Aircraft Accidents and Family

Ken Burns’, The Civil War Series, Episode Four, ‘1863: Simply Murder’, Narration: “In Texas, General John P. McGruder captured a Union flotilla at Galveston. After the bombardment was over Confederate Major A.M. Lee went aboard the badly hit USS Harriet Lane. There he found his son, a Federal Lieutenant, dying on the deck.

That is a sobering historical account; imagine being the instrument of a family member’s destruction. Even fiction, like O’Flaherty’s The Sniper, remind us how, even the most noble of causes, can be damaging to our community, or metaphorically speaking, our family. We, as co-members of this industry, might take a lesson from this, to choose our words – and battles – wisely.

Some weeks ago, there was an article written for the Travelers Weekly’s website titled, “THE FAA WAS TOLD TO SET PLANE-SEAT STANDARDS. THAT WAS NEARLY TWO YEARS AGO.” The lead paragraph stated, “A Congressional mandate for the FAA to set minimum standards for seat width and pitch passed 22 months ago. But the agency still isn’t saying when it will move forward with those regulations.” The Writer’s Bio says he is a travel reporter; it does not mention his aviation regulatory or design experience; per the Bio, the Writer (He) has none. His allegation suggests the FAA is in the comfort business – not regulatory and oversight. The Writer’s article is based in conjecture, clouding the FAA’s vital role by confusing those outside the aviation industry who look to the FAA for safety.

Per the article, “The FAA last November conducted a series of evacuation tests designed to inform its decision on aircraft cabin configurations.” It further stated, “… the agency has not updated its evacuation assessment standards since 1990,” that, “… airlines have increased the number of seats on planes, squeezing rows closer together in the process.” The Writer is correct; the standards have not been updated or, as industry says, ‘revised’. Why should they be? What did the Writer’s experience suggest needed changing? Is he saying the airlines intentionally violate the regulations; that FAA inspectors have averted their eyes from safety? Beyond the Writer’s stated opinion, what evidence did he present supporting his conjectures? Why did he choose to skillfully employ the verb ‘squeezing’, to employ an exaggeration for how passenger seating design has changed? He could have used ‘reducing’, ‘decreasing’ or ‘shortening’, but then that would have had less dramatic effect. With regards to design, the Writer’s use of the verb ‘squeezing’ is dishonest; it only appears clever by introducing a futile emotional argument.

The article then called out another violator of the Congressional mandate, the Office of Inspector General (OIG); “In May 2019, the OIG’s office said it would complete the audit last fall [Fall 2018 or 2019?]. However, that timeframe came and went. An OIG spokesman this week [August 2020] said the final report is on track for delivery by late September [2020].” Was the Writer suggesting the OIG violated Congress’s direction? Did the Writer understand how long effective testing can take? Does he realize the five-year long process required to change a regulation? Portraying the OIG and FAA as disobedient agencies that ignore Congressional mandate, only serves to divide the industry. The Writer’s uneducated opinions sew distrust in government agencies, whose job is to guarantee safety … not comfort.

I do not read travel magazines, but someone in the aviation safety arena I belong to, does. A reader of Travelers Weekly, an aviation lawyer (AL), added his opinion, that the FAA failed to follow through on the Congressional ruling. He stated, “… a provision in the FAA Reauthorization Act of 2018 that calls for the FAA to report to Congress (Sec.337) on evacuation certification, including changes to width and pitch of seats to facilitate evacuation.” (It felt like an ‘Harumph!’ was missing). He added, the Congressional committee heard from, “… safety advocates that jamming as many seats on a plane was compromising safety,” Jamming? More exaggerated verbs, as if seats were forced into seat tracks against their design to restrain them. More dishonesty and useless emotional babble.

The AL wanted wider seats in Coach, that’s clear. Who doesn’t? However, these complaints sound like the type of misinformed insinuations the National Transportation Safety Board (NTSB) make against the FAA, e.g. not doing their job, etc. The NTSB, like the AL, does not understand the FAA’s job either.

Coincidentally, the AL’s opinion was echoed by a former NTSB Board Member (BM), who took derisive shots at the FAA, saying, “Amazing how some folks still think the FAA is there to support the industry and not the taxpayers and passengers paying the bill!” (Harumph! Harumph!) His comment was unnecessary churlish disdain; very unprofessional. This particular BM had no transportation experience and, thus, no cause to be acrimonious. In addition, he should have known better. After dropping out of the NTSB, this BM continues to make a stink.

I have great respect for lawyers; some good friends of mine are lawyers; some lawyer friends are also piranha fish … but I digress. A lawyer with practical industry experience, knows the regulations; he does not look at them myopically. Experienced aviation lawyers know, despite following the same regulations, United is not like Delta and, just as important, American does not operate like a regional airline. They fly different equipment in different environments with different passenger requirements, e.g. seating. Let us be honest, this seat argument was not about safety; it was about comfort. Any reference to safety was purely hypothetical. What’s the next Congressional Mandate for? More peanuts? Fluffier blankets?

