Aircraft Accidents and Safety Ignorance

A trained Service Animal, aka, a seeing eye dog, assisting his disabled owner.

On January 3, 2021, Representative Emanuel Cleaver (Missouri) concluded the Congressional opening prayer by saying “A-men and A-women.” Why would a former minister feel it necessary to apply gender to Amen, which translated from Hebrew and Greek means ‘So be it’, Verily or Truly. Ignorance like this reflected Georgia Representative Hank Johnson’s oblivious remark; he oversaw technology regulation and feared that Marine troops on Guam would “become so overly populated that it [Guam] will tip over and capsize.” Some may say, “Oh, that’s just Hank” or “That’s just Emanuel,” but this is not funny. These elected officials decide on budgets for Defense, Homeland Security and Transportation, vital government committees that need serious-minded officials. These legislators represent the ignorance we too quickly overlook.

Realizing ignorance of the lawmaking process at the highest levels exists, how secure is the flying public that the same ignorance is absent when deciding aviation safety measures or policies, that our elected officials are not displaying safety ignorance? I recently flew from the northeast, at 6:00 AM eastern; twelve dogs of all types and sizes populated the gate waiting areas. No service dogs helping blind or physically disabled persons anywhere. No service animal harnesses, only leashes. This terminal demonstrated a growing trivialization of a just law, the Americans with Disabilities Act (ADA) of 1990.

I see dogs and cats all the time in the hardware store. I do not know why a pet is needed for choosing plumbing fixtures, but then hardware store pets do not threaten my safety. Bring a chihuahua into a restaurant? That would not be cool; that … is a public health issue. Bringing pets – or what many call an emotional support animal (ESA) – on a plane? That is a public safety issue. We see flight attendants review emergency procedures before flight. Why? Because safety instructions are crucial for humans to survive a crisis. Are ESAs trained for disaster? Is their instinct for self-survival ever considered?

In the 50s, Lassie always managed to relay to the Martins, through barks and whimpers, that Timmy was in danger again. Could that brave Collie have led Timmy through a smoke-filled plane to the emergency exits? Not likely. Why? Lassie was not trained to deal with emergencies; she would not know an escape slide from a bowl of Alpo. Instead, Lassie would, with her incessant barking, cause the injury (and probable death) to Timmy, most of the passengers and the flight crew.

Has anyone ever questioned why ESAs are given unrestricted access to airplane cabins? It started with the ADA; many legitimately disabled persons’ needs had been dismissed, those with physical or mental disabilities. The ADA, being signed into law, was a good thing. However, like all good things, there are those who would exploit matters for their own selfish ends, despite the safety threat to others.

How do people, with no concept of aviation safety, write the rules that put us at risk? How do the ESA owners get diagnosed with mental and/or emotional disabilities? The usserviceanimals.org website makes registering an ESA simple; “A doctor in our network may be able to prescribe an emotional support animal with just one phone call.” In one phone call?! Is that a MEDICAL doctor? In the next bullet the line changes to, “… mental health professional [MHP] who approves you [the customer].” The website changes direction from a ‘doctor’ – type unknown – to a ‘mental health professional’, which could be anyone in the mental health field. If it was a qualified MHP, wouldn’t the website say how qualified?

Are these real doctors who are diagnosing the mentally or emotionally disabled … with a phone call? How? How do MHPs diagnose mental or emotional disabilities over the phone? Diagnoses are being made by questionable MHPs, who then fill our aircraft with safety hazards. Would an ESA owner’s mental or emotional disability diagnosis follow them through life? A blind person cannot drive a car; can mentally or emotionally disabled people drive cars or own guns? Maybe Homeland Security should track these emotionally or mentally disabled persons, require them to undergo enhanced security checks. Why? Did we all forget Germanwings 9525’s and Egypt Air 990’s first officers? Are unqualified people making aviation safety decisions, putting us at risk? Do airlines check these ‘doctor’ qualifications? Per the website, the applicant must, “… have a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” … to travel with an ESA. Are some ESAs trained as attack dogs; are they weapons? What training does an ESA undergo to become a real service animal? How rigorous is the service animal’s training? These are valid safety questions.

