Aircraft Accidents and Lessons Unlearned XXIX: Eastern 855

On May 5, 1983, Eastern Airlines flight 855 departed Miami International Airport (MIA) bound for Nassau, Bahamas. The Lockheed L1011, registration number N334EA, was almost twenty minutes out of Miami when the #2 engine low oil pressure light illuminated. The Captain shut down the engine and made the decision to return to MIA.

As the aircraft turned back to Miami, it was climbing through 20,000 feet, when both the #1 and the #3 engines’ low oil pressure lights illuminated. Ten minutes later the #3 engine flamed out; the aircraft was now flying on one engine and still fifteen minutes from MIA; #3 engine’s bearings had turned to molten slag. The crew attempted to restart the #2 engine, but the #1 engine flamed out, its bearings seized. The aircraft descended from 13,000 feet to 4,000 feet without power, not unlike a glider. At 4,000 feet the crew restarted the #2 engine and the L1011 limped back to MIA on one engine.

Losing one engine was normal training for the crew; though not common, an engine-out was not outside the realm of possibility. Even a two engine-out scenario was a training scenario, but it was less likely. All three engines out, even with the same symptom – an engine low level light preceding a flameout – was statistically impossible. And yet, apparently, it was not.

The emergency was brought about by the absence of magnetic (MAG) plug chip detector O-rings, normally installed with the MAG plug in an engine’s oil system following a MAG plug check. This check required the MAG plug be removed from the engine, the magnetic probe checked for metal contamination and then reinstalled with a new O-ring to seal the plug to the engine port. A MAG plug check was (and still is) a normal maintenance item accomplished on the engine manufacturer’s dictated schedule. The three engines had a scheduled MAG plug check performed. The oil in each engine was depleted during the short flight time before the crew turned back for MIA.

All three engines were worked on by two mechanics; one worked on numbers one and three engines and the other worked the number two. The MAG plug kits the two mechanics used on N334EA contained the replacement MAG plugs, but without the O-rings. The mechanics, and other mechanics in Miami, usually received the kits, complete with the O-rings. This was a contributing cause of the accident.

The mechanics, accustomed to having complete MAG plug kits never verified that the O-rings were on the plugs before installing them. They then performed a leak check for the engines to confirm that the plug installations did not allow oil to bypass the MAG plugs. However, the time that the mechanics spent on ‘motoring’ the engines was inadequate: ten seconds; the oil did not have enough time to flow through the system to where the MAG plugs were. A second contributing factor to the accident.

There were these two contributors and one root cause that led to the accident flight. The first contributor: the mechanics’ failure to check the kits for the O-rings. The mechanics had been lulled into a false sense of security by having complete kits handed to them. Both mechanics were still responsible to verify the O-rings were included in the kits and installed with the plugs. The rut the mechanics fell into was complacency. When they performed a redundant task so many times, they assumed they knew the job by heart, e.g. replacing a tire or servicing oxygen. Due to modifications or even accidents, maintenance manuals are revised with different torques or an extra step to prevent a problem already identified. It is the mechanic’s responsibility to make sure the job is done right. No matter how often a job is performed, the manual must be checked for changes and a component for complete parts.

The second contributor: the inadequate amount of time spent ‘motoring’ the engine. The job card should have identified the motoring time needed for a proper engine leak check. From my experience running engines, you can motor an engine for at least two minutes without starting it; after that time the starter could be damaged. Two minutes was enough time for a proper leak check. Another issue was gate time, as in ‘the time before the aircraft is to be on the gate for the next flight’. Rushing through a job to meet an ETC – [pronounced ETIC] (Estimated Time – Completed) – to make a flight departure time, could push the safety limits by employing shortcuts.

The root cause, however, was culture. Had this plug problem happened at other air carriers? Delta, Pan Am, TWA and other carriers flew the L1011; did they have problems with incomplete kits or destroying an engine due to oil starvation? What part did Maintenance Planning play? Management? The Engine Manufacturer, Rolls Royce?

Or did this only happen at Eastern Airlines? Did the culture at Eastern or perhaps only at the Eastern Miami maintenance facility, contribute to the confusion about MAG plug kits? Did the National Transportation Safety Board (NTSB) go to the Eastern maintenance facilities in Kennedy airport, Atlanta or Boston to determine if the problem was limited to Miami? No? They did not? Why not?

Culture issues; they have been contributors to many accidents since 1983. Culture issues have plagued mergers over the last few decades. Culture problems have not been limited to Maintenance but have emerged in Operations (Asiana 214), with cargo contractors (Fine Air 101) and maintenance providers (ValuJet 592). Yet with these and many other accidents, culture issues were never mentioned in accident reports; indeed, culture has never even been looked at as a viable issue. Was it because culture issues never existed or was it because culture issues were never thought to exist?

