Aircraft Accidents and Ginger Rogers

Ginger Rogers was an agile, talented dancer with incredible timing and footwork; her career on Broadway, in Vaudeville and the cinema cemented her in the hearts of Americans. She could make waltzing beside the ever-graceful Fred Astaire look as normal as a walk across the park, to music of course; her elegant dancing outshining Astaire, because Ginger Rogers, “… did everything he [Astaire] did – backwards … and in high-heels”. One thing that cannot be said of Ms. Rogers was that she was not a 200,000-pound aircraft. So why do so many unappreciated semi-professional rug cutters want to treat a B737 or A320 as if Ginger is pushing back to the taxiway?

There appears to be a new trend making its way in the news these days: dancing wing-walkers. No, not the type of wing-walker who rode on the top of a biplane in the 1930s; the only person’s safety they risked was their own. These are airport personnel who guide the aircraft back, relaying warnings to the pushback tug driver or alerting the pilots to dangers at their wingtips. It is specifically NOT to trivialize these safety people but to explain why they are vital that this article is based.

Look, everybody likes to have fun at work and, according to the job, fun can be had to differing degrees. However, there are times when fun must be put aside, and care must be taken. Firemen don’t spray each other with the fire hose; truck drivers don’t swerve through lanes to the beat of their favorite song. The airline passenger filming the unchoreographed escapades of the breakdancing ramp employee sees only a six by twelve snapshot of the ramp activity. It is far different from the view the pilots see or the person pushing the aircraft back observes, the one who has, for the duration of the pushback, full responsibility of the airplane, flight crew, passengers and every single person on that immediate ramp area.

The person sitting in the pushback tug only sees – an airplane, which takes up 80% of his view, just radome, nose gear and aircraft belly. Off to the side are the ramp employees, aka wing walkers, who can see what is behind the aircraft, to the side of the aircraft and anything along the extensive wingspan that the aircraft occupies in its reverse-bound odyssey. As the aircraft is pushed backwards, the pilots are fully dependent on the ramp crew to maintain a safe distance from anything that can jeopardize the aircraft’s safety, which includes: ramp equipment, personnel, taxiing aircraft and aircraft being pushed back from adjacent gates. There are also aircraft starting engines, whose jet blast can affect safety.

Ramp employees have been known to fall under the wheels of wide body aircraft under the best of conditions; their legs crushed or worse. Ramp employees wear hearing protection that does its job well, blocking any noise from reaching the employee, including aircraft engine noise. Wings have been known to be breached by ramp equipment that was haphazardly parked to the side, their safety gates or loader decks infringing on the aircraft silhouette, the no-go area that an airplane occupies in the gate. Plastic bags have escaped baggage carts, only to be ingested into an aircraft engine, which cancels the flight. The ramp is a dangerous place, whether in a hub airport or a small station. There are hazards galore that threaten safety, life and aircraft.

Let’s expand the view the young passenger/video-taker is missing. As the video-taker is safely sitting inside the aircraft, the mechanics or ramp personnel are pushing the aircraft backwards into an active area. As the pushback continues, the aircraft is turned (backwards) to go left or right to the taxi line. Obstacles that were not originally in the aircraft’s path, now move into view and, thus, into a menacing position. For instance, a fuel truck, heading towards gate 8, may stop to allow the pushback to continue, its tank now in the wing’s path. At night, the dangers are less visible.

This is why wing walkers are not just a safety measure but a critical necessity to the passengers reaching their destinations. However, these airport personnel, whose job it is to keep passengers and aircraft safe, are being distracted from their very important safety work. Suddenly, wing walkers need to ‘get-their-groove-on’ for the occasional airline passenger who, despite ignoring the very important safety brief taking place and having their cell phones off, choose instead to be an audience to these ‘Tony Maneros’. Videos keep popping up in the digital media showing ramp personnel, who are supposed to be watching the clearance of the aircraft wing or tail, now hamming it up for the aircraft passengers. Hoping to be discovered, these guys (and gals) just break out the moves, lighted wands playing light-sabre visual effects across their path, as some passenger eagerly videos the performance.

My take on these antics is simply this: Stop it! Cease! Desist! Please, in the name of God, knock it off!

As the performing ramp employee, aka ‘Tony Manero’, is focused on putting on the best performance of his recent career, the consequences of ignoring the dangers may seem trivial to the average passenger. But are they? Ramp equipment parking areas are prime real estate, although a loader or ground power unit may occupy a footprint off to the side of the aircraft’s silhouette lines (parking area) a safety rail may intrude into the silhouette area, in the turning arc of a wing’s winglet, e.g. maybe someone left a belt loader’s ramp in the raised position. An airplane isn’t pushed back in a straight line; the reason for wing walkers is to prevent damage from unexpected sources.

