Aircraft Accident and Comprehensive Alaska Safety ASR-20/02

Comedian George Burns once said, “Too bad all the people who know how to run this country are busy running taxis or cutting hair.” The comedic centenarian was poking fun at the abundance of opinionated folks who felt that they knew more about politics than the politicians. Unfortunately, there is a list of others who would place themselves at the forefront of the aviation safety opinion peddlers, claiming their own knowledge of aviation far exceeds that of the Federal Aviation Administration (FAA). That list would include self-described aviation experts and the National Transportation Safety Board (NTSB). The self-described authors cannot change; the NTSB can.

An FAA friend of mine asked me if I really did dislike the NTSB. I said, “I don’t, I really don’t.” What I do find to be the NTSB’s weakness is their inability, after fifty-three years, to explore Root Cause Analysis and comprehend its benefits. The NTSB, instead, ‘bangs the table,’ criticizing aviation concepts that they can’t understand to move agendas which are paths to nowhere.

On February 20, 2020, the NTSB called, “for a comprehensive effort to improve aviation safety in Alaska,” due to Alaska’s high accident rate. The NTSB titled its aviation recommendation: ASR-20/02, “Comprehensive Alaska Aviation Safety Approach Needed”. ASR-20/02 was written to revise the FAA’s processes for overseeing Alaskan operators, particularly Part 135 operators, but it won’t

Per the NTSB report, “From 2008 to 2017, the total accident rate in Alaska was 2.35 times higher than for the rest of the United states. The fatal accident rate in the state was 1.34 times higher, according to NTSB statistics.” The NTSB have taken this track before, particularly when the Sunshine meetings are held. NTSB Board Members exaggerate statistics; they spout half-truths in feigned disgust. As with sunshine meetings, ASR-20/02, unfortunately, is deceptive; it is a chance for Board Members to get camera time, not address a problem. NTSB Chairman Member Sumwalt is a very intelligent man; I do believe his intentions are sincere. However, ASR-20/02 is a mischaracterization of facts; it serves little purpose in proposing solutions.

First, to suggest that fatalities are a product of some gruesome numbers game is a stretch, like comparing apples to orangutans. Fatal accidents are a product of two things: opportunity and occupants. Opportunity means that if an aircraft’s engine quits over hundreds of square miles of forest, as opposed to over hundreds of square miles of clear fields, chances are the landing will not be survivable. Occupants means if a widebody passenger jet crashes with 300 souls onboard it would take 75 four-passenger single engine aircraft accidents to equal that fatality number. This is deceptive; fatality rates are not a product of safety. Fatality rates only elicit emotional responses from the public.

The concept that Alaska presents many distinctive aviation safety problems is not new; no one argues that Alaska’s unique environment makes for unique challenges. To get some perspective, Alaska’s land area is 571,951 square miles, roughly 20% the land area of the ‘lower forty-eight’, the contiguous United States, which has a total land area of roughly 3,000,000 square miles. The FAA oversees the state of Alaska’s non-major air carriers with a few offices with perhaps 100 inspectors.

In addition, Alaska has glaciers, thousands of square miles of forests and lakes; numerous scattered towns that are not accessible by roads – including the capital, Juneau – but are only accessible by water or air. Hundreds of aircraft pilots operate in these extreme conditions, flying into areas that challenge the rules just so as to supply native Alaskans with basic essentials.

The Alaska FAA inspectors cannot provide constant on-site oversight; they have limited resources, e.g. transportation, to reach these places or help establish safe alternatives. The FAA has restrictions to how they can visit these hundreds of operators’ pilots and their maintenance facilities. These inspectors are subject to extreme weather conditions, the same that dictates how Alaskan aviation folks operate, how they can reach their customers. Oil fields in some of the human-challenging locations, test the mettle of the Alaskan aviation community. These are the realities of the Alaskan environment. People working in Washington, DC cannot grasp these challenges.

Then one must understand the FAA as it exists today. Programs have been implemented, such as the FAA’s Safety Assurance System (SAS) program, one of many effective safety programs honed over years to improve safety and communication between the FAA and industry. The FAA introduced the SAS program with the commercial air operators, e.g. major air carriers, using its established industry to fine tune SAS – then called the Air Transportation Oversight System (ATOS) – before incorporating the smaller industry air carriers and repair stations into a next generation program.

The safety of Part 135 Air Taxis, On-demand operators, which the NTSB has placed on its Most Wanted List, now falls into this SAS program. Other successful FAA programs have been developed, e.g. Safety Management System (SMS), Aviation Safety Action Program (ASAP), Suspected Unapproved Parts (SUP) and the Voluntary Disclosure Reporting Program (VDRP). It would have been a welcome sight if, in my years of teaching at the FAA Academy, I had seen NTSB investigators taking these FAA classes to learn how ASAP, SUPs, SAS, VDRP or SMS programs work; how FAA inspectors oversee Part 135 operators; how the FAA’s success with the industry has increased safety. Why? Because the NTSB cannot improve safety if the average NTSB investigator does not understand how the FAA works.

