Aircraft Accidents and Consequences

In the 1957 cartoon, Ali Baba Bunny, my hero Daffy Duck learned an important life lesson. Having recently acquired a Sultan’s fortune, he cleaned a tarnished lamp, releasing a genie. Afraid the genie was after his new-found riches, Daffy stuffed the genie back in the lamp, thus “desecrating the Spirit of the lamp”, angering said genie, who pointed out that Daffy would now suffer the consequences. Daffy responded, “Consequences, schmonsequences, as long as I’m rich.” The genie then shrunk Daffy to the size of an oyster, denying him the chance to enjoy the wealth he was now too little to transport.

It is amazing how people constantly desire things that lead to more dire consequences. If only they had the foresight to see beyond the wish. They are like children who repeatedly forget important lessons, e.g. ‘DO NOT touch a hot stove’. W.W. Jacobs said, “Be careful what you wish for, you may receive it,” which applies to the Daffys of the world, all good intentioned people looking for the short-term fix, that evolve into uncontrollable long-term problems.

In a June 5, 2019, a Maintenance, Repair and Overhaul’s website MRO-Network.com article titled: U.S. Lawmaker to Introduce Bill on Aircraft Maintenance Disclosure (Goldstein, Broderick), U.S. Rep. John Garamendi (D-California), a senior member of the House Transportation & Infrastructure (T&I) Committee, wanted to reintroduce legislation “… that would require [air] carriers to disclose more information about their maintenance activities to the public.” This lofty, indeed silly, goal only echoed a sensible American’s view of U.S. lawmakers as, “a bunch of Sideshow Bobs stepping on a field full of rakes.” Important Note: Sideshow Bob is another cartoon character intent on embarrassing himself.

My articles are not usually this cynical, but this bill is too ridiculous. Congressman Garamendi was quoted as saying, “As a person who spends at least 5,000 miles a week on an airplane, I want to know that airplane is well maintained, and I want to know where its maintenance was done, so I can hold that airline accountable.” Question: How does one spend 5000 miles a week on an airplane anyway? It appears the congressman’s “5000 miles a week” claim is his only aviation experience qualifier. Per his website, since 1974 Garamendi has been a career politician, who moved from bureaucratic position to bureaucratic position to … wait for it … a bureaucratic position. He has zero experience in aviation or business. The congressman says he is a ‘Rancher’; that is either a career choice or a tasty salad dressing. Either way, Garamendi has had nothing to do with commercial aviation.

Aircraft accidents are tragic events. Meeting with family members who have lost a child or spouse is heart-wrenching and humbling. However, in any tragedy’s aftermath, one should never overcompensate with impractical band-aid solutions; it is inane. Numerous lawmakers, unfamiliar with aviation, cultivated emotional crusades for ‘change’ that duped the victims’ families and provided false solutions, all the while exploiting the families’ losses.

The bill”, the article says, “would require carriers to display notices providing the public with the location at which aircraft most recently underwent heavy maintenance, as well as the dates of such maintenance. That information would have to be “prominently displayed” on carriers’ websites and boarding documents, and airline workers at the ticket counter would be required to communicate it clearly to passengers.” Who thinks up this stuff? This statement illustrates, with blinding clarity, Garamendi’s ignorance of what goes into maintaining commercial airliners.

A displayed notice is not like listing a burger’s ingredients on a fast food menu or what fat content French fries have. Major carriers, e.g. American or Delta, have roughly eight hundred aircraft – each – in their fleets. Those aircraft may be maintained in ten to fifteen different major repair stations, worldwide. The ‘display notices’ list will get quite long, considering that any airport could receive any tail registration number in any airline’s fleet on any given day. That is fifteen times the number of airliners per an airline’s fleet, e.g. one hundred and fifty B737-800s.

It is not clear whether the requirements would extend to the component level,” stated the article. What a foolish reflection; of course it would extend to the component level. If not right away, soon enough. Remember, this is the US Congress; They’re not happy until you’re not happy. In that case, multiply the fifteen repair stations by hundreds of certificated component repair stations contracted to the major repair station. Ailerons removed for reskinning and balance are not outsourced to the landing gear overhaul shop. Countless contractors chrome cylinders, repair composites or specialty service thousands of components in each aircraft. Then there are all those numerous engine and propeller repair stations. Do each of these contractors make Garamendi’s ‘display notices’ list? “Be careful what you wish for …

So, the question is: Why? Why pursue this information? Does listing each contract repair station give Jane C. Passenger a warm feeling of security before her business flight? Would Joe Q. Tourist even recognize terms, e.g. metal quenching, balancing or resin infusion to forego that Disney vacation? What about Congressman Garamendi; would he understand what overhauling an Inertial Drive Generator requires? My high school buddy regularly flies to Ireland for business; maybe I should get him a deck of ‘D’ phase check work cards, you know, to read on the plane.