What can happen if an aircraft’s wing strikes an unyielding metal loader gate? A wing’s winglet could be ripped from the wing tip; this would ground the airplane. Perhaps the gate could rend open the bottom of the wing’s fuel tank, spilling hundreds of gallons of jet fuel over the ramp; this would cause a fire hazard, cancelled flights (other nearby airliners where the fuel migrates to) and missed connections.

Well, what about the performing ramp employee’s safety? Does he see the baggage cart tongue in his path? Does he see the set of equipment chocks laying on the floor where they are not supposed to be? The resulting consequences of the dancing ramp employee tripping over a baggage cart tongue or chocks are a snapped ankle, a spiral fracture or the need to count missing teeth after head-butting a heavy steel cart.

Now there are deice personnel who are joining in the fun; they twitch their hips in the confines of their deice bucket, rolling their hands while doing everything they can to be entertaining, perhaps be the subject of a video that goes viral. Left unchecked, however, these people will be the subject of something, though they will not be happy about it. Their job is to properly deice the airplane, so the aircraft does not crash at the end of the runway. Their job is more important than a viral moment on the net.

To any ramp manager whose employees desire the Broadway lights and attention, please find them somewhere else to work, such as loading aircraft or, better yet, put them somewhere they can’t be tempted by the performing bug. Please! They are dangerous.

Wing-walking may be a tedious job; it is understood. Many of us who have worked for an airline have been wing-walkers at one time or another. Mechanics wing-walk for their entire careers, especially those who work in the hangar or tight ramps when moving aircraft for maintenance. Like everything in aviation, wing-walkers serve a very important purpose: Safety. They provide safety for the airplane, every person on the ramp and every soul on the aircraft.

Oh, and the deice guys who think it is their time to shine with the busted moves? Pay attention to what you are doing. If deicing was that irrelevant, you would be handed a broom and told to sweep the wing or something ineffective as that. This is not a joke; people’s lives literally depend on your work quality.

Please leave the dancing to Ginger Rogers; she was a professional. Her moves were choreographed, practiced and streamlined. Wing walkers and deicers, your job should occupy all your attention – stick to it. Passengers, please don’t encourage the wing walkers to perform; look straight ahead at the flight attendant and, even if you have heard it a dozen times, follow what he or she is saying. And please, everyone traveling, Happy Chanukah, have a Safe Holiday and Merry Christmas. And God Bless our Military and keep them safe all year and especially during the Holiday Season.

Aircraft Accidents and Lessons Unlearned XXXII: Northwest Airlink Flight 5719

Picture by Douglas Bader

On December 1, 1993, on approach into Chisolm-Hibbing airport in Minnesota, an Express II Airlines, Inc. Jetstream BA-1300, doing business as (dba) Northwest Airlink, tail registration number N334PX, impacted terrain. The accident number, DCA94MA022, was researched for information through the National Transportation Safety Board (NTSB) archives, but no archived reports were found, except for those that were comprised in the final accident report AAR-94/05.

The problem with a report like AAR-94/05, is that it is based on an emotional argument, not factual. It preceded other emotionally based reports, like ValuJet 592 and Colgan 3407. The facts of the investigation, often straightforward, get lost in the tragedy’s victim numbers or circumstances. An investigator’s job is not to get distracted but to remain focused on the accident’s facts.

The Probable Causes of the accident were as follows [numbering added for clarity]: “The National Transportation Safety Board determines that the probable causes of this accident were [1] the captain’s actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrumental meteorological conditions. Contributing to the accident were: [2] The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain; [3] the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures; and [4] the Federal Aviation Administration’s inadequate surveillance and oversight of the air carrier.”

What is gained by looking at an accident that occurred twenty-six years prior? What is to be learned from a small commuter accident? That is precisely the point, that each accident, from a passenger-packed jumbo jet to a single-engine private plane, is important because each accident, if incorrectly investigated, leads to another. Each has a lesson – or lessons – to teach us and, as in this case, lessons to be unlearned that were taught wrong to begin with.