With Eastern 855, universally accepted complacency was the Eastern Miami maintenance facility’s five hundred-pound gorilla, the elephant in the room. The mechanics’ failure to be diligent and the time-related practice of inadequate leak checks were traceable to the Eastern Miami maintenance facility’s culture. To list all the wrongs that led to Eastern 855’s near ditching at sea would take more than one article could handle; Eastern and the 172 souls aboard flight 855 dodged a major bullet. If other air operators had learned what there was to learn from Eastern 855, many more lives could have been saved.

Randy Pausch, professor of computer science at Carnegie Mellon University, once said about the ‘elephant’ metaphorical idiom, “When there’s an elephant in the room, introduce him.” The industry, e.g. airlines, repair stations, manufacturers, etc. know there are cultural problems in their ranks – they know this. Unlike human factor issues, these are indigenous to the certificate holder and to the groups within.

Safety conversations with Federal Aviation Administration inspectors could result in an unbiased view of an operation’s culture, undetectable from the inside. An outside auditor can identify recognizable patterns that lead to major mistakes. Relying on management to unearth any culture problems would be a dead end when they could be part of the problem. If a certificate holder expects the NTSB to help, they usually show up in connection with an accident. It is unlikely the NTSB would find the culture problem.

Culture issues are the Lessons Unlearned that have led to numerous accidents since May 5, 1983. Although rarely recognized, culture problems have been major contributors to accidents; the root cause overlooked in favor of probable cause. We should not have to wait another thirty-six years for someone to point it out.

Aircraft Accidents and Taking Vacation

Last month I flew with my wife on vacation; I coughed up the money for First-Class. Unfortunately, First-Class is not even a whisper of what it used to be, but that was not the most interesting part of my First-Class vantage point, which was the front-most seats on the right side of the plane – not a regional airliner but a narrow body – right where the passengers first enter the cabin.

The first incident involved a passenger who stowed an electric wheelchair in the closet across from the First-Class lavatory. Not a problem, happens all the time. The flight attendant (FA), who was the only one in this event who displayed any sense of professionalism and safety-mindedness, confronted a woman, the daughter of the wheelchair’s owner, an elderly woman sitting with said daughter twenty rows back. The FA requested that the daughter separate the battery from the wheelchair and keep it with her; the wheelchair battery was a small unit that stowed easily in the overhead compartment, under the seat or in a purse.

The middle-aged daughter began arguing with the FA, firmly stating, over and over, that she had never been asked by the airlines to do this before, that she leaves the battery attached “all the time”. The FA did not back down and even relented to ask the Captain out to the discussion … you know, to support her.

And this is where it got silly. The Captain, who had every reason to support the FA, to tell the daughter if she did not like the conditions she could disembark, instead called his operations department people to see if the woman could leave the battery attached. My wife kept half an eye on me to see what I would say or do. My safety spidey-sense was tingling but I sat quietly and watched the drama from the aisle seat.

Before anyone insult the FA, understand that there have been documented cases I have read where wheelchair lithium batteries have overheated and burst into flames because the controls were crushed up against a wall, a coat or a box. I have seen wheelchair battery fires that had been filmed where the chair’s controls were locked into the ON position, before causing an unquenchable fire in the belly compartment of the aircraft, fortunately while still on the ground. Even with all available extinguishing agents brought to bear, they could not extinguish the blaze until the wheelchair was completely consumed, almost taking the loading equipment with it.

I understand that this Captain did not represent the thousands of captains who take charge of their flights. In fact, the gate agent should have stopped this incident before the wheelchair was even loaded on board. However, no measure of pressure from a passenger should ever make the crew accountable to anything other than the safety of the plane and those onboard. And before I come under attack, I have been working with the airlines for thirty-seven years. I, as a mechanic, had many dealings with airline captains of either gender who demonstrated absolute control of any situation on their airplane. Are airlines so cowed; are they now folding to the pressure produced by entitled passengers who don’t get what they want? I hope not; there were plenty of young children on that flight whose safety was paramount.

Then there was the return flight.

On the flight back, my wife and I sat in the same seats on the same model aircraft. Before boarding, we were waiting by the gate area. An elderly woman in an airport wheelchair was waiting to board. In the cushion-filled baby stroller she pushed in front of her – that’s an elderly woman … in a wheelchair … pushing a baby stroller – was a Shih Tzu dog. She was apparently not wanting to draw ire from anyone so the Shih Tzu had a leash – a pink leash – with the words ‘Service Animal’ emblazoned in gold letters.

Its name was Bitsy-boo.

But wait, there’s more.