The silliness continues because it doesn’t stop here. Next, they will want airframe and powerplant certificate numbers because …  something-something about safety. List their work hours or what trade school they went to; what branch of the service they trained in. Need more safety? Pilots’ should post their photos just like a taxi driver. Why? Because Garamendi’s years of inexperience tells us it’s safer.

Then Garamendi speaks candidly, “… there is a ‘structural problem’ at the FAA posed by the agency’s sometimes contradictory dual mandates of protecting safety while promoting U.S. industry.” That statement is followed by Garamendi’s underlying theme, “We’ve made a choice to allow that conflict to exist within the FAA, which led to 346 people losing their lives because getting [the MAX 8] up and running was more important than getting the issue resolved.

Ahh, there it is! He’s an expert! A throat-catching emotional crusade, using those families’ pain for his agenda. Those MAX 8s are grounded, still being investigated. But Garamendi knows what happened because aviation ‘experts’ speculated about the MAX 8 crashes. Garamendi will now save us all.

This is the danger of inexperienced speculation. This is why speculation is wrong. Speculation leads to foolish ends. Speculation fans the flames of fear while crushing reason.

What is even more frustrating, beyond the shameless mendacity, is the time, energy and money wasted on this lawmaker’s efforts. As our country struggles through many important challenges, Congressman Garamendi wants to skew our attention to … a shiny set of keys; a bridge to nowhere; a distraction.

But let us assume Congressman Garamendi’s intentions are honorable, that he wants to stop the scourge of accidents. Perhaps, then, he and his colleagues should look to really improving safety by:

  • funding the Federal Aviation Administration (FAA) manpower; expand the number of qualified inspectors to increase the surveillance activities that repair stations and air carriers need;
  • giving help to the FAA to oversee the increasing number of unmanned aerial vehicles;
  • looking into who will oversee the aerial taxi industry that will be tested in Dallas next year;
  • stop shaming the transportation oversight agencies tasked with the safety of the transportation industry;
  • help the oversight agencies with acquiring improved technologies;
  • realistically fund programs for, e.g. NEXTGEN, and other transportation improvements.

It’s funny (not ha-ha funny) but lawmakers, like our good Congressman, will not entertain these suggestions; it is easier to fabricate agendas. Aviation safety comes second. To quote my hero Daffy Duck when talking about dishonesty, “It’s dith-th-th-th-pick-a bull!” �

Aircraft Accidents and Lessons Unlearned XXVI: Northwest Airlink 2268

On March 4, 1987, a Fischer Brothers Aviation Incorporated Construcciones Aeronáuticas, SA (CASA) C-212-CC aircraft, doing business as Northwest Airlink (NWA) flight 2268, crashed on landing at Detroit Metropolitan Wayne County Airport in Romulus, Michigan. The aircraft was operating Title 14 Code of Federal Regulations Part 135 supporting Northwest Airlines, a precursor to regional airlines.

Unfortunately, beyond accident report AAR-88/08, the National Transportation Safety Board (NTSB) Archives had no other investigation records. Archived factual reports gave the reader a view into how the NTSB investigators, e.g. tested the aircraft systems to gain facts or reviewed pilot training for procedural failures. These factual reports gave a first-hand look at the investigators’ experience in the investigation specialty, e.g. powerplants, maintenance, operations.

One disappointing pattern going back thirty-two years, was the NTSB’s ‘blame the Federal Aviation Administration (FAA) for … something’ routine. These regular allegations either did not apply or were too vague, using phrases like, “The FAA did not provide proper oversight.” What does that even mean? The NTSB did this too often; it worked against safety if the FAA is always tagged without any valid reason, except to be based on an investigator’s lack of aviation experience. Ritual cries of ‘Wolf!’ are empty; industry, indeed the public, become immune to this rhetoric.

The [NTSB] determines that the probable cause of the accident was the captain’s inability to control the airplane in an attempt to recover from an asymmetric power condition at low speed following his intentional use of the beta mode of propeller operation to descend and slow the airplane rapidly on final approach for landing.”

The investigators held the captain and his flying skills responsible for the accident. In section 2. ANALYSIS. sub-section 2.1. General, the operations investigator documented that a DC-9 lifted-off of Runway 21-Right where NWA 2268 was cleared to land, that the DC-9 departure met separation standards between the two aircraft. “Consequently, the air traffic control handled the flights properly and no wake turbulence or ‘jet blast’ effects would have contributed to the accident.” This directly contradicted the Probable Cause, which stated, “Factors that contributed to the accident … the presence of a departing DC-9 on the runway …” How did a DC-9 contribute to the accident (page 47), when ten pages earlier (page 37) it was absolved of any culpability?

