Aircraft Accidents and Kobe Bryant

A Flight Data Recorder

“Emotions are the enemy of Truth.” You might expect that to be a Star Trek quote, a Vulcan adage to explain away a vengeful alien’s demise, but it is not. Emotions are the antithesis of what all accident investigatory groups, e.g. the National Transportation Safety Board (NTSB), are supposed to be about. Mister Spock’s lack of emotions shows how investigators should view all accident investigations – dispassionately. Body counts – though tragic – have nothing to do with WHY an aircraft crashes. They never have.

On January 26, 2020, Kobe Bryant was killed when the helicopter he was in crashed, accident number DCA20MA059. The helicopter, a Sikorsky S-76B, was owned and operated by Island Express Helicopters, a Code of Federal Regulations, Part 135 operator. The helicopter impacted terrain. The accident investigation continues; the root cause is still undetermined.

All the accident’s victims should be mourned. The loss of life is always tragic and should be recognized. However, Mister Bryant’s name should be separated from accident investigation DCA20MA059. His involvement is the only reason the NTSB dedicated vast resources to the investigation. But investigatory agencies tend to become mired in the emotional issues. DCA20MA059 is an investigation. The NTSB should concentrate on the accident’s causes, not the tragic loss of life. To do otherwise could be perceived as exploiting Kobe Bryant’s celebrity – and tragedy – to push an agenda.

In a Saturday, June 6, 2020, article titled: “NTSB Urges Helicopter Makers to Install Black Boxes Months After Kobe Bryant Accident”, Fox News’s Vandana Rambaran said, “In an unprecedented move Tuesday, the National Transportation Safety Board directly urged six of the largest helicopter manufacturers to install black boxes that provide information in a crash, like the one that killed NBA star Kobe Bryant.” First, this is not unprecedented; investigative agencies have been circumventing oversight agencies, like the Federal Aviation Administration (FAA), for years. The NTSB has used different venues to avoid regulatory challenges, e.g. accident hearings, sunshine meetings, the media and, of course, Congressional Hearings. These attempts are silly. Why? Because the NTSB lacks the aviation experience to second guess the FAA’s authority in regulatory, engineering and technical knowledge.

The flight data recorder (FDR) is viable equipment on any aircraft, assuming, that is, if it is correctly interrogated. On December 18, 2003, a Líneas Aéreas de Suramericanas (LAS) DC-9 crashed in Mitu, Colombia. This DC-9 had an early generation FDR system, the most basic FDR with minimal sensors. The Colombian government asked the NTSB to read the FDR data, which the NTSB analyzed, along with the Cockpit Voice Recorder (CVR). The NTSB interrogator ‘discovered’ that the stabilizer trim cables jammed and caused the accident. But this was inaccurate. What really happened was the cargo floor failed; the broken floor pinned both the engines’ and ALL the flight control cables, not just the stabilizer trim. The NTSB did not discover the accident’s true root cause before meeting with the Colombian officials because the inexperienced NTSB interrogator misread the rudimentary FDR’s data.

How did the NTSB misread the LAS FDR data? Because the NTSB hired only one experienced investigator who worked commercial airliners, e.g. the DC-9. That person, who was at the meeting with the Colombian officials, pointed out the interrogation error, thus embarrassing the NTSB’s Director of Aviation Safety. The NTSB interrogator did not ask anyone to assist him in reading the FDR data. This is an important point; a common, rudimentary FDR system, used by airlines, could not be interrogated by the NTSB, because there was no one there who understood the DC-9’s sensors or cable system.

What does this have to do with helicopter accident, DCA20MA059? A fixed wing aircraft has sensors for its FDR located all throughout the airframe, from the nose gear to the upper rudder; from one wing tip to the other wing tip. A fixed wing aircraft uses air speed to generate lift over its wings, aka Airfoils.

However, a helicopter creates its own lift with rotation of the main rotor; the main rotor blades are the airfoils. There are no flight controls on the blades because the lift is manipulated by the changing angle of each blade. Since there are no flight control panels, there are no spoiler, aileron, flap, rudder, elevator, tab or ground spoiler sensors. Data on a helicopter is simplified, localized; all data-producing components are located near the pilot; important sensors’ data can be downloaded from the pilots’ gauge programs, e.g. oil pressure, attitude, bank angle, fuel quantity, transmission rotations, from sensors in the engine(s), the controls for the main rotor and the tail rotor.