When the woman boarded, she took the aisle seat across from my wife and I … of course. The dog took its place at her feet – she originally had the dog sitting in the window seat until the gentleman who bought the seat showed up. The dog remained loose at the woman’s feet the entire flight, sleeping on the airline supplied pillow and blanket … you know, the one you probably used on your flight, the one you put up against your child’s face. I never use those pillows or blankets because I never see the planes swap them out at the gates. Chalk that up to airline travel experience.

This Shih Tzu rolled its whole fur-covered body all around on that blanket/pillow combo; its … whole … body. The blanket/pillow combo was rubbing up against that nice clean floor. Then the woman took the dog into the lavatory and when she returned to her seat, the dog put its lavatory exposed paws all over the blanket/pillow combo … that other people, some who have dog allergies, will place up against their faces.

According to an August 8, 2019, article in airlines.org: http://airlines.org/news/airlines-for-america-applauds-department-of-transportations-guidance-on-emotional-support-animals/ titled: Airlines for America Applauds Department of Transportation’s Guidance on Emotional Support Animals, Airlines for America (A4A) the industry trade organization for the leading U.S. airlines stated, “Airlines for America applauds the Department of Transportation’s enforcement guidance on emotional support animals (ESAs). The availability of fraudulent ESA credentials online has enabled people who are not truly in need of animal assistance to abuse the rules and evade airline policies regarding animals in the cabin. With over a million passengers bringing ESAs on flights last year, airlines and airports saw a sharp increase in incidents such as biting and mauling by untrained animals.”

The flood of ridiculous ESA approvals have made modern politics look sane by comparison. ESAs, e.g. peacocks, full grown sows, cats, exotic birds, snakes, turkeys and even miniature horses – I kid you not, look it up – have represented a selfish corruption of the Americans with Disabilities Act’s intent, to allow passage for trained service animals to accompany their owners, e.g. a blind person’s seeing eye dog or a veteran with post-traumatic stress disorder. These are people with a true need and their animals are specially trained for dealing with emergency situations. Why is this important?

I took part in a Federal Aviation Administration (FAA) cabin fire simulation. The FAA demonstrated the reality of an onboard fire and evacuation; it was quite illuminating. The simulation could not reproduce all the effects of a real onboard fire, e.g. noxious smoke, debilitating heat, screaming, disorientation, injuries, shock and the constant shoving, but what it could duplicate was real enough.

I could barely see the hand in front of my face. The floor lights were hardly visible and were distorted in the smoke. The direction of voices became confused. People stepped in front of me, knocking me aside or others pushed me from behind. It was nearly impossible to determine where the exit was. Most evident was the subliminal instinct for survival, not just mine but everyone’s survival.

Now imagine a real onboard fire with all the effects the FAA could not duplicate. Then add in a Shih Tzu named Bitsy-boo, scared senseless, dragging a pink ‘Service Animal’ leash, tripping children separated from their parents, biting whoever is in its way, causing other passengers to pile up on the floor like cordwood. The body count adds up; the count is not limited to the old and feeble but includes the young and helpless.

Common sense does not always prevail; in some cases, common sense takes years to be brought forward; look at Congress. Meanwhile the innocent suffer for the selfishness of the entitled. There are no ‘constitutional rights’ when it comes to aviation; no one owes anyone, anything, whether it’s a soft drink, a full-length movie or a place for your pet to sleep. What is required, however, is that everyone who flies must be offered the chance to do so in the safest manner possible. That is what you pay for each time you purchase a ticket. As a travelling public, is that what we are getting?

Aircraft Accidents and Lessons Unlearned XXVIII: TWA Flight 6

Photo by Bill Larkin

On May 6, 1935, a Transcontinental and Western Air Incorporated Douglas DC-2 crashed near Atlanta, Macon County, Missouri. The Secretary of Commerce, as per section 2 (e) of the Air Commerce Act of 1926 dispatched two investigators to the site. All information for this accident was taken from the Air Commerce Bulletin Volume 7, Number 1, published in Washington, DC, July 15, 1935.

This accident investigation was accomplished in the days when accidents were common, not because of what was NOT available in technology but because the aviation community was learning how to convert a new industry into a civilian use. The United States’ entry into World War II was six years away and the fruits of the Chicago Convention of 1944 were exactly three years after that. Navigation equipment, autopilot, weather forecasting were decades in the future and even further along from perfecting.

After refueling at Albuquerque, New Mexico, the plane was cleared to fly to Kansas City, Missouri, despite the western night frequency of the aircraft’s two-way radio was non-functional. This prevented the flight crew from communicating with any ground stations for weather information or flight instructions.

