Aircraft Accidents and Unfortunate Responses

A Greek, a Hindu and an Egyptian meet in the desert … No, that’s not the lead-in to a joke. It is the first chapter in the complete and unabridged novel by Lew Wallace, Ben-Hur: A Tale of the Christ. In the story, Judah Ben-Hur becomes consumed by vengeance against the Roman government; the thought of retaliation occupies his mind. It is only in his second meeting with the Christ that he understands his self-destructive ways and forgives those who wronged him. Judah learned to understand before he acted and let fall the sword from his hand. He learned to think … before he spoke.

Recently, the National Transportation Safety Board (NTSB) announced online that the July 14, 2020, Atlas flight 3591 NTSB accident Hearing “a success”. All the NTSB findings and recommendations would make the final report. At last, the NTSB would inform Industry what went wrong. This news generated talk and … some unfortunate responses.

Atlas 3591 crashed into Trinity Bay on February 23, 2019. The NTSB first updated the investigation on their website: on March 5, 2019, ten days after the accident, where they announced an initial Cockpit Voice Recorder review. Then – NOTHING. For 289 Days – Forty-One Weeks – Nine Months – nothing but chirping crickets. A review of the NTSB website showed that there were no other major aviation accidents in work. Then on December 19, 2019, the NTSB posted Atlas 3591’s Hearing would be on July 14, 2020, which was still another Seven Months later. The docket was finally open. Important updates? Go look in the docket.

This needs to be clear: the B767 (accident aircraft) is one of the most popular Widebody passenger airliners in the world, certified to fly 3 to 4 hours away from land on one engine. As per the Boeing website, One thousand and ninety-one B767s of all versions have been sold to air operators and the military around the world – 1255 with those ordered. Some major airlines brag upwards of 70 to 90 B767s in their fleet. The B767 can carry upwards of 269 passengers (not counting crew) onboard. Yet, it took 497 days to learn anything substantial about this popular airliner. It was unthinkable to have a 497-day information blackout, to leave industry in suspense for 1.5 years. It was a disservice to safety.

In response to the July 14th Hearing announcement, I commented online, “I find it troubling that an accident involving one of the industry’s most popular airliners, the B767, took almost ten months before the Public Docket opened … that seventeen months passed before the hearing was conducted.” A widebody airliner pilot responded to my comment, “Amazing how the Kobe Bryant crash investigation has been expedited, but this [Atlas 3591] took 1.5 years?” The airliner pilot’s observation was accurate. The Kobe Bryant (KB) helicopter accident investigation’s docket opened in 143 days – two times faster than Atlas 3591’s.

However, the airliner pilot’s response challenged the mindset of today, that no one should question government agencies, like the NTSB, even when they put public safety at risk. An NTSB manager responded to the airliner pilot, “Not a bad idea to get your facts straight before posting ridiculous accusations. The accident which claimed the life of Kobe Bryant and 8 others has not been completed. And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” This … was an unfortunate response. The manager’s statement was condescending. It was indicative of an NTSB that treats public reaction with indifference.

This is a problem. To dismiss a derisive comment is understandable, but to show disdain over a factual statement, albeit with some cynicism, is another. The airliner pilot’s skepticism was the result of his frustration at the NTSB’s ‘slow-to-action’ attitude towards Atlas 3591’s investigation. The purpose of safety recommendations and reports is to generate conversations among those in industry, to encourage research and development. Dismissing an aviation professional’s voice discourages this vital dialogue.  

No person should believe that government agencies are always right; to suggest that they can never be wrong, would be absurd. “Not a bad idea to get your facts straight before posting ridiculous accusations”? How unnecessary. An accusation? It was not. Furthermore, the manager’s response was sarcastic and unprofessional. The NTSB is a government organization, funded by taxpayers. The general public’s comments are expected and welcome, especially when based in fact.