Was the ADA hijacked? There are real disabled people who deserve the ADA’s benefits; serious people with real handicaps, e.g., the blind, the deaf or heroic soldiers who suffer from post-traumatic stress syndrome. What challenges have ESA owners been forced, by chance or birth, to overcome? Are these ESA-reliant folks putting their needs above others? The truly disabled depend on this sensible ADA law’s benefits; the ADA was secured by those who truly earned the right; it recognized deserving disabled’s challenges to their independence, their justifications to freedoms in our society. Anyone who pretends to have disabilities corrupts the ADA. These ESAs present safety problems that endanger us all.

It is to wonder that the flying public accepts the presence of numerous untrained ESAs on countless flights every day – without question. Why? Because we trust our legislators – even ignorant ones – to ‘do the right thing’ for the people? Legislators should have given all safety hazards their full attention by vetting the safety risks. Legislators should have had qualified professionals analyze the aviation safety risks, then, employed this data to protect the flying public from all safety threats. Instead, to evaluate the ESA risks, the United States Department of Transportation (USDOT) created the Air Carrier Access Act (ACAA). This law contained guidelines to approve – not even question – persons to carry ESAs onboard commercial flights. Was the ACAA a legitimate answer or was it just another promise that Guam would not capsize?

In September 2019, (per the USDOT website) the ACAA Advisory Committee (AC) was formed, a group of professionals, some even with aviation ties. The AC counseled the aviation community on who is a disabled person and how their care animal should be treated on a commercial flight. Data analysis and emergency evacuations were not factors to the AC; they did not promote aviation safety.

There were nineteen AC members. Representing the airlines were an International Air Transport Association (IATA) lawyer; a General Counsel for Airlines for America – another lawyer; a Vice President, Airport and Government Affairs; and a Corporate Compliance Disability Program Manager, whatever that is. The nineteen AC members had no operations experience, no one qualified who could – or would – speak to the safety risks of introducing numerous untrained animals into the chaos of an air crash emergency situation. There were no experienced commercial pilots, no experienced flight attendants, not one Federal Aviation Administration (FAA) Principal Operations Inspector (POI). A pilot, a flight attendant or FAA POI would know firsthand the dangers incurred during an aircraft emergency; they are professionals who are responsible for an airlines’ evacuation procedures, the safety of thousands.

The AC, however, had lawyers.

During two airline accidents, Delta 1086 and British Airways 2276, passengers stopped to grab their luggage and laptops in the middle of a post-crash evacuation. These people intentionally defied the evacuation procedures, blocked the aisles and endangered passengers’ lives … for laptops. Would an emotionally-challenged pet owner be just as irresponsible? Would an ESA logjam an aisle? Would an owner try forcing a pet carrier through a narrow CRJ overwing exit; let the pet free to dart between passenger’s legs or trip them with a leash? Could dogs barking drown out the flight attendant’s instructions? All this confusion in a cabin thick with acrid smoke, blinding and choking everyone; where each second means life or death. We are talking about ESA owners diagnosed as being mentally and/or emotionally disabled.

What requirements must airlines fulfill in determining if an ESA is a legitimate service animal, other than, you know, trusting the ‘reliable’ resources of the US Service Animals website’s MHPs? Per the USDOT website, the airline can trust, “the credible verbal assurance of an individual with a disability using the animal.” THIS is safety ignorance; an airline, responsible for thousands of passengers’ safety, trusting an eight-year-old child with an emotional disability. But it gets better; the airline representative can assure an ESA is a service animal by, “looking for physical indicators such as the presence of a harness or tags.” Out of the three airports I flew through that day, only two ESA dogs, out of dozens, had a harness or tag that said, ‘Service Animal’. The rest were on exercise leashes; one Pekingese was even in a baby carriage. What do the airlines do to assure the ESAs are legitimate service animals? Who knows? In fairness, they are probably not allowed to do anything. The growing number of ESAs mean safety events will happen. There will be human fatalities. It is not a matter of if, but of when.

