep backing up.  When the furlough ends, FAA inspectors will not only have to comply with what they have scheduled, but with what was left to chance during the furlough’s duration.

Mechanics and pilots are not receiving their certificates, air carriers are not receiving their supplemental type certificates, engineering questions are not being answered and planes are sitting without permission to ferry to maintenance bases.  This costs, not only the air carriers money, but thousands of pilots, air traffic controllers, mechanics and manufacturing jobs that are on hold until the furlough ends.  Even then, the backlog will take months to clear.  Is all this financial suffering in the private sector due to some elected officials’ idea that it is ‘immoral’ to follow the Rule of Law?

Laws and Regulations are made for good reason; this is embodied in events from the Titanic to 9/11.  All Laws have to be equally applied, to everyone.  If the FAA were to lose itself in emotion, their mission would be nothing but pounding the table.  Instead they research the Regulations, being fair and assuring that all certificate holders dealt with are following the CFRs – not just those who do, but those who try not to.  The contrast between following the CFRs or ignoring the CFRs, is the difference between concluding your flight safely at Point B or at a smoking hole.

And, in answer to a certain critic, that is what I’m so afraid of.

Aircraft Accidents and Border Security

The Carl Sandburg quote goes, “If the facts are against you, argue the law. If the Law is against you, argue the facts. If the law and the facts are against you, pound the table and yell like hell.” In other words, there are two types of arguments: Factual (whether law-based or founded on recent factual data) and Emotional. Both arguments are now being waged to discuss, among other things: Aviation Safety.

I often question the NTSB’s actions, but one thing I’ve never debated them on was the design of the accident reports themselves. When I investigated accidents, I was required to write a Factual report and an Analysis report, both of which were included in the Final report, but one based on the other. A Factual could not include ambiguous or suggestive information. The Analysis was always based on what facts the Factual laid out and how they affected the accident.

I watched the President’s speech on Border Security last night and the rebuttal by Majority Leader Pelosi and Senator Schumer. Everyone has a position and no one’s views should be dismissed or trivialized. However, what I am interested in is FACTS, not opinion, emotion, ideology or political directive. I want to know facts because only facts are what drive correct decisions. I’ve seen emotion drive how the aviation community corrects serious problems or caves to special interest; I’ve never known these emotional decisions to fix anything, ever.

The President laid out factual reasons for the wall, border security enhancements and manning. Congresswoman Pelosi laid out emotional arguments, calling a border wall, ‘immoral’. The President factually addressed the crime problems on the porous border in cases of documented homicides, drug smuggling, child trafficking, sex crimes, assaults and returning illegals who were previously deported. Congresswoman Pelosi emotionally stated that the ‘President’s crisis’ was ‘manufactured’. The President spoke to facts that were delivered by those who work on the border, who stated, unequivocally, the wall has to be built. While at a border-security meeting on January 6, 2019, Congresswoman Pelosi told Department of Homeland Security Secretary, Kirsten Nielsen, “I reject your facts.” How does one do that, reject facts presented by the person whose responsibility is, literally, Homeland Security?

Look, I get it; Security does raise emotional alarms. But, as with everything, there are rules that must be adhered to or else chaos follows. The President did NOT say, immigrants are banned; he said, they must enter the country legally and be known. My grandparents were immigrants in 1910; they didn’t cross several acres of land, but the Atlantic Ocean in what would be considered ‘steerage’. They processed through Ellis Island. They were always proud of their earned American status and never abided going around the system.

Names like Kate Steinle, Ronil Singh or Marilyn Pharis are not manufactured; they are real casualties of an out-of-control situation the President is trying to secure. The term ‘immoral’ was applied to the denial of entry to those illegal perpetrators of such crimes; even the Pope says it is immoral. I’m Catholic and have lived through six Popes. Pope Francis is not only wrong, he’s inexperienced in politics and has priorities that drive me crazy. He needs to be a Spiritual leader and stick to that because he is no Pope John Paul II.

I believe that all those in Congress need to make decisions based on facts – not emotions. FACT: Border security folks are not Nazis. FACT: Police officers are not Ku Klux Klan members. FACT: ICE agents are not Hitler’s SS stormtroopers. Let’s move all the nonsensical politics aside, put the ideologies away and table those irrelevant agendas because this shutdown is doing more damage than good. And the longer the Congress denies the needs of the American people, the worse it is going to get.

I mentioned aviation safety before. First off, aviation is only one of five disciplines of Transportation that is being affected by the shutdown. That’s hundreds of thousands of Transportation inspectors not making sure transportation safety is complied with, not because they don’t want to do their jobs, but because they CAN’T. That’s right, the Members of Congress are blocking them from doing their job. Those that are working are not getting paid. How long will that last?

