Aircraft Accidents and Memories

Fifty years ago, Apollo 11 took off for its historical moment: the first two men to walk on the Moon. I say two because it was not a one-man gig. Anyone cognizant in the Summer of ’69 has fond memories of Neil Armstrong stepping off the ladder and onto the parched white surface of our favorite satellite. His first words were emblazoned on our American hearts for decades as we cheered, “U-S-A! U-S-A!”, while giving raspberries to Russia.

It is hard to forget important events, those that stand out as milestones, both tragic, like nine-eleven, and wonderful, like the 1976 Bicentennial. Unfortunately, we forget the tragic lessons too early; sometimes we choose to, and others are lost to a preoccupation with other matters. The less spectacular the tragic event, the sooner we push it to the back of our minds. In aviation, if the fatality rate, for instance, is low, we, in the aviation industry, tend to forget.

Incidentally, does anyone remember Atlas flight 3591? One hundred and forty-seven days ago? Outside Baytown, Texas? The Miami-to-Houston flight, a Boeing 767-375BCF, suddenly plunged into the swampy waters of Trinity Bay with little indication of an emergency.

The National Transportation Safety Board (NTSB) launched immediately. According to the NTSB website, they were at the accident scene within hours with the usual cadre of NTSB engineers; they found the flight data recorder and cockpit voice recorder and after several days of recovery returned to NTSB Headquarters. On March 5, 2019, the NTSB website posted a report titled, ‘NTSB Laboratory Completes Initial Review of Cockpit Voice Recorder, Recovers Flight Data Recorder’. The report just stated that the recorders’ data were being reviewed.

But then something happened: Ethiopian Airlines flight 302. The B737-MAX crashed shortly after takeoff on March 10, 2019, a mere fifteen days after Atlas 3591. One hundred and fifty-seven people lost their lives on Ethiopian Airlines 302, but it was worse because another B737-MAX crashed over four months earlier. On October 29, 2018, Lion Air flight 610 crashed with a loss of life at one hundred and eighty-nine. In four months, the B737-MAX was involved in two similar accidents costing three hundred and forty-six lives. The B737-MAX was grounded; intense scrutiny of the aircraft had begun.

As it should have. It was one thing to crash under different circumstances, but the two MAX accident causes were too close for coincidence. And yet, the NTSB was not the lead investigatory group on either accident. They did assist, but the lead roles belonged to the National Transportation Safety Council (Lion Air) and the Ethiopian Civil Aviation Authority (Ethiopian Airlines).

What, then, was on the NTSB’s plate? The NTSB’s Director for the Office of Aviation Safety, in a speech at the 2018 Embraer Safety Stand Down in Wichita, Kansas, said of the Title 14 Code of Federal Regulations (CFR) Part 121 operators that accidents among these air carriers, “is a very short conversation. It’s the sound of crickets … they’re just not happening anymore in the U.S.” Unbelievable! That ‘inspired’ comment was good to know because then that meant that the NTSB was not too busy to update the industry about the Part 121 operations flight Atlas 3591, seeing as, you know, Part 121 accidents, “they’re just not happening anymore in the U.S.”.

Where were the updates? Consider American 587, the A300-600 that crashed November 12, 2001. Long after terrorism was ruled out, the NTSB provided seven updates in the first five months after the accident. Atlas 3591 has had only one update in the five months since February 23, 2019. On March 12, 2019, the NTSB posted to its website for Atlas 3591, accident number DCA19MA086, the only accident update, concluding with the final sentence, “Additional Information will be released as warranted.” That additional information has not been updated for one hundred and thirty days.

Why, then, has Atlas 3591 practically disappeared off of the NTSB’s update pages? What were the differences in the four flights just discussed? American 587 resulted in 265 deaths; Ethiopian Airlines 302 had 157 deaths; Lion Air 610 resulted in 189 killed. Atlas 3591 had three pilot fatalities. There is no suggestion that accident priority is focused on fatality counts, although when I worked as an NTSB investigator, I investigated at least two Title 14 CFR Part 121 accidents that received … less than adequate NTSB Office of Aviation Safety attention: Colgan 9446 and Emery 17, two and three pilot deaths, respectively. It would be unethical to pick which accidents are to receive full NTSB investigation resources by the fatality count, especially when accident investigation generally has nothing to do with the lives lost; it is about why the plane crashed.

To be candid, it is obvious 99% of the time, why accident victims perish, e.g. blunt force trauma, asphyxiation, post-crash fire. These injuries are consequences of the accident; in most cases, they are not the cause of the accident. A lot of accident related information can be gathered from the victims, e.g. damage to the face and hands, smoke in the lungs or symptoms of an explosive decompression; again, these injuries are the results of the accident, they are not the cause. All victims’ families want to know why their family member died just as much as how they died. In my monthly series Lessons Unlearned, I do not mention victim counts. As an NTSB accident investigator, it did not matter how many people were killed in the accident I investigated, whether it was the three pilots in Emery 17 or all 265 in the plane and on the ground with American 587. Emotions were distractions; sorrow was a luxury I could not afford if I wanted to be partial, effective and analytical. My job was to find the accident’s root cause … period. That happens to be the NTSB’s job as well. Or does the NTSB settle on probable cause?

Why would Atlas 3591 be important? Because it is not about the fatality numbers; it is about the chances, as in: What are the chances another B767 has a similar problem? Shouldn’t the question be: What are the chances another CARGO B767 has a similar problem? No, it should not. Cargo aircraft only differ from passenger aircraft because of the upper deck; one has seats and the other has cargo restraining devices. Some differences may be a little deeper, but not too deep. The truth is that what caused Atlas 3591 to fall out of the sky could very well cause a passenger version to fall out of the sky, as well. Which means finding Atlas 3591’s root cause could save hundreds of lives.

One might argue that the cargo aircraft could have been out of balance due to freight misloading. Not likely from what the industry knows of Atlas 3591 so far. If the aircraft was nose heavy, the pilots would have noticed long before arriving at Houston and would have benefited from the spent fuel. Tail heavy? True, burning off the fuel would have moved the center of gravity aft; with flaps extended and airspeed reduced, this would have presented a recipe for trouble. However, the NTSB did not report that the plane suffered an aerodynamic stall, but that it fell nose first. The March 12th update stated, “FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent.” If the NTSB has contradicting information, then it is important they provide it.

The point of this speculation is to drive home the point that, aside from any phantom cargo issues, the events that caused Atlas Air 3591’s B767 to crash might very easily happen to a passenger B767. There are, at last count, over eleven hundred B767s manufactured, most of them in passenger service. Some versions of the B767 can carry 375 people; that’s almost as many fatalities as Ethiopian Airlines 302 and Lion Air 610, combined.

Many B767s are ETOPS qualified, meaning Extended over Water Twin Engine Operations. An ETOPS airplane is qualified to fly on one of the two engines, while cutting across the ocean. The ETOPS aircraft does not operate on only one engine; in an emergency, however, where the second engine fails, an ETOPS aircraft can operate on the remaining engine to the nearest airport that may be hours away.

Determining the root cause(s) of Atlas 3591 cannot be ignored or delayed; they must be discovered. The memories of the accident are short lived; people forget just what they should not, that this is in the best interests of the flying public; a tragedy waiting to happen … again. The NTSB needs to stop worrying about the B737-MAX; it is grounded and not flying anytime soon. Get back to Atlas 3591 because it is … that … important!

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