The FAA and the National Transportation Safety Board (NTSB) must conduct joint studies into the risks these ESAs pose to passenger safety. The FAA and the NTSB have the best resources to do the analytical leg work, like the FAA test beds in Atlantic City and Oklahoma City, where controlled testing provides qualified data. The FAA and the NTSB should then develop guidelines; FAA Doctors should decide whether these MHPs are capable of making diagnoses. ESA owners should have their ESAs properly trained for emergency situations or revoke their ESA status. Finally, the FAA and the NTSB should present these findings to the US Congress to have them look at the facts and act accordingly.

The US Congress wrote the ADA with its ambiguities, they should correct the ADA’s inconsistencies. Truly disabled individuals deserve to have their handicaps recognized for the hardships they are, not to be grouped with those who claim a right they do not deserve. And when the ADA is corrected to be what the ADA was meant to be, we, the traveling public, can all say, “AMEN.”

Aircraft Accidents and Lessons Unlearned XLV: Eastern 212

Eastern Airlines DC-9

On September 11, 1974, at about 07:34 Eastern Standard Time (EST), 11:34 Greenwich Mean Time (GMT), Eastern Airlines flight 212, a DC-9-31, registration N8984E, crashed while on final approach into Charlotte International Airport. The Eastern 212 accident report: AAR-75/09, stated that Eastern 212 crashed due to a controlled flight into terrain – CFIT, a term given to an aircraft – mechanically and operationally sound – that is intentionally or unintentionally flown into the ground; the aircraft does not crash due to mechanical or control issues but crashes due to negligence. The National Transportation Safety Board (NTSB) determined in its Probable cause, “… that the probable cause of the accident was the flight crew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline in that the crew did not follow prescribed procedures.”

There was no denying that the two-pilot flight crew engaged in non-operational political conversations below 10,000 feet. AAR-75/09 said, the “… crew conversed on non-operational topics [or subjects]”; they engaged in talk that distracted from the landing. From the limited information drawn from the recorders, the previously concluded discussions did not distract them from the landing sequence. At 07:31:07 the non-operational conversation ended; at 07:33:57, the flight crew reacted to the pending crash. For two minutes and fifty seconds before impact, the flight crew did not engage in non-operational conversation; they were focused on the landing approach.

Flying today, flight crews are required to maintain a ‘sterile cockpit’ below ten thousand feet, meaning that the flight crew must have workable silence – no distractions. Jumpseaters and flight attendants must avoid interrupting the crews’ duties (unless for emergencies) while completing the takeoff sequence or while making the approach as the work intensifies; this applies to both instrument and visual approaches. The report stated, “This accident exemplifies the absolute necessity of strict adherence to prescribed procedures, particularly those pertaining to altitude awareness, during an instrument approach.” Non-operational talk was not the failure to adhere to prescribed procedures. In fact, it was their engagement in operational talk that doomed the flight. These conversations proved to be the ‘failure to follow prescribed procedures’.

It is nearly impossible, from report AAR-75/09, to determine at what altitude different crew conversations recorded by the cockpit voice recorder (CVR) took place at. On page eight it was stated, “The malfunction [in the flight data recorder (FDR)] rendered the vertical acceleration trace unreadable but caused little difficulty in the readout of other parameters.” From page one to page five, NTSB investigators pieced together a detailed log of actions and times chronicled of what had happened on flight 212 until the crash at 11:33:58 GMT. Although the recording of conversation and times can be followed, the altitudes at which the information was presented was confusing.

Why is this a problem? Distractions, such as the kind the NTSB said Eastern 212’s crew experienced (“poor cockpit discipline”), that led to the crash, might be compared to texting while operating a train or dialing a phone while driving. Operational consequences of pilot distractions in flight would be when they ‘bust’ an altitude (when a pilot unintentionally flies above or below their assigned altitude) or miss their air traffic control (ATC) radio transmitted instructions. There were no signs that ATC was ignored; at 07:22:00 and 07:31:09, the Eastern 212 captain acknowledged ATC’s directions to turn or descend; he responded to ATC. The flight 212 pilots knew where they were supposed to be … or thought they did.