When will the NTSB employ Root Cause Analysis instead of Probable Cause, aka Probable Guess? One has only to review past accidents in Alaska to understand how the NTSB missed important issues with the Alaskan Part 135 industry, e.g. the Ryan Air Services, flight 103 accident investigation, #DCA88MA004. Part 135 is so very different from major air carrier; in Alaska those differences are magnified. Part 135 issues focusing on paperwork or weight and balance, were overlooked completely. These mistakes resulted in Alaskan Part 135 aviation safety not being improved.

If, by being unaware of FAA programs, the NTSB will continue to miss opportunities, they will pass up numerous chances to improve safety and fail to spot the true threats to aviation safety. By focusing on Probable Guess instead of common sense, the aviation industry will be stuck in pushing ineffective agenda items, e.g. cockpit video cameras.

What, then, would be proactive measures that would improve safety in Alaska? The NTSB could use their influence with the United States Congress to put forth proposals to increase the budget for the FAA in Alaska, hire more inspectors and place them strategically so that they are more effective in the unique environment there. Push Congress for more inspectors to be hired, to supplement the need in Anchorage and Juneau. Those are ideas that would improve safety, common sense ideas that would work.

It would also prove productive if the NTSB hired investigators that were up to the challenge of the FAA’s jurisdiction; hire investigators that worked in the specific transportation industry, not just for Aviation, but for Rail, Highway, Marine and Pipeline, as well. Don’t limit the hiring of investigators to engineers who have no fundamental experience of working airplanes in an air operator or repair station capacity. Have these investigators take an FAA class, work side-by-side with an FAA inspector. Before ASR-20/02 came out, the NTSB should have had NTSB investigators work in the field with Alaskan FAA inspectors, in the most challenging months of the year when the inspecting conditions are most difficult.

It does nothing for safety if the recommendations coming from the Board have no teeth, no insight, no thought put into them. Chairman Sumwalt stated, “We need to marshal the resources of the FAA to tackle aviation safety in Alaska in a comprehensive way. The status quo is, frankly, unacceptable.” One expects the Chairman to add, “Harumph! Harumph!” Instead, the statement, “We need to marshal …,” suggests the NTSB is in this fight, shoulder-to-shoulder, with the FAA, but they’re not. The NTSB needs to be shoulder-to-shoulder, but more importantly, they must be supportive. The NTSB must understand what is going on; they must become experienced; they must be quick to aid with, not just words, but actions.

Is the constant condescension of the FAA’s work really necessary? Nothing is learned if the critic does not know that from which he or she speaks. While it is true that taxi drivers and barbers have opinions, they know can’t accurately judge politicians because they are not politicians. The NTSB does not hire FAA inspectors or the experienced. ASR-20/02 cannot be taken seriously; it won’t make us safe.

Aircraft Accidents and Lessons Unlearned XXXV: Executive Air Charter, Inc Flight 5452

According to National Transportation Safety Board (NTSB) report, AAR-88/07, on May 8, 1987, an Executive Air Charter, Inc. doing business as an American Eagle commuter flight, a CASA C-212-CC aircraft, flight 5452, departed San Juan, Puerto Rico, on a flight to Mayaguez, PR. Unfortunately, that is the last clear account in the report’s History of the Flight section. The narrative of how the aircraft crashed then reverted to hearsay, quoting multiple witnesses. A statement by one witness said the aircraft turned right on final into Mayaguez, nosed over and struck the ground. Multiple witness reports were always unreliable; they contradict each other, or recollections are often exaggerated.

American Eagle (Executive Air Charter) 5452, accident number DCA87MA030, is one of the most important accidents to yet be analyzed; the NTSB Archive information was not available. The fatalities in American Eagle 5452 were minimal, yet this accident report represents the Achilles heel in the NTSB’s investigatory process: the absence of experience, particularly in Aircraft Maintenance and aircraft-specific issues. Report AAR-88/07 failed to provide quality safety recommendations or findings.

Reading through report AAR-88/07, there is confusion on what was actually discovered that pointed to Aircraft Maintenance actions as the most prominent probable cause, aka probable guess. Was the right hand propeller out of adjustment? Was the right governor bad from the repair station? Did the flight crew make a mistake?

On May 1 through 5, the right hand (#2) Honeywell-Aerospace TPE331 turboprop engine was swapped due to previous discrepancies. During run tests, the right propeller was replaced because of extensive propeller vibrations. The propeller governor was also adjusted. The plane test flew successfully before flying four consecutive revenue flights on May 5th. On the first revenue flight, the captain reported problems with the right propeller; Maintenance adjusted the propeller’s governor. On the day’s last flight, Maintenance adjusted propeller blade angles to address another problem.

On May 6th, the airliner flew eight scheduled revenue flights without any discrepancy. On May 7th, the aircraft flew two flights and the captain reported a problem; Maintenance readjusted the propeller blades, then eight revenue flights with no issues. The aircraft crashed on the first flight on May 8th.