But aviation safety. Why would aviation safety be an issue? For the last three weeks, inspectors have not been on the job assuring aviation safety on airline ramps, in repair stations, flight schools, that mechanic and pilot certificates are approved or that certificates needing to be revoked are revoked. People’s personal aviation businesses are hit with large financial costs and could very well go under before they begin; certificate startups are put on hold indefinitely affecting hundreds of workers. Transportation security is going to be down to skeleton crews, leaving many travelers stranded and flights delayed or cancelled.

More importantly, for the last three weeks, while the cat was away … In order to make money any business has to save money, which means hiring cheaper labor, e.g. illegal workers they can exploit. For instance, would a person repairing aircraft components need an FAA airframe or powerplant certificate to repair the component? No. Would the person returning the component to service have to have a certificate? Yes, BUT we would have to assume he/she oversaw that the uncertificated person performed the repair correctly. Meanwhile the person actually repairing the component does not need to be certificated.

Do you think an illegal immigrant working an airline ramp is going to report that they punched a hole in the pressure vessel of an aircraft? Probably not; too much attention; best to not say anything. How many aviation jobs can be occupied by illegal immigrants that could facilitate drug smuggling? There are many places to hide drugs on aircraft. These are real issues.

Then there are the other government agencies that are being crippled by the shutdown: State, Defense, Justice, Interior, Agriculture, Commerce, Labor, etc. They all have their own workers trying to keep America running. You want to blame the President? He did state his case and supported it with facts: the border wall means security and safety for America.

Facts versus opinion. I’ll take facts every time. They are tangible, hard, cruel and fair. Opinions? There’s only one place for opinions and emotions; that place is on one’s sleeve.

Aircraft Accidents and Lessons Unlearned XXI: US Air Flight 405

On March 22, 1992, at 21:35 Eastern Standard Time, US Airways Flight 405, a Fokker 28-4000 airliner, crashed at LaGuardia Airport during its takeoff roll. As per National Transportation Safety Board (NTSB) accident report AAR-93/02, the aircraft rotated off Runway 13, but immediately lost lift, rolled left, hitting an Instrument Landing System (ILS) Localizer Antenna and a Pump House. The aircraft came to rest partially inverted in Flushing Bay.

NTSB accident report AAR-93/02 determined the Probable Cause of the accident to be, “the failure of the aviation industry and the Federal Aviation Administration (FAA) to provide flight crews with procedures, requirements and criteria compatible with departure delays in conditions conducive to airframe icing and the decision by the flight crew to take off without positive assurance that the airplane’s wings were free of ice accumulation after 35 minutes of exposure to precipitation following deicing. The ice contamination on the wings resulted in an aerodynamic stall and loss of control after liftoff. Contributing to the cause of the accident were the inappropriate procedures used by, and inadequate coordination between, the flight crew that led to a takeoff rotation at a lower than prescribed air speed.” US Airways or their procedures were not even mentioned in the Probable Cause or Recommendations.

The NTSB displays confusion in this accident. Even when accident report AAR-93/02 cites a germane problem on page 76, Finding 20: “Accident history shows that non-slatted, turbojet, transport-category airplanes have been involved in a disproportionate number of takeoff accidents where undetected upper wing ice contamination has been cited as the probable cause or sole contributing factor,” the NTSB shrugs off the glaring fact. The NTSB alludes to this critical issue in Recommendations A-93-24 and A-93-25, suggesting testing be conducted between the FAA and the National Aeronautics and Space Administration to “explain the disproportionate number of takeoff accidents of non-slatted airplanes.” That’s it? By their own admission, in 1992, an inconsistent number (???) of non-slatted aircraft are having accidents on takeoff in icing conditions – enough for the NTSB to take notice of – but the NTSB’s focus was on making sure ILS antennas are made of breakable material?

A non-slatted winged aircraft does not employ leading edge slats, like those used on many commercial aircraft. One term for these wings is: ‘critical wing’; the camber is flatter on both upper and lower wing surfaces, which makes the lift produced dependent on a smoother surface – no contamination. Any ice – even granular ice – can disrupt airflow over the wings enough to be a threat.

In 1992, Title 14 Code of Federal Regulations (CFR) Part 121 airliners with critical wings were not as numerous as they are today. In this report, the NTSB ignored the safety ramifications of many CFR Part 135 aircraft employing non-slatted wings. This opportunity to address the safety of a large population of aircraft was lost, even though the NTSB recognized that non-slatted aircraft accidents were occurring. Instead the NTSB wrote about a confused jumble of ‘contributors’ to Flight 405’s accident using ambiguously soft language, e.g. “encourage air traffic control …” or “establish a wind tunnel …”; words that have the urgency of saying, “pretty please with sugar on it.” As per AAR-93/02, “At the time of this accident, US Air was using Type I glycol-based fluid for deicing airplanes. As with other domestic air carriers, US Air had not equipped any of its facilities to dispense the Type II fluids to provide extended anti-ice protection to its aircraft.” The choice of only using Type I deicing fluid generated specific aircraft holdover time (HOT) numbers: the time between the moment deicing starts on an aircraft and when that aircraft must begin its takeoff roll.