Incidentally, didn’t the AL mention safety advocates addressed the committee? How did these safety advocates determine that safety was at risk? What Data did they provide that spoke to these risks? Did they conduct testing? How did they conclude the 1990s standards were out-of-date? Some aviation schools have the resources to provide such testing. Were any employed? What qualified these safety advocates to speak on this subject? Were they engineers who spent years designing safe seats? Did they generate manufacturer’s procedures for evacuation standards? Or, maybe, they were Board Members who left the NTSB and became … Consultants. The safety advocates’ credentials should have been qualified.

The FAA did comply with the Reauthorization Act of 2018’s requirements; seating questions were answered many years earlier. Title 14 Code of Federal Regulations (CFR) Part 25 Appendix J: Emergency Evacuation and Subpart 25.803 were revised, based in testing and reliable data – not opinion. Even the former NTSB BM should have been familiar with these regulations.

Did the article Writer or the AL think that all aircraft models would be tested; that the MD-80, B737, Airbus 330, Embraer 135, etc. would each be analyzed? Would each operator’s fleet be pulled from service, towed to a hangar and reseated for mandatory measuring? More likely, average seating arrangements, i.e. one standard fuselage, would be tested to qualify all models … together. What the Congress failed to realize was that, when analyzing aircraft seating designs, one size does fit all.

Average career politicians, who sit on oversight committees, are not chosen for theirexperience; they are chosen because of politics – just like NTSB Board Members. Committee members have no experience; they only care about votes. If they can secure a vote by promising to nail a wave to the shore – or force the FAA to ignore its mission – they would do it. When they are voted out, career politicians leave their government positions to become Consultants – and Safety Advocates – with zero experience. Perhaps Congress’ time would be better used looking at safety advocate qualifications.

No one is happy sitting in an airline seat these days; the cabin-wide first-class seating of Midwest Express Airlines is gone. There are alternatives: car, train or boat. I travel a lot, so I drive … a lot. Let us be clear: the FAA cannot force an air operator to change their seat design because they are uncomfortable … UNLESS, those seat designs are unsafe – and only unsafe for flight, per Title 14 CFR Part 25. Airlines make seat design decisions to increase sales … period. They are, after all, a business. If one does not like an airline’s seats, then don’t fly with them. The power lies with the consumer, not the FAA.

The rhetoric of the article Writer and the AL serve no purpose but to sow derision into the aviation safety process, making others question the integrity of those consigned to advancing safety. The disregard for these facts is demonstrated in NTSB accident reports, a politician’s pandering to special interests or the occasional lawyer’s frivolous lawsuit. The FAA and the OIG exist to fix safety problems – real ones, not the emotional kind. Reporting otherwise irreparably damages the integrity of the aviation family.

Aircraft Accidents and Lessons Unlearned XLII: TAM Flight 3054

TAM A-320

On July 17, 2007, Táxi Aéreo Marilla (TAM) Linhas Aéreas flight 3054 (TAM3054), an Airbus A-320, registration PR-MBK, crashed while landing on Runway 35L at São Paulo/Congonhas airport (airport identifier: SBSP). After touching down, the aircraft did not slow; it veered to the left, overran the southwest side of the runway, crossed over Washington Luis Avenue and struck both a cargo building and a fuel service station at ninety-six knots. It caught fire; the aircraft was destroyed. The investigation was conducted by Brazil’s Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA), [translated] the Aeronautical Accidents Investigation and Prevention Center. No archived evidence could be located on the investigation agency’s website to review; all information presented here is taken straight from the report: RF A-67/CENIPA/2009.

There are problems analyzing accidents written in a language that is not native to the reader. It was important that the Findings/Recommendations had received the proper interpretations to other languages, such as English. How does anyone benefit from the analysis if the translation was poor? Even the manufacturer terminology can baffle the investigator, cascading into more confusion. Consider the old game, Telephone Line, where a message spoken to the first person in line is drastically different when it reaches the fifteenth person. Confusion can result from simple terminology; the General Electric CF6-50 engine had a Constant Speed Drive that drove an engine generator at a consistent speed. On a later model, the CF6-80 engine, the device was called the Integrated Drive Generator – same purpose, different name. When an investigator is unfamiliar with the terminology differences from Boeing logic to Airbus logic, the end report becomes gibberish.

On page 52 of the TAM report, such an uncertainty exists, “… Aeronautical Accident Prevention Program (PPAA) of the company [TAM] for the year 2007, those accredited professionals were not considered for the development of accident prevention actions.” The Operations and Maintenance departments, by definition, subscribe to accident prevention in every action they perform; an accident prevention program would be redundant. What was an accident prevention program? Were investigators experienced in airline cultures? Other problems could arise, such as an overreliance on the manufacturers and the airline to fill in the blanks for them. How likely were manufacturers and airline to expose their own weaknesses? The A320 was/is a popular airliner around the world; the importance of a lost opportunity to learn cannot be stressed enough, especially if lost in translation.

