Aircraft Accidents and 2020

A scene from the 1951 MGM movie Quo Vadis

The beauty of reading: an ability to immerse oneself in the pages of classic literature. Arrogance makes us assume that novels from the 1800s and earlier are not applicable to today, but that … is incorrect. Ralph Waldo Emerson wrote, “Fiction reveals truths that reality obscures;” Henryk Sienkiewicz’s book, Quo Vadis (1896) is just such fiction, set against Emperor Nero’s reign. ‘Quo Vadis’ is Latin for ‘Where are you going?’; Saint Peter asks this in a vision. The back story has Nero authorizing Rome’s burning in 64 AD. Faced with a furious citizenry, Nero used propaganda and influence to blame the fire on the Christians, a defenseless religious people. Soon, hundreds of innocent Christian men, women and children were slaughtered in the most brutal ways. Quo Vadis is a timeless tale that demonstrated how false narratives destroyed civilizations, just like today, in the year 2020.

In March 2019, the Boeing B737-MAX was grounded after two high-profile air disasters: Lion Air 610 and Ethiopian Air 302. In what could only be described as an international kangaroo court, Boeing was dragged into the media’s hysteria and subjected to inept opinions – lean on knowledge, fat on ignorance. The MAX was exposed to inept analysis from investigators with no access to – let alone knowledge of – Boeing’s designs. Finally, the maladroit conclusions of the Ethiopian and Indonesian accident investigators, proved prejudicial and unqualified. Did anyone read reports KNKT. and AI-01/19? Did anyone understand the mistakes that could not be concealed?

How biased: government-run airlines investigated by government employees. Aside from the fact these government employees were not discerning about the latest technologies, governments are opposed to finding blame in themselves and less likely to admit blame when confronted. Ethiopian and Indonesian government investigators were woefully unqualified to analyze the Boeing’s latest designs of digital-based turbine engine aircraft. In addition, the investigators were engineers, ones who did NOT … could NOT … understand what they were looking at.

What was myopic was that engineers do not play active roles in aircraft maintenance, airline operations or take part in day-to-day airline activities. How many pilots on delay tell Operations to send out an engineer? How many mechanics rely on engineers to troubleshoot everyday system problems? Adding insult to injury, these accident investigators/engineers were bureaucrats who shifted blame from their airlines’ deficient training and antiquated culture practices, i.e., from themselves … to Boeing.

Then it got worse. In stepped the media and their non-aviation news ‘experts’, who amassed confusion and stoked public fear. Armed with hearsay, the media discredited Boeing and set the industry back twenty months before the Federal Aviation Administration rescinded the 737-MAX’s grounding order on November 18, 2020. By then Boeing’s reputation took a crippling hit in public trust; they lost billions in redesigns. Who did this was irrelevant; What they did was imperative, followed closely by Why.

How did industry ‘fix’ the MAX? Did they turn to mechanics experienced with digital aircraft technology or pilots with thousands of flight hours in digital aircraft? No, industry trusted the very work group that designed the ‘problems’ into the MAX: the engineers.

It was evident from both reports (and to those paying attention) that the investigating engineers, the media and the ‘experts’ did not understand the technology.

The inexperienced accident investigators, reporters and aviation ‘experts’, those who could not explain the B737-MAX’s technology to themselves, lacked the ability to explain the technology to others. And yet, these people seized control of the conversation and drove the narrative. Why were we so quick to accept the incompetent media’s word, let them steer us to the cliff’s edge and over?

The destructive mainstream media strategies of, e.g., CNN, Fox News, MSNBC and other major news channels and publications, can so easily destroy reputations that take decades to rebuild. Have any of these reporters ever turned a wrench; landed in zero visibility; taught up-and-coming aviation people? Did they play us – all of us – as fools?

The year 2020 marched on, and suddenly we had run out of pocket change; stores across the nation could not even break a one-dollar bill. Had the United States Mint run out of cupronickel or was someone trying to force us to pay with credit cards or debit cards? How curious.

The COVID-19 tally of those infected had risen. However, the COVID death toll had flattened. Because of available testing we were now receiving accurate numbers of those who contracted COVID … and lived … or had been unwittingly living for months as COVID-positive. Why, then, are we still wearing masks; avoiding restaurants; listening to politicians about COVID safety? Are we no longer concerned about the 2020-21 strain of the annual flu or does the annual flu season not happen anymore?  

Cynical tactics were never more evident than with the November 3rd election night. It does not matter who each of us voted for president: President Trump, Senator Kamala Harris or Mickey Mouse. Who we voted for was irrelevant; What we voted for was imperative, followed closely by Why.

What transpired on election night should scare the living hell out of every American citizen. We can no longer trust that a two hundred-year old, reliable voting system is still used. Even if we believe – or do not believe – fraud occurred, the question of fraud was raised with convincing evidence. That demanded that a serious investigation be run.