Express Airlines II, dba Northwest Airlink, flight 5719 was a Title 14 Code of Federal Regulations Part 135, ten or more passenger air commuter, contracted to Northwest Airlines as a regional server. The investigation was a major accident investigation – accident number DCA94MA022 – because it involved certification requirements for its operations and maintenance, exceeding those of a general aviation aircraft and other smaller certificates. The timeframe, from accident (December 1, 1993) to final report (May 24, 1994) – no hearing – was just under six months; there were nine investigatory groups formed that contributed to the accident investigation. However, six months is extremely quick and did not lend itself to much time for testing, detail or completeness.

The root or actual causes of the accident were not run to ground; instead the investigators settled on probable cause. Beginning with the fourth probable cause: “… the Federal Aviation Administration’s inadequate surveillance and oversight of the air carrier;” was ambiguous. Imagine a picture of a square mile of the mid-Pacific Ocean; an arrow is placed on a wave, stating: ‘You Are Here’. The probable cause had no point of reference, no usable information. What did the NTSB, with its limited certificate holder experience, find that the Federal Aviation Administration was inadequate in? A finding about Air Carrier Operations Bulletins failed to clarify the collapse of trust or what constituted a failure of surveillance and oversight. No lesson was learned; indeed, no lesson was generated at all.

Probable cause number one: “… the captain’s actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrumental meteorological conditions.” The first ten report pages, ironically titled: 1. FACTUAL INFORMATION, described a captain who was hard to work with, following him from the previous day to the day of the accident. His every growl and ill-tempered action from 24 hours before the accident flight was analyzed and commented on by gate agents and cleaners. Were these persons experts in human behavior? Did they even know the captain? This was hearsay. From the cockpit transcript, crew conversation leading up to the accident was casual dialog; no disagreements. There was no arguing or interrupting associated with poor communications. Where was the breakdown in crew coordination?

The captain was criticized by a cleaner (no one else was onboard) for dressing down the first officer for an improper preflight because the first officer missed the broken landing lights. It was the captain’s job to require the first officer to do his job. Crew coordination takes two; each pilot is responsible for his/her breakdown of the communication. However, from the transcript, there were no miscommunications or problems. The captain was tough, but for an investigator to base a report’s probable cause on the word of people the captain rarely had interactions with, let alone conversations with, was unprofessional. The NTSB Board Members should have pushed back on the hearsay; instead, they were disengaged.

The second probable cause: “The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain.” Was this probable cause correctly focused? The captain’s training history demonstrated several problems, including several failed proficiency checks, yet the captain maintained his rating after retraining. The investigators did not succeed in their pursuit of training information. Serious training issues should have raised alarms with the Operations investigators. Why did the investigators not question the instructors’ training techniques, pursued the instructors and their quality? The instructor information was scarce.

The third probable cause: “… the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures.” What ‘widespread, unapproved practice’ did the company fail to identify? The report did not say. The investigators had access to the trainers who gave instruction to the pilots. Were they teaching unapproved practices and what were those practices? The problem with interviewing persons who have much to lose (the instructors) is that they will shine attention on the deceased crew, the ones who cannot argue in their own defense. The investigators should have had better interviews with other Express II pilots to see if they were receiving different training.

The Findings in this report did not represent factual information; the use of terms, such as ‘suggested’ or ‘should have’, diverted from the facts of the investigation, allowing speculation to be reported as fact. The nonexistent amount of time dedicated to testing, the lack of a hearing and the unnecessary analysis in factual matters, signified that the investigators’ efforts were inadequate. The report never made clear why the captain’s actions were unsafe, or why the first officer’s responses were in question.

The investigators dropped the ball and focused attention in the wrong direction. What, then, could have been the cause of the accident? Two questions: What about icing and was the aircraft deiced in Minneapolis airport before it departed? The investigators spent a lot of the report questioning the pilots’ integrity; what efforts were given to prove mechanical integrity? Too little was done to show if icing or frozen water was a contributor.

Deice fluid is made of 50% deice fluid and 50% water. During deicing, water has been known to get trapped in fairings surrounding the elevator pushrods. At altitude, the deice water freezes at below freezing temperatures. At cruise, small inputs are the norm, while at approach speeds the larger inputs are critical. What if they were hampered by ice? If the aircraft was deiced in Minneapolis, trapped ice could have made elevator movements sluggish or non-existent. The aircraft would have been more difficult to control at slow speeds or to recover from a steeper descent. Speculation? Perhaps, but the investigation failed to explore other effects upon the aircraft’s flight control integrity. This accident investigation showed no lesson learned; nothing of value came out of the report. The investigators’ rush to close the accident report found nothing that would increase safety and ignored the obvious. This questionable investigation itself should be a lesson unlearned.