US Airways was within their rights to only use Type I deicing fluid. It is, however, important to clarify the difference between Type I deice fluid and Type II anti-ice fluid. Some aviation ‘experts’ suggest it is acceptable for a flight crew to ignore an air carrier’s approved deicing policies and use, e.g. a push broom, to remove ice and snow from an airliner, even one with a critical wing. It is/was not acceptable; it is/was dangerous; it is/was wrong … period, for deicing an airliner.

Deicing fluid (DF) is usually – not always – glycol- or ethanol-based. DF is mixed within the delivery system, e.g. a deice truck, with water and heated to near the boiling point of water. The mixture percentages are important and must be known to determine the HOT. The heated DF is sprayed on the fuselage, wings and empennage to melt/clear ice and snow. If the deicing event starts at the cockpit, then the HOT is calculated from the moment the DF is applied at the cockpit – not later. The heated fluid contacting the cold airframe, cools down dramatically and runs off leaving very little residual protection from snow or refreezing. This is why HOT times are so critical. As per AAR-93/02, the HOT for the Type I DF used on Flight 405 was eleven minutes and thirty-seven seconds.

Anti-ice fluid (AIF) is not heated or diluted. Instead the ambient temperature AIF is applied as a coating of pure glycol or ethanol immediately after the aircraft is deiced; the AIF retards the ability for snow or ice to rebuild. AIF has a longer HOT because of its superior negative effect on frozen precipitation, but it does not last forever. Constant precipitation affects AIF’s integrity, but its protection has a greater HOT than DF. AIF was not used on Flight 405; its absence better explains what went wrong.

Flight 405 was originally scheduled to depart Gate One at 19:20. The first deicing was at 20:26, an hour later. The Captain called for a second deicing because a broken deice truck blocked Flight 405’s path. The second deicing ended – concluded at – 21:00 (per US Airways deicing records). Properly deicing an entire airliner the size of a Fokker 28-4000 with one deice truck takes a minimum of ten minutes; a larger B727 with a similar T-tail takes ten minutes to deice, per my experience. Flight 405’s deicing started at 20:50 – forty-five minutes before the takeoff roll; thirty-three minutes after Flight 405’s HOT expired.

If this was the first time icing caused a major airline accident, the NTSB’s ignorance could be excused. However, Air Florida Flight 90 (January 1982) and Arrow Air Flight MF1285R (December 1985) occurred within the previous decade; they were hard, costly lessons where icing was ignored to the tragedy of many lives lost. These two accidents were cultural issues, as was US Airways Flight 405.

So, what did go wrong that tragic night? Both the NTSB and the FAA have made the term ‘Pilot Error’ an ambiguous phrase, applying to anything that can’t be figured out via hard work and attention to detail. It’s a rubber stamp for those who don’t understand what really happened in an accident. However, according to AAR-93/02’s Recommendations, Air Traffic Control’s attention to detail did not cause this accident. The FAA could not look-over-the-shoulder of the pilots that night. The airport firefighters’ response time had less to do with Flight 405 ending up in Flushing Bay as did the ILS antenna’s lack of frangibility.

This time ‘pilot error’ referred to the pilot’s actions before the flight. This accident’s root cause was the flight crew’s failure to follow frozen precipitation event procedures. Critical wing or no critical wing, one of the pilots should have assured the wings were airworthy by conducting a ramp visual inspection – outside – at the wings or calling again for deicing. The Reason: Flight 405’s second DF HOT was exceeded by thirty-three minutes. Ice and snow had re-accumulated on the wings.

Flight 405’s tragedy was not because of gate holds, airport taxi delays, other airlines using incorrect procedures, ground personnel’s professionalism, briefing cards or ILS antennas’ frangibility, as AAR-93/02’s Recommendations would suggest. Two pilots defied their training and common sense; they, alone, ignored the DF HOT. Whether lulled into a false sense of security, thinking that the Laws of Physics would forgive them this oversight or just their refusal to stand outside in the snow, the pilots failed to protect the flight. Twenty-six other people paid the ultimate price for this error in judgment.

The NTSB continued to fail in their understanding of airline culture, thus neglecting their responsibility to the travelling public. What is the purpose of an accident report? To find out what caused the accident … the accident … the accident. Instead, AAR-93/02’s Probable Cause watered down the HOT issue by blaming the FAA, air traffic control, the entire airline industry and the aircraft manufacturer. The NTSB leap-frogged over the non-slatted critical wing icing issue that affected Part 121 and Part 135 aircraft, even though they questioned it. Twenty-seven years later, the NTSB still does not understand airline culture. Twenty-seven years later, we still have Lessons Unlearned.