Each time the pilots wrote up a discrepancy, the mechanics addressed the problem. This is important; it not only demonstrated that Maintenance was addressing pilot discrepancies immediately, but that several legs had been flown without incident. The NTSB engineer did not realize that repeat write-ups can happen, that a problem can resurface because conditions at altitude are different than conditions on the ground; cables can tighten in colder air or engine vibrations at flight idle can offset settings that were perfect during ground operational checks. Adding to the technical confusion, were numerous trouble-free consecutive flights that were flown … without incident. Which brings us back to the baffling History of the Flight section and its confusing description of the crash. What this points to is the fundamental inexperience of NTSB investigators to understand the mechanics’ actions.

Per section 1.12.1, General Information, “The right wingtip first struck the ground 643 feet short of the runway threshold and 67 feet to the right of the extended runway centerline.” The aircraft traveled about 100 feet, presumably in an upright position. The fuselage remained intact, except for the cockpit. All passengers survived with minor injuries.

It is uncertain why this information was not relayed in the History of the Flight section. It could have been easily established by observing ground scrapes, wreckage distribution (found in Appendix D), fuel spatter, localized fuselage damage, techniques that were taught at the NTSB Academy investigator classes. Instead, AAR-88/07 dedicated twice as much report space to conflicting witness descriptions, amounting to some speculation in the recording of facts. The impact evidence was not corrupted; ground impacts are evidence intensive, as opposed to water impacts, because the evidence is preserved. More importantly, evidence found at the impact site did not support Aircraft Maintenance being to blame.

The NTSB employs only engineers to conduct aircraft-specific investigations, e.g. Powerplants, Structures, Aircraft Maintenance and Systems. This is a major problem for the investigatory process. An aircraft engineer, who designs airliners, has experience that is limited to designing a single system of an aircraft’s dozens of systems. Furthermore, they were never exposed to airliners operating in the airline environment. Since they never did, they did not know what to look for as cause for an accident. This calls for an analogy.

In the 1981 movie, Raiders of the Lost Ark, in a rush to capture the map to the Ark of the Covenant – which was engraved on a medallion – the Nazi interrogator, Toht, accidentally burns the map into his palm. Using this imprint, the Nazis forge a new map and begin digging … in the wrong place. Why? Because the rest of the map’s instructions were on the backside of the medallion.

For over five decades, the NTSB has used engineers to investigate aircraft-specific issues. This is akin to digging for answers in the wrong place. It is true engineers have access to aircraft blueprints, but maintenance investigations have little to do with blueprints; they are about people, work hours, maintenance manuals, inspection programs, training, etc. The Federal Aviation Administration (FAA) places such a high importance on Aircraft Maintenance, that half the FAA workforce is dedicated strictly to overseeing that specialty. An engineer who investigated aircraft maintenance issues would be just as ineffective if he investigated pilot issues just because the engineer designed the aircraft the pilot flies.

From the maintenance that took place on May 5th through May 6th, the NTSB engineer concluded that the “evidence indicates[ed] that the carrier’s maintenance personnel were inclined to take the most expedient means to correct an engine rigging problem …” There was no evidence to support this assertion, no interviews. The NTSB engineer came to this conclusion without factual proof as a basis.

The 1.6.2 Maintenance History section of AAR-88/07, the pilot discrepancy reports stated the various mechanical problems found by previous pilots logged in the maintenance logbook; the pilot write-ups were documented. However, even though mechanics addressed the pilots’ concerns each time, the report did not say what the mechanics’ actions were. This raises questions: What did the mechanics do to fix the problems? What did the mechanics document in the logbook? What did the maintenance manual instruct the mechanics to do? Did the maintenance manual give proper steps to adjust the propeller?

This is where the NTSB engineer did not dig in the right place. Many maintenance manuals were written with poor instructions. As an aircraft sees time, the manuals are revised to correct the manual instruction errors. As to the quality of maintenance, larger airlines have the benefit of more experienced mechanics, those who base their work practices on ‘tribal knowledge’; the tricks of the trade that the manuals cannot demonstrate, e.g. blocking cables. Especially these days where major airlines can afford to draft the most experience, like sucking oxygen out of the room, there is no one to pass on the tribal knowledge to the mechanics at the smaller airlines, such as regional airlines.

This is key to understanding how despite a newly replaced engine and propeller being installed, major problems had surfaced. What was important was to find out why they repeated and fix the problems, e.g. manuals or training, that led to the repeat discrepancies. That did not happen.

This is why the safety benefits of this accident were non-existent, too much guesswork, just like the reliance on witnesses for the accident description. The NTSB engineer who investigated Aircraft Maintenance issues did not cover the bases; he allowed speculation to replace facts; he shrugged off researching the maintenance program or maintenance manual quality. The NTSB engineer did not have the fundamental experience to pursue the answers. He did not know where to dig.

This accident was a lost opportunity to improve safety. The accident came at a time when regional airlines were still growing into what they are today, where numerous regional airlines fly in contract to the major airlines. Instead, it became a lost opportunity to capture and fix problems with the young regional airline industry. This problem has now grown and possibly spread to more airlines.