Stark incongruities, e.g. the DC-9’s presence, drove technical problems with this report. Investigators’ flare for ambiguous analysis and speculation were partly understandable because recorders were not installed. While this may limit evidence, it does not make investigating impossible; it must not hinder fact-finding. The report was littered with allegations that drifted nowhere; they had nothing to do with the accident. Recorders would not have changed these investigating problems.

Other claims had no documentary evidence or were based solely on hearsay, e.g. in relation to a steep approach, AAR-88/08 stated, “This documented practice induced by whatever motivation on the part of the captain, might explain the manner in which the approach was flown.” If Fischer Brothers found the captain had engaged in reckless behavior, the report showed no paper trail, no discipline dispensed. Instead, the Finding’s ‘documented practices’ were fellow pilot interviews; second-hand undocumented information, hearsay; certainly not information that should contribute to analysis. A non-fact, based on assumptions, had no place in this accident report.

In subsection 1.17.3, Crewmember Interviews, the operations investigators interview twenty-two company pilots to determine the accident captain’s flying habits. The report states, “The majority thought highly of the captain.” However, seven interviewee observations were bulleted by the investigators, referring to unconventional flying habits the captain exhibited. The investigators felt the comments important to mention, yet they failed to discover if the flying habits were unorthodox, dangerous or even if they contributed to the accident. They were a path to nowhere.

The operations investigator’s familiarization with the accident aircraft was rudimentary; he understood only the accident aircraft’s basic operating principles. Thus, it was critical to assure the accident pilots’ training was the best; that management was diligent in arresting unsafe behavior. Why? Every accident needed – and demands today – to be the last accident of its type … ever. An accident investigation must guarantee there is never another TWA 800, United 232 or an Air France 447.

Since the NTSB did not hire an airframe and powerplant certificated investigator until 2001, it is safe to say the NTSB investigator who looked at maintenance issues was not experienced in the subject matter. Investigators who ‘looked at’ maintenance were engineers for Systems, Powerplants and Structures, as per AAR-88/08. In section 2. ANALYSIS. sub-section 2.5. Aircraft Maintenance, the report stated, “Although the airplane was found to have been maintained in accordance with the airline’s approved maintenance program and no evidence was found of a component or system failure, three areas concerning the airplane’s performance and airworthiness do deserve comment.” In truth, no, they did not. If the three areas were complicit in the tragedy, then they deserved mentioning. However, this was an accident report, where facts and recommendations must relate to the accident. Anything else diverts from the urgency of the accident’s findings. In addition, the investigator reviewing maintenance was not experienced in maintenance. What light could this investigator’s analysis have shed on safety?

First issue: the most recent flight idle descent check. The investigator assumed the idle check, “… indicated that it [the operator] was attempting to follow prescribed maintenance procedures.” There was no maintenance history documented in the report supporting this speculation. Incorrect idle settings did happen …  still do. The pilot then wrote up the problem in the aircraft maintenance log (AML) so maintenance could fix it. The investigator did not mention AML entries. If an idle issue did exist, it could have been the result of normal wear-and-tear, requiring replacement or rigging. This was normal.

Second issue: the flap system. The report states, “Although there was no recorded history of recurring flap system difficulties experienced by Fischer Brothers and no pilot reports of a similar nature …”. What did this ‘finding’ have to do with the accident? Why mention it? Every aircraft and engine had flaws that surfaced through long-term operation. They were signs of wear-and-tear. To highlight each quirk would require writing multiple reports that had nothing to do with the accident investigation.

Third issue: incorrect feathering spring assemblies installed in the propellers. The report stated that the single springs “… could have delayed movement …” of the propellers’ blades. “However, the degree to which the propellers’ recovery could have been delayed could not be determined,” That was two “could haves”. ‘Could have’ was considered factual? The investigators made conclusions about a ‘problem’ that they could not even prove contributed to the accident. The investigators never mentioned why the springs were installed or if they had been approved through engineering or modification.

Reviewing the Recommendations, the Probable Cause referred to questionable landing procedures and obstacles, yet they never addressed the approach that contributed to the accident. If the investigators determined the approach raised concerns from a safety standpoint, there should have been safety suggestions that reflected this, e.g. a call for each principal operations inspector (POI) to confer with manufacturers to assure operators’ pilot approach training – not just operators of the CASA C-212 – met the manufacturers’ designs; introduce this improved training into the POI’s operator’s flight training. Report AAR-88/08 did not make us safer. The confusion of what belongs in a major accident report versus facts over allegation make this report inconsequential. This is tragic; nine people were killed and nothing was solved. s