When the flight reached Wichita, the ceiling dropped to 600 feet, a much lower ceiling than allowed for such a flight was authorized to fly, which was 700 feet. To be clear, weather forecasting in 1935 was antiquated by today’s standards; no Doppler radar, no satellite imaging and no 24-hour communications from other airports across the US. What exacerbated the situation was the airplane’s lack of air-to-ground radio communications, leaving the flight crew blind and deaf to any obstacles in the flight path. The air carrier’s ground station in Kansas City managed a one-way communication on the company frequency, directing the flight crew to attempt a landing at Kansas City despite the ceiling being so low.

Low on fuel, the pilots brought the aircraft below the clouds at Kirksville; for more than two miles, the aircraft flew low over slightly rolling terrain in scattered fog and mist. While navigating a low depression near the ground, the aircraft dipped its left wing to go around fog; the left wing dragged into the ground, throwing the aircraft out of control.

The investigation relied heavily on witness statements from those in Kirksville who saw the plane as it appeared and disappeared through the low clouds. Estimated altitudes, air speeds and engine noises proved to tell the final seconds of Flight 6. The days of cockpit voice recorders and flight data recorders were years away; minimum equipment lists were the result of accidents such as this.

Transcontinental and Western Air (TWA) flight 6 was unique for two reasons. First that the limited investigatory technologies available at the time did not hinder the investigators from completing a timely and efficient report; indeed, the report was completed in three months with valid recommendations The second reason was one of the accident victims, forty-six-year old Senator Bronson Cutting (R-NM), his death on this flight helped redirect a major change for the aviation industry.

The accident investigation was excellent in its simplicity. In the absence of any other fantastic outside contributors, e.g. ground witnessing of an engine fire; a barn or other farm structure in the airplane’s path or lightning strikes, the investigation focused squarely on the facts. Because the investigation did not veer into any bureaucratic nonsense or was belabored by ‘expert’ grandstanding, the recommendations were straight to the point; they hit the problems square on the head without any maybes or analytical side stepping. TWA flight 6 was a case study in root cause analysis in the days before root cause analysis.

Root cause analysis, used regularly by Federal Aviation Administration (FAA) inspectors, breaks down a problem to its lowest denominator, often by asking WHY, then subsequently asking WHY to every answer until the final answer cannot be broken down any further. This is evident in the findings where the cause was not the airplane dragging its wing into the ground but in that the airplane had been flown so close to the ground due to radio problems before dispatch (Recommendations b, c and d).

From this accident effective recommendations were written, including:

  • The installation of instrument approach facilities at airports;
  • Licensing of airline dispatchers;
  • Improved fuel reserve regulations;
  • Rules dictating pilot flight-time limitations.

These recommendations were proactive; more importantly, they stayed on topic, which was aviation safety. The same cannot be said today about recommendations today that tend to go off topic and wander into agenda items. Furthermore, today the focus is on ‘probable’ cause, not root cause; this is the equivalent of a ‘maybe’ cause, what might have happened, not necessarily what did happen.

It is also indicative of how accident investigation has become overly complicated. This accident took less than three months from the tragedy to the publishing of the recommendations and findings. The average National Transportation Safety Board (NTSB) aviation investigation takes over a year; months pass before an initial update is even released. For instance, Atlas 3591 occurred over five months before this article and no update; this is unbelievable.

The NTSB uses every available technology and dozens of investigators (TWA flight 6 – two investigators), yet in the time between an accident and the first update, a reoccurrence of the same circumstances that caused a first crash can be duplicated.

The second consequence of the TWA flight 6 accident was the death of Senator Bronson Cutting (R-NM). The death of a member of Congress was not remarkable except for the Senator’s loss became the catalyst to move towards separating Commerce from Transportation. The Civil Aeronautics Authority Act of 1938 was adopted in the aftermath of Senator Cutting’s passing. This Act formed the Civil Aeronautics Board, the predecessor of today’s FAA.

The transfer of aeronautics from Commerce to Transportation took responsibility for aviation out of the commerce field; aviation agencies had moved from the oversight of business (under Commerce) to the oversight of safety. With the admission of the US into World War II, other changes would occur, including the introduction of the International Civil Aviation Organization (ICAO), which launched the US and its allies into the international air market in 1945.

TWA flight 6 was a standout accident investigation, especially for its time. Qualified investigators were focused, their attention on safety and what needed to change. Findings and Recommendations were clear; their purpose was to improve aviation, not mire it in ambiguities. The fledgling industry embraced new technologies, modifying their techniques to adopt the new technologies and foster innovation. Most importantly, there was no arrogance, no pride. Aviators knew their limitations and those investigating accidents knew theirs. And because of this, the aviation industry grew to what it is today.

Will it stay safe?