It is true that government does not create jobs or prosperity; government also does not improve safety. Only government believes otherwise. Government is a referee, an umpire, a neutral outsider whose job is to assure everyone follows the rules. What rules? The regulations industry helps to write. NTSB labs do not create safe products; NTSB recommendations do not generate aviation safety. Manufacturers, air operators, repair stations, pilots, mechanics, flight attendants, aviation schools, air traffic controllers and the flying public; these folks make aviation safety possible. They are the check and balance. Because of their safety contributions, we are assured industry will survive with integrity.

Look at the timelines: the KB helicopter accident docket opened in only 143 days. The Ethiopian Air 302 B737-MAX accident investigators presented their FINAL report in twelve months (March 10, 2019 to March 9, 2020). The NTSB provided findings and recommendations for Ethiopian 302 and Lion Air 610 within that timeframe. Why? Neither 737-MAX accident was an NTSB investigation. Where was the urgency to improve safety with Atlas 3591? Why did it take 289 days to open Atlas 3591’s docket? Aviation professionals should have asked why.

In May 2002, as an NTSB investigator, I assisted Taiwan’s Aviation Safety Council (ASC) with the China Airlines 611 investigation, a B747 that was in pieces on the China Sea floor. An NTSB Structures investigator quickly discovered the root cause, relayed the information to the ASC. By August 2002, the ASC told industry and safety fixes were expedited. Information was delivered in a timely manner.

What about the next part of the NTSB manager’s unfortunate response? “The accident which claimed the life of Kobe Bryant and 8 others has not been completed” is odd. Not for using Mister Bryant’s name. Often accidents refer to their celebrity victims, e.g. JFK Jr or Payne Stewart. It was the, “… and 8 others …” that was odd. What do accident fatality numbers have to do with fact-based analysis?

Since my days working NTSB major accidents, I have found it strange that accidents involving cargo or with low profiles, e.g. low victim count, receive insufficient attention. For example, in 2001, Emery 17 (three pilots) took almost two years to reach a limited Hearing. Colgan 9446 (two pilots) was not given a full Go-team or Hearing. National 102 had an investigator-in-charge with zero previous major accident investigation experience. Fine Air 101 (four crewmembers) had unqualified investigators. Why?

By exploiting the death count, the NTSB manager assumed (incorrectly) that emotional disputes are relevant. Were the “8 others” helicopter victims more important than the three in Atlas’s B767? What about the unnecessary risk to the thousands who flew on B767s with possible unknown problems for 1.5 years? Emotional disputes had nothing to do with either accident. To use the “8 others” to somehow justify the Atlas 3591 delay was absurd. Emotions have no investigatory substance; they are devoid of facts. Did pontificating about victim numbers help find root cause or were they just a distraction? 

Take a look at the emotional arguments for destroying history by removing statues of our Nation’s Founders. Why? Will it erase the sin of slavery? Won’t the memory of former slaves and abolitionists be erased as well? Should the Pope push to have the Roman Colosseum leveled for the Christians that were slaughtered there? Should Jewish leaders raze Auschwitz or other Nazi labor camps; remove Passover from its calendar, just because they are reminders of suffering?

The NTSB manager then dug in his heels: “And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” Was this defensive slap because the NTSB’s authority was questioned? “… digging through muck?” Another unfortunate response.

I make no secret of my criticisms of NTSB investigations. But the NTSB investigators I worked with, those investigators on-site, whether qualified by industry standards or not, chose to ‘dig through muck’ because that is what accident investigation is. Whether on a mountainside or in a field in Kansas, all accident investigations, by the NTSB or any other organization, are the pursuit of facts and truth; the pursuit of root cause; the pursuit of aviation safety, no matter the effort or conditions.

For every emotion, there is an equal and opposite counter emotion (apologies to Sir Isaac Newton). The NTSB manager demonstrated that emotional overtones are not welcome in professional discourse. His unfortunate responses devalued those NTSB investigators’ efforts who put forth some good work.

The government is not the answer to safety. Aviation safety’s only hope in this everchanging technological world will come from timely facts, entrepreneurship and those who make safety improvements each day. Aviation safety does not pivot on government intervention. That point being made, it is our obligation to question all government analysis, especially when it comes to safety. In addition, free and open dialogue among influential aviation professionals should never be discouraged by government bureaucrats who spout … unfortunate responses.