Late night comedians assured us that the election was legit; Daytime talk show hosts laughed at the suggestion of any fraud. Their years of questionable political superiority aside, the concept of fraud should have even made them shudder; indeed, they did not know the difference between criminal lawsuits and civil lawsuits, when searching for the truth. As these personalities focused on the distraction instead of the election, celebrities, e.g., singers, movie stars and other entertainers, assured us with their trustworthiness, that all was well, that we needed to move on. Any one of these people who balked at the possibility of fraud with disdain and sarcasm was not looking out for the People.

Meanwhile, the media seemed unusually quiet; they stood with hands in pockets, staring at the floor while shuffling their feet, intent to ignore all that was going on. On November 10th, the New York Times said, “Voting fraud is extremely rare.” Extremely rare?! Just how rare is ‘rare’? How extreme is ‘extremely’? Why would fraud be allowed at all, even when extremely rarely?

A week after the election, the Michigan Secretary of State’s spokesperson stated emphatically that “We have not seen any evidence of fraud or foul play …” Can his analysis be believed? Where is his proof? Another politician said, “… it would be nearly impossible to do voter fraud.” Nearly impossible is not a denial; it is a distraction. Perhaps these politicians did not understand the technology. Or, perhaps, they did. Perhaps they knew how easily the technology could be corrupted to sway the election.

Who promised to fix the ‘broken’ election system? The very group that broke the system: Politicians, whose agenda-driven power brokers divided this nation along racial, gender, demographic and income lines, were now going to save us. Government bureaucrats would, again, ‘fix’ the mess they made.

Then there were corporate executive officers, like Mark Zuckerberg (Facebook) or Jack Dorsey (Twitter), who manipulated social media to allow only the news they wanted us to hear. Two men, who made their billions without discipline, who somehow tripped and fell face first into billionaire status, provoked the political outcome of their choosing and played their customers in the process.

Other bad actors played more damaging strategies. They demonized Police Officers, called them ‘racists’, despite minority police officers in, e.g., New York City, making up 57% of the police force. Domestic terrorists burned our cities, looted businesses and unashamedly annihilated our way of life. While these terrorists launched unprovoked attacks on innocents, Hollywood and sports figures bailed them out, lifted them up and supported their rampages. This action was allowed, encouraged and applauded.

The media and politicians have desensitized us. We shrug off the assaults and victimizations of Mexican children smuggled across the borders by Coyotes. The shocking drive-by gang-related shootings of adolescent children attending birthday parties or barbeques became lost amid calls for defunding the police. We ignored at what point a life is valued. Our immunity to all that is shocking … is shocking. Have we become so apathetic? Does our nation’s upheaval not interest us anymore?

As in the novel, we should all be asked, “Quo Vadis;” “Where are you going?”. As the story played out, corruption and fraud turned an entire civilization against itself, led the average Roman citizen to betray his or her neighbor for power. How different are we? It is becoming a crime to want the same successful principles our earlier generations lived and died to defend. The year 2020 may have shown us – hopefully, not too late – that we are in danger of a decline of our decency and morality towards one another. So, should we ask ourselves, “Populus autem Americae, Ubi Sumus Iens?”

Translation: “People of America, where are we going?”

Aircraft Accidents and Lessons Unlearned XLIV: Korean Air Cargo 6316

Korean Air Lines MD-11

On April 15, 1999, Korean Air Cargo flight 6316 (KAL6316) crashed shortly after take-off from Shanghai Hongqiao International Airport (SHA). The McDonnell-Douglas MD-11 aircraft was operated as a scheduled international cargo flight between Shanghai and Seoul, Korea. The aircraft was airworthy; the flight crew was qualified and trained. This should have been an uneventful routine flight.

The accident report, 99-091-0, was accomplished as an investigation per the International Civil Aviation Organization (ICAO) Annex 13 provisions by the Civil Aviation Administration [the People’s Republic] of China (CAAC). Participating with technical support were the Korean Civil Aviation Bureau (KCAB), the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), Boeing (who had purchased McDonnell-Douglas at the time), Pratt and Whitney Engines and Korean Air. The report shows that the NTSB was tasked with reading out the flight data recorder (FDR) and the cockpit voice recorder (CVR).

There were three people on the cargo aircraft during the accident flight. The Captain had a total of 4,856 flight hours in the MD-11. The First Officer (FO) had 1,152 flight hours in the right seat of the MD-11. Both pilots had recently undergone training and were qualified to fly the MD-11. The third person was a technician (mechanic), flying with the aircraft; he had twenty years with Korean Air working their trunk aircraft, including the MD-11. The technician was not heard on the CVR; mechanics are not known to fly in the cockpit, even on cargo flights, so any input he might have provided was absent.

The CAAC made efforts to remove all other possible contributors to the accident: weather, navigation aids, communication, air traffic control, recent maintenance, long-term maintenance, aircraft airworthiness, fuel distribution, fuel contamination, weight and balance. All these possible contributors were eliminated, one-by-one, as unlikely causes. The CAAC report was thorough in this process; as the Arthur Conan Doyle quote stated, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” What remained was most improbable: two qualified pilots, who got so behind events, that they unintentionally crashed the aircraft.