A curious report problem: the number of recommendations. This report had fifty-two Conclusions and fifty Recommendations– an incredible number of recommendations for a single-aircraft accident. In the accident report, Quantity ≠ Quality. Recommendation numbers are not proportional, are not indicative of safety value. Some recommendations were valid, insightful; unfortunately, good information was lost in the commotion.

There were three focuses for the final report: Runway Integrity, Training and Mechanical Anomalies. Of the twelve possible (probable) causes, there were five the report considered ‘contributors’ to the accident: Training, Cockpit Coordination, Management Planning, Little Experience of the Pilot and Management Oversight. Any reference to the ‘pilot’ was ambiguous. Were both pilots considered inexperienced, or just one? Runway integrity should have been considered a contributing factor and the factual information about this should have been exploited. The report spent resources analyzing the runway’s condition, but the report did not list it as a contributor nor as an undetermined factor.

The aircraft was operating with a deferred #2 engine thrust reverser. This meant the right engine could not be used to stop the aircraft once it touched down on the runway. Thrust reversers are not required to stop the aircraft, but this scenario, exacerbated by the wet runway, created a landing challenge. The #1 engine thrust reverser would be deployed on landing, thus introducing a yaw effect, where the aircraft will pivot left in the direction of the deployed reverser. On the right engine, the thrust lever (TL) was set out of configuration (to Climb), which provided forward thrust to further drive the aircraft left.

Per the flight data recorder (FDR), at touchdown, the number one TL was at ‘IDLE’ while the number two TL was at ‘CL’ (Climb). The report stated on page 67, “If one lever stays at the “CL” position during landing, it deactivates the actuation of the ground spoilers, significantly reducing the aircraft braking capability (between 45% to 50%)” Did the pilots mistakenly misconfigure the aircraft for landing, essentially deactivating the autobrakes and ground spoilers? Why were the TLs not moved together on landing, why the split? Did they pay attention to the Minimum Equipment List (MEL) procedures for the deferred reverser? How did this reflect in their training? Was this pursued with TAM post-accident?

Maintenance was not listed as a contributor, an unfortunate oversight. The investigators failed to interview members of Maintenance, especially at Porto Alegre, the airport TAM3054 had departed from. The #2 reverser had been deferred since July 13, 2007, mechanically locked out to prevent inadvertent deployment. Any pilot concerns in Porto Alegre may have been discussed with the mechanic who launched the flight, including pilot/MEL procedure compliance issues.

Both the cockpit voice recorder (CVR) and the FDR confirmed the ground spoilers did not deploy. Autobrakes also did not function on touchdown in SBSP. These issues should have been explored with Maintenance. The mechanic could have provided insight into why the pilots’ actions led to the spoiler problems. Were the MEL procedures understood before launching the accident flight? What about anti-skid? Page 42 stated, “The Anti-skid system, in turn, functioned normally, preventing the blocking [locking?] of the main gear wheels during the braking.” PR-MBK was launched out of Porto Alegre with an allegedly functional anti-skid system … or was it?

According to information provided by the operator, several of PR-MBK’s last maintenance records from Porto Alegre were destroyed in the accident; they were being transported to Congonhas for entry into Maintenance’s database. Why were there no copies kept in Porto Alegre? Were TAM maintenance log pages normally duplicated and, if not, why not? Did an investigator pursue this point?

One good point made, though lost in the recommendations, concerned training on page 95. “The theoretical qualification of their pilots was founded on the exclusive use of computer interactive courses (CBT) which allowed a massive training but did not ensure the quality of the training received.” Anyone who has received CBT for maintenance or flight, understands the problems associated with this method, that the computer is the sole instructor during an important phase of the training. CBT is a poor instructor in that it cannot answer questions as thoroughly as a trained instructor. Quality depends on a distraction-free, uninterrupted learning environment, one that does not add to confusion.

Concerning the second in command (SIC) pilot’s experience, per the report, page 10, “The SIC had recently been hired by the company as a captain [When?]. He did not have previous experience in the A319/320 airplanes and did his A-320 training (already as a captain) at the very company.” If correctly translated, the SIC – first officer – had a captain’s rating with no previous experience before TAM, in the A-320. The SIC had 14,760 total flight hours, 237 flight hours on the Airbus A-320.

The report’s Findings pointed to credible administrative and cultural issues with TAM that were not pursued, while drifting into unproven findings, such as the Captain’s ‘mild headache’ (page 95), saying it, “… may have influenced his [captain’s] cognitive and psychomotor capabilities during the final moments …” A migraine would have been debilitating. A mild headache?

Recommendation 172/A/07 suggested, “… a warning system to allow the crew to identify a wrong setting of the thrust levers …” Another alarm or warning? The fallacy of overregulation and/or overengineering, taking the responsibility from the pilot and giving it to the aircraft. How does removing the pilots’ responsibilities to aircraft system monitoring benefit safety? How does adding another alarm help?

The TAM3054 accident report was confusing. Worse, it wasted resources on irrelevance and ignored issues that could have benefited safety. It was not that CENIPA missed the important safety mistakes, it was that CENIPA did not shine a bright enough light on the very important problem of inadequate pilot training, coordination and flight management.