And this is where the point of the LAS accident comes into play. The NTSB’s Director of Aviation Safety recently stated, “The more information we have, the better we can understand not only the circumstances of a crash, but what can be done to prevent future accidents.” Precisely! This is a true statement. It also underlines what the NTSB doesn’t do, namely hire investigators with specific talents. If the NTSB is truly concerned with accurately determining Root Causes of helicopter accidents, as they should; if the NTSB wants to become skilled in investigating helicopter accidents, as they must; they only need to follow one simple solution: HIRE … MORE … HELICOPTER … EXPERIENCED … INVESTIGATORS. That is all. Problem solved.

When I worked at the NTSB, there was only one investigator – since retired – who had helicopter experience. Since then, it appears the NTSB has hired only ONE investigator with helicopter expertise – just ONE. What does this mean? The NTSB has only one person qualified to investigate helicopter accidents. Only one person who can help interrogate a helicopter FDR.

The ‘lone helicopter investigator’ raises another issue. How has the NTSB been investigating helicopter accidents when they never hired helicopter-experienced people to interpret the data? How did these people (accustomed to investigating fixed wing accidents) determine if Ground Resonance or Retreating Blade Stall occurred? Were these accidents investigated correctly?

Per the NTSB’s website, the NTSB stated, “In addition to asking manufacturers to install crash-resistant recorders on newly built helicopters, the NTSB also asked them to provide a means to retrofit their helicopters with crash-resistant systems capable of recording flight data, cockpit audio and images [Italics added] on their helicopters not already so equipped.” And there is the rub. Would helicopter safety be improved by installing cameras and voice recorders?  

As per the NTSB update for DCA20MA059, “The pilot [singular] and eight passengers were fatally injured and … forces and fire.” Let us be clear – there was only ONE pilot. In almost all emergency medical helicopters, police helicopters, news helicopters, traffic helicopters and Part 135 commuter helicopters, there is only ONE pilot. In an emergency, there would be no discussions. Single pilots do not talk to themselves. A pilot would not give a play-by-play of the emergency, stating what each gauge reads. The pilot would not announce what he is doing. There would be no intelligible words to record.

Then what would a helicopter CVR capture? Passengers screaming? Equipment being tossed around? The thumping of the main rotor or engine(s) drowning out all conversation. Let us be clear, Cockpit Voice Recorders are just that: COCKPIT voice recorders. They are designed to record voices and noises INSIDE an enclosed cockpit compartment. Helicopters do not have enclosed cockpits. A CVR is designed to capture pilot conversations. Passenger and flight attendant conversations are not meant for the CVR.

Per the Rambaran article, “The FAA has failed to act on an NTSB recommendation that turbine-powered helicopters record data, audio and images during flight, so the safety board instead reached out to Sikorsky, Airbus Helicopters, Bell, Leonardo, MD Helicopters and Robinson.” First, the FAA has not failed at anything. Second, Ms. Rambaran does not understand that CVR audio would bring ZERO results to an accident investigation. Cameras, on the other hand, make the emergency worse. How?

Imagine Ms. Rambaran – or any professional – having someone video her every … single … action while she is working, e.g. driving to a story; filming her while she ‘gets’ her story; recording every time she drove over the speed limit or rolled through a stop sign; stopping for lunch (how long did she take?); watching her chew her food; filming over her shoulder while she types her story; second-guessing her use of spell check; checking if she used opinions or facts in her news story. Every choice she makes is brutally scrutinized; every decision, interrogated. And … she knows her actions will be questioned.

Cameras add to a pilot’s stress and do not increase safety. Where would one put the camera? Facing the pilot? Above? Below? To the side? Focus on the instruments? Focus on the controls? Looking out the window? Is it focused for inside or outside of the helicopter? Do you use color film?

Ms. Rambaran continues: “The FAA has, in the past, resisted mandating crash-resistant recorder systems because it could not calculate a cost-benefit ratio.” This is true. Helicopter cameras and CVRs are a financial extravagance; that’s a fact. Besides, a change to the Federal Aviation Regulations for helicopter CVRs would take five years and cost over five million dollars for CVRs that will never increase safety.

My condolences to Kobe Bryant’s family and to the families of those who lost loved ones in that accident. The NTSB should steer away from the emotional side of accidents, focus on real problem-solving. They need to use tools that work. They must hire only qualified, experienced investigators; not waste time and money on agendas that amount to irrelevant technology that does nothing for safety.