Aircraft Accidents and Lessons Unlearned XLI: Atlantic Southeast Flight 529

Atlantic Southeast Airlines Embraer EMB-120RT

As per National Transportation Safety Board (NTSB) accident report AAR-96/06, on August 21, 1995, Atlantic Southeast Airlines flight 529 (ASA529), an Embraer EMB-120RT, registration number N256AS, crashed during an emergency landing attempt near Carrolton, Georgia, 31 minutes after departing Atlanta Hartsfield International Airport. The flight, operating as a scheduled flight to Gulfport, Mississippi, had experienced a separation of five feet of a single left (#1) engine propeller blade during climb through 18,000 feet of altitude. The blade, one of four, departed the engine propeller, immediately introduced an out-of-balance condition in the still turning engine, which contributed to existing damage on the engine, cowling, remaining propeller assembly and wing until the propeller came to a stop.

The NTSB determined, “… that the probable cause of this accident was the in-flight fatigue fracture and separation of a propeller blade resulting in distortion of the left engine nacelle, causing excessive drag, loss of wing lift, and reduced directional control of the airplane. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered by Hamilton Standard because of inadequate and ineffective corporate inspection and repair techniques, training, documentation, and communications.” It further stated, “Contributing to the accident was Hamilton Standard’s and FAA’s failure to require recurrent on-wing ultrasonic inspections for the affected propellers.”

The NTSB’s decision to blame the Federal Aviation Administration (FAA) for reasons not-accident-related, diverted necessary attention away from the accident’s root causes. The NTSB’s probable causes demonstrated their fundamental misunderstanding of the FAA’s responsibilities of active oversight of the manufacturer/repair station, as well as Hamilton Standard’s own obligations. The NTSB’s repeated allegations that the FAA was directly to blame in many other accidents remains a problem and demands note. The theory that ‘casting a wide net’ generates more causes only confuses the Findings and does nothing for safety. This NTSB practice inhibits actions that can lead to improvement by placing blame where it serves no benefit, in other words, a counterproductive ‘cry of “Wolf”’. It is not because the FAA had no culpability for its certificate holder’s actions – the FAA did. But to categorize all safety issues as “FAA failures” is irresponsible and passive. It would be just as foolish to blame the NTSB for getting past probable causes wrong, which would be a more accurate Finding. Aviation safety would be better served with useful recommendations. Instead, an important issue was missed.

Recommendation A-96-143 stated, “… the need to require inspection (“buy back”) after the completion of work that is performed by uncertificated mechanics at Part 145 repair stations …” Federal Aviation Regulation (FAR) Title 14 Code of Federal Regulations (CFR), Part 145, Subpart E, Section 145.211 (c): Quality Control System addressed this topic for decades, yet the NTSB failed to research that fact. Since AAR-96/06’s publication, this Part had been revised twice as shown in Federal Register (FR) 41117 (8/6/2001) Volume 66 and FR 9176 (3/5/2018) Volume 79. Section 145.211 was not revised; the NTSB recommendation A-96-143 served no purpose.

This is the problem: NTSB engineers that investigate aircraft maintenance issues do not work with the FARs that deal with aircraft maintenance, in this case Title 14 CFR Parts 65 or 145. Engineers would not know how a repair station run by a manufacturer is divided into two separate entities: the manufacturer and the repair station. NTSB engineers do not comprehend the terms uncertificated mechanics, repairmen, inspectors, the roles each plays in a repair station or their limitations.

A second recommendation, A-96-149, stated, “Evaluate the necessary functions of the aircraft crash ax, and provide a technical standard order or other specification for a device that serves the functional requirements of such tools carried aboard aircraft.” This baffling recommendation referred to the first officer’s futile attempts to break through the cockpit window with the aircraft’s crash ax when the traversing window jammed from structural damage. The ax’s handle broke. The cockpit’s available space was not designed for swinging an ax with a longer handle. Furthermore, local first responders also failed to break through the window with larger axes and more swinging room. A-96-149 was irrelevant.