Per page 10 of the report, the aircraft impacted the ground at a twenty to forty-degree, nose down attitude, wings level. All primary instruments on the MD-11 are digital; the ‘gauges’ are video displays that are fed data from the Flight Director, Air Data Computer, etc. Any FDR data captured during the accident flight was lost in the post-crash fire. The only analog instrumentation – the sole ‘snapshot’ recovered – were the standby gauges; the standby altitude/airspeed indicator was locked at 398 knots at time of impact.

All flight control components had been meticulously examined for proper condition and to determine no sabotage had occurred. The engines had no issues during flight. The aircraft was properly balanced; it had achieved an altitude of 1370 meters (4500 feet) during the 2-1/2 minute flight; the crew did not talk about control issues caused by being tail or nose heavy; there was no evidence of a stall. No mechanical or technical issues were discovered. By all evidence, the aircraft was in an airworthy condition. On page 48, the report stated, “The above mentioned evidences indicate that the accident airplane’s sudden dive was at the wish of the crew rather than other causes.” A most improbable truth.

On page 9, the report stated that the only usable recording device was the CVR; “… no useful information could be retrieved from the recovered portions of tapes of the FDR …”. The Korean to English translations of the CVR recordings were choppy; conversation, terms and sentence structure did not convert smoothly from the Korean pilots’ native language to English. Even so, the conversations were mostly recognizable, yet the tell-tale urgency and other voice inflections were missing, leaving the reader to guess at what the pilots were reacting to, indeed talking about. This is unfortunate; reactions, such as excitement, doubt, rises in pitch or volume would have been more telling. Another unfortunate fact was that the mechanic was not in the cockpit; the pilots [appeared to be] worried about instrument readings.

The report was correct in highlighting that the Captain did not conduct a pre-takeoff brief; the pilots did not run through the departure, including expected turn points or emergency plans. As it happened, this flight had unforeseen events that contributed to an increasing state of confusion. The report also stated that the root cause of the accident was confusion about altitudes; the air traffic controller relayed altitude in meters while the FO stated to the Captain altitude in feet – 1500 meters versus 1500 feet. This was unquestionably another contributor to the flight crew’s inflight confusion. However, there was more going on during the flight than questions about altitude.

At 16:03:06 (4:03;06 PM), the crew initiates a left turn, but the FO was confused about when to complete the turn. At 16:03:37, the Captain stated, “It might turn upside down. What’s wrong with this?” At 16:03:54, the FO said, “Slat, why doesn’t it work? Slat, slat up.” Finally, at 16:04:05, the Captain said, “Well, what’s wrong with this airplane today?” All three statements occur within one minute; the first is stated at one minute into flight and the last stated thirty seconds before impact. Through this, there were no communications with air traffic to report problems.

The flight crew never elaborated on what they were seeing. For example, was the ‘slat problem’ that the slats would not retract or was it an indication problem? What ‘might turn upside down’? What was the Captain seeing that he asked, “…what’s wrong with this airplane today?”

Even before takeoff and the ensuing confusion, the FO got meters-to-feet wrong. During engine start, with the towbar still attached, the Tower says to go to nine hundred meters; the FO tells the Captain nine hundred feet. This was not due to heavy workload; the pilots were loading data into the computer and they were entering the wrong information. Just like the later confusion of altitude, the Captain did not challenge the FO or tell him to confirm the numbers. Cockpit resource management (CRM) appeared to be non-existent; no challenges, no questioning and a lot of guessing took place.

On November 22, 1968, Japan Air Lines flight 2 ditched in shallow water in San Francisco Bay, two and a half miles short of the runway in heavy fog. The DC-8 landing was determined to be the result of poor flight crew communication during an Instrument Landing. The FO and Second Officer did not question the Captain, a result of cultural issues within the cockpit; the Captain would not … could not … be questioned. There was no CRM; it did not exist. In 1999, CRM should have been standard practice.

The FO on KAL6316 did not insist on a pre-takeoff briefing even though it was required by Korean Airlines procedures. The FO confused meters with feet of altitude, possibly giving the Captain the wrong altitude to enter into the Flight Management System. The FO became confused again, this time with the air traffic clearance before entering the information into the Flight Control Panel. Just like with the pre-takeoff brief, there was no challenge, no verification. Instead the pilots just changed settings without confirmation.

The CAAC was correct in its Probable Cause, but they did not go far enough. It was culture that brought down this aircraft. Complacency did not bring about the failure to perform a pre-takeoff briefing; culture made the briefing unimportant. This was evident because neither pilot pushed for the briefing; neither one questioned the briefing’s absence; neither one seemed to care. Every subsequent problem hinged on the briefing and the briefing hinged on a culture that demanded it be done.

Recommendation 4.2 spoke to the briefing, requiring pilots conduct them. This recommendation was good, even though briefings had been required for decades. Briefings should not have had to be recommended because this aircraft should not have crashed. Recommendation 4.6 was also good, requiring air traffic to speak to one measurement, metric or standard – not both.

The CAAC did a great job with this report; they hit every mark on the investigation. All investigatory bodies still need to accept the existence of culture as a root cause and study culture’s effects on safety. Until they do, culture will continue to elude the most efficient reports, thus eluding being addressed and fixed.