Aircraft Accidents and Lessons Unlearned XXXVIII: The English Language

Partial Book Cover from English in Global Aviation

Two inspectors and I conducted surveillance on a Florida-based operator. My fellow inspectors had found issues with the operator’s weight and balance (W&B) forms. I later walked past the ramp manager’s office, where the two inspectors were talking with the manager (who spoke not-so-good English) about the W&B forms. The inspectors spoke s-l-o-w-l-y, VOCIFEROUSLY, as if the non-English fluent manager would better understand what they were telling him, but it did not help.

Since I began writing articles, I am one of a few authorities writing about mistakes made in aircraft accident reports, specifically aircraft maintenance mistakes. I am reading a book by the authors Eric Friginal, Elizabeth Mathews and Jennifer Roberts called, English in Global Aviation (Bloomsbury Academic, 2020). It is a brilliant book focusing on misuses of the English language – the language of international aviation – in aviation and how these misuses affected aviation safety.

The book is encouraging for its honesty. The authors know their topic; their expertise speaks to safety issues never raised before in accident investigations. The book is timely; it analyzes how accident investigations have been affected (negatively?) by, e.g. conversations between English-speaking pilots and foreign air traffic control (ATC); foreign pilots, whose native language is not English, with United States’ ATC; foreign pilots slipping between English and their native language in the cockpit.

Listening to the cockpit voice recorder (CVR) of an accident flight is difficult for many reasons. CVR transcripts can be frustrated by sounds that are hard to hear around, such as rushing air, audible alerts, pilots speaking over each other or pilots alternating between English and their native language. It is discouraging that an accident investigation agency (AIA) like the National Transportation Safety Board (NTSB), continues to misinterpret CVR data of an accident flight’s last minutes.

The authors first example is to discuss American Airlines flight 965 (AA965); the Boeing 757-223 struck the summit of El Deluvio mountain on December 20, 1995, near Cali, Colombia. The authors discovered important language errors in phraseology in the radiotelephony communications between Colombia’s ATC and the AA965 pilots. These misunderstandings eventually led to the airliner impacting terrain.

It was unfortunate that the Colombian AIA, Aeronautica Civil of the Republic of Colombia (ACRC), led the investigation. I was a liaison to the ACRC in 2003 for a DC-9 accident in Mitu, eight years after AA965. The ACRC missed basic air cargo modification issues while the NTSB bungled the flight data recorder readings. As with the Mitu accident, the ACRC’s inexperience on the AA965 investigation meant that important issues had been missed.

The authors spell out how, in AA965, radiotelephony communications, phraseology and plain English mistakes, led to the accident because of simple misunderstandings. The book lays out a more informative sequence of events, but the Root Cause was that the Colombian controller’s grasp of English phraseology caused confusion between the controller and the AA965 pilots.

The authors stated, “Accident investigation is not about blame; it is about a fearless and comprehensive uncovering of any and all information that may be applied to prevent future accidents.” In part, I disagree with the authors’ view. AIAs, e.g. the NTSB, obsess about Blame and they take it out of context. Clearly, investigation reports must determine Root Cause(s), not be used as lawsuit fodder. Responsibility should replace Blame. Responsibility for safety failures must be established and addressed. If not, Probable (aka Probably) Causes become – indeed, have been – nothing but politically-correct whitewashes; they have become absurd and useless. Nothing gets solved; safety is not improved; aircraft continue to crash.

Consider the NTSB’s AA965 recommendation: “… the Federal Aviation Administration (FAA) should develop with air traffic authorities of member states of the International Civil Aviation Organization (ICAO), a program to enhance controllers’ fluency in common English-language phrases and interaction skills sufficient to assist pilots in obtaining situational awareness about critical features of the airspace, particularly in non-radar environments.” This NTSB word salad missed the point entirely. Nothing about responsibility. No urgency. No plan. No direction. A safe recommendation that solved … nothing.

On page 23, the authors said, “Accident investigators are committed to a thorough and unbiased review of all the evidence available.” This statement is true but gives AIAs too much credit. Consider Lion Air 610 (LA610) and Ethiopian Airlines 302 (EA302) (Aviation Lessons Unlearned articles XXXI, 11/2/2019, and XXXVII, 4/30/2020), two accidents alluded to in the authors’ Preface. In both LA610 and EA302 obvious investigatory mistakes were made and there was insufficient evidence to base the Findings on (like AA965?). Government agencies investigated government airlines with extreme bias (ACRC looking into the Colombian ATC?). And why did the NTSB and ICAO assign blame to Boeing? Was it convenient? All at once, Blame became acceptable, almost a noble act. An international pile-on with little-to-no proof. Then investigatory agencies, including the NTSB, guaranteed future disasters by repeating what was easy, the mantra: “It’s Boeing’s Fault.” They did this while ignoring obvious problems with the airlines’ cultures, English translations, pilot training and understanding fundamental maintenance practices.