Was the unfortunate propeller blade’s departure the main contributor to this accident? It did contribute directly to the tragedy. Was the propeller’s overhaul to blame? Again, yes, this led to the tragedy. However, the NTSB should have studied whether the plane could have successfully landed with the damage it incurred, particularly how to survive a propeller blade separation at climb. The NTSB’s probable guesses did not address training and, worse, the NTSB never pointed to this training omission in the recommendations. The NTSB failed the industry.

Was this the first time that a propeller blade was thrown?  No, and probably would not be the last. The truth was confirmed nine pages into the cockpit transcript. The NTSB knew when it happened, why and how. What the NTSB did not do was to make this type of event survivable in the future.

The focus of an accident investigation is to prevent, not only the circumstances that led to an accident, but the repetition of history; that is the ‘product’ of an accident report. A key NTSB investigatory team on a major accident is Survival Factors, a group of professional investigators who determine what should change to guarantee the survival rate goes up in the next event, e.g. seat design, fire resistant materials. The purpose of the Operations investigators and the aircraft-specific investigators, e.g. Powerplants, Aircraft Maintenance, is to work towards surviving an accident when the unexpected happens. The ASA529 accident was similar to other accidents, like United flight 232, in that they were the victim of catastrophic failures, next to impossible for the pilots to anticipate.

Before United 232 crashed in Sioux City, Iowa in July 1989, the #2 engine failure had jettisoned engine metal, which cut into all three of the plane’s hydraulic systems, making the DC-10 uncontrollable. The solution was to assure that another #2 engine failure would not simultaneously damage the three hydraulic systems in the future; a hydraulic fuse was placed in the #3 hydraulic system. Simple, yet effective.

After the ASA529’s #1 engine propeller came apart, the pilots flew ASA592 for nine minutes before impact; the pilots made heroic efforts to maintain control and save the plane and all aboard. To protect future flights, the NTSB had a duty to lead the industry in analyzing the final minutes of ASA529 and generate solutions for how to survive a propeller failure in the future.

To do this, the NTSB should have taken the facts of the aircraft’s condition during the last nine minutes. What other damage was incurred when the propeller came apart? Were the flight control systems victims to the propeller blade’s damage? Why would that be important? With Southwest flight 1380, when the #1 engine threw a fan blade; the blade could have exited at any point within 180 degrees of travel, yet the blade was launched at the exact degree that resulted in tragedy; the plane remained manageable, but a passenger died.

AAR-96/06 did not report fuselage damage, e.g. flight control cables, pushrods, etc. affected by the propeller blade’s trajectory; the aircraft did not depressurize; damage was limited to the #1 engine, nacelle, propeller and surrounding wing structure, which was harmed extensively. Despite this, the pilots managed to continue on to Carrolton regional airport for nine minutes. The circumstances of the propeller coming apart in flight would be impossible for pilots to anticipate. Although aviation safety dictates that all is done to prevent a repeat of this event, it could be duplicated; it would be just as unpreventable.

The pilots successfully flew the wounded aircraft under extreme conditions; they did their best. But even with all they did, there were lessons to learn that could have been incorporated into pilot training. A good recommendation would have been for manufacturing, industry and the FAA to build a training program that, after studying the accident, would have figured out proactive measures to survive a similar event using knowledge taken from ASA529. It was encouraging for the industry to know that, in the aftermath of ASA529, the FAA, industry and aircraft manufacturers of both propeller and jet aircraft have categorized the circumstances, analyzed the contributing events of their actions and improved pilot training to learn from ASA529 and survive.

It would be hoped that the NTSB would focus on improving aviation safety by concentrating on solutions while avoiding casting subjective aspersions. The cost in people and machines is too great to waste time impugning the reputations of valuable organizations; it only serves to divert attention away from facts. ASA529 never should have happened. But will it happen again?