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

2 thoughts on “Aircraft Accidents and Lessons Unlearned XXVI: Northwest Airlink 2268”

  1. Very interesting points. But, that’s why NTSB states probable causes with investigating accidents even when there is no substantial findings found.
    I see this lack of FAA oversight a continuous problem and will be until people are held accountable, which doesn’t seem to happen in the government.

    1. I agree Jose. However, I find the ‘probable cause’ concept problematic because it excuses the investigators from finding root cause. That’s where relying solely on the manufacturer’s honesty makes a mockery of the investigation. Recorders have turned into a crutch, like much of technology today. What did they rely on before recorders; what did they do without them or when they could not be retrieved? Engine controls don’t easily move from place after impact; fuel control settings don’t spring load to a neutral position when power is lost; analog gauge (used at the time) needles were often arrested when the lens shattered. What was needed was experienced investigators who, not only knew what to look for, but could keep a practiced eye on the investigation party members.

      Thanks for the reply.

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