The authors spoke of Avianca flight 52 (AV52) in 1989 (Aviation Lessons Unlearned XXXIV). In this case roles were reversed: a Colombian flight crew with a limited grasp of the English language trying to land in Kennedy airport. The root cause: the crew failed to divert to Boston, their alternate. The authors had found that AV52’s First Officer did not have a command of the English language; the captain relied on him for communicating their desperate fuel situation and emergency. In AV52’s accident, the NTSB had investigatory authority and the best Probably Cause was … AV52’s ‘fuel management’ problems(?). AV52 preceded AA965 by six years. If someone on the NTSB’s AV52 investigation team understood basic English phraseology issues, would AA965 have been prevented? We will never know.

What of the cultural problems? Before AA965, what importance did Colombia place on quality English being spoken by their ATC controllers? Six years earlier, if the international AV52 PILOTS had poor English skills, how much less would Colombia have invested in their in-country controllers? Colombian ATC standards appeared to be much lower than US ATC standards. With AV52, ICAO overhauled language requirements for international carriers. What did ICAO do about controllers after AA965?

The authors make a critical point at the end of Part One of the book: “… language issues played a role, which accident investigators recognized at some level, but which did not rise to the level of being recognized as a causal or contributing factor …” This echoes the main point of the Lesson Unlearned articles, that important information has repeatedly been missed, information that could have directed investigators to contributing factors and then the accident’s specific root cause(s). For instance, why was the Colombian controller in AA965 interviewed twice before the ACRC learned about his phraseology doubts? How was that missed the first time? Did anyone connect AA965 to the AV52 accident? What have been the consequences of these mistakes?

In chapters 4 and 7, the authors talk specifically to Aircraft Maintenance. “Accident investigators are pilots, engineers, and other technical experts.” The authors highlighted the obvious: no mechanics – and that is the point. Have English-speaking mechanics caused accidents through communication mistakes? In the Colgan 9446 accident, during an Operational Test of the elevator trim system, the mechanic in the cockpit running the pitch trim switch thought ‘leading edge (LE) UP’ meant the Elevator Panel’s LE; the mechanic observing on the tail thought ‘LE UP’ referred to the Trim Tab panel’s LE; these panels move contrary to each other. A simple communication mistake led to a reverse trim and then the accident.

Even airframe and engine maintenance manuals are, what mechanics would consider, ambiguous, in some cases, confusing. Major airliners have manuals that are difficult to understand from a mechanic’s point of view, which is why using engineers to investigate accidents is pointless; the engineers’ contributions to maintenance manuals are from an engineer’s point of view. Employing engineer investigators continually ignores ambiguous maintenance instructions used for continued airworthiness.

It is encouraging that the authors give high importance to Maintenance as a causal factor in accidents because AIAs have ignored Maintenance for decades. In the two accidents, LA610 and EA302, involving the B737-MAX, each accident’s root cause involved either the operator’s inexperience with routine Return-to-Service procedures or the operator’s pilots did not recognize (maybe ignored?) the deteriorating maintenance situation. Language barriers played a large part in these accidents; perhaps the translation of maintenance instructions from English to the native language was not the best quality.

Mechanics, unlike pilots, have the benefit of time. If instructions are confusing, call the manufacturer; if a return-to-service test does not clear the problem, call the manufacturer. In both the LA610 and EA302 reports, calls to Boeing were not mentioned. How could investigatory agencies ignore the obvious?

On page 23, “Investigators examine the corporate culture of the company for which the pilots work.” Oh, if only. For instance, AIAs, such as the NTSB, employ pilot investigators without airline experience while qualified FAA-certificated maintenance-experienced investigators are non-existent. These investigators have no experience with culture; they cannot recognize cultural issues; they cannot understand basic operator culture. Culture, in Operations or Maintenance, has rarely been properly examined as a causal factor, indeed looked into at all. The use of these investigators, unqualified in the specialties they investigate, damages investigation quality and postpones safety improvements.

I have worked accidents where English was a point of contention, where even those who live in an English-rich environment got it wrong. I have also worked international accidents where primary languages played heavily into misunderstood instructions. English in Global Aviation demonstrates that another set of causal factors are being ignored by accident investigating authorities around the world and the consequences are being felt by the flying public.