The NTSB was correct, that the pilots failed to follow procedure. For instance, per Eastern En Route Procedures, “During descent, the pilot not flying will call out the assigned altitude upon going through the last 21,000-foot level prior to the assigned level. The last 1,000 feet should be at a target rate of 500 feet per minute.” The first officer was the flying pilot; it was his leg. The captain (pilot not flying) should have been focused on his responsibility, calling out the altitudes, at the least monitoring them. This was where the failure occurred; during an instrument approach the pilots’ attention should have been on the instruments instead of on visual ground references.

The procedure for the Final Approach Fix required, “… the pilot not flying (captain) will call out the altitude deviation from ‘bug’ speed as appropriate, and the result of the flag scan.” This, clearly, was not done; this failure alone should have called attention to another possible failure – ‘possible’ because it was never investigated – that the first officer and captain were reading two separate altitudes.

There is an ancient superstition that “bad (or good) things occur in threes”. Perhaps in this case, it came true, or as some in the Human Factors world may say, “the holes of the swiss cheese lined up”. The first contributor was the failure to follow procedure, to monitor the instruments.

There was ground fog obscuring the terrain during the approach; the pilots’ focus on ground references proved to be the second contributor to the accident. Ground fog should have had little to do with the instrument approach, but since the pilots decided to look out the window, it led to the third contributor: the distraction of the Carowinds Tower.

This approach was an instrument approach, so ground references were unnecessary, yet the flight crew discussed a 340-foot amusement park tower called the Carowinds Tower. For over one minute, the pilots’ attention was outside the cockpit and on the distant ground reference, not on the instruments. If, indeed, they did sight the Carowinds Tower, would that have given them a false sense of altitude as being over one thousand feet? From their perspective viewing the Tower, were they looking down, looking from the side or looking from a great distance? Should the Tower question have drawn their attention back to the instruments? Should this have caused the pilots to check their instruments in relation to each other?

In section 1.12 WRECKAGE, the wreckage distribution was discussed in great detail. All flight controls were in their normal positions, no evidence of fuel contamination, engine reversers were stowed, all this physical evidence pointed to a normal approach. The report did state that, “Most of the aircraft’s systems and instrumentation were destroyed.” It described how several of the captain’s instruments were reading normal but made no mention whether any investigation into the first officer’s instruments could be or had been looked into. Did the first officer not react to aural altitude warnings because his instruments read differently than the captain’s? Was the first officer, who survived, interviewed post-crash?

There was one other confusing detail: the changes in altitude as recorded by the FDR. Per AAR-75/09, at 07:31:54 the FDR recorded the aircraft at 2,750 feet; at 07:32:41, the FDR showed altitude at less than 1,000 feet. But at 07:33:17, forty seconds before impact, when the CVR recorded the first officer request, “Fifty degrees Flaps;” the altitude recorded by the FDR at this time was 1,480 feet.

It is understandable that terrain varies in height, especially in hilly or mountainous areas. Was the first officer confused into thinking the aircraft was higher than the altitude alerts called attention to? Were the two pilots’ instruments reading differently?

One last observation: in regard to the pilots’ neglect of the altitude aural warning, the report stated, “Based on pilot testimony taken at the hearing, it appears that the crew’s disregard of the terrain warning signal in this instance may be indicative of the attitudes of many other pilots who regard the signal as more of a nuisance than a warning. If this is indeed the case, the Board believes that airline pilots should reexamine their attitudes toward the terrain warning alert, lest the purpose for which the device was installed be defeated.” The takeaway from this statement was that the pilots should accept all warnings because they are designed to save lives. However, too many alerts in increasing numbers of tones might become so much noise that work contrary to their purpose. Consider a car alarm that constantly goes off or a smoke detector that senses smoke where smoke does not exist. Are all alerts necessary; do they work only when necessary? Are they overkill? Do they alert pilots to problems or are they redundant? Can important alerts be silenced or ignored too easily? These are questions for not only the airlines, but the manufacturers: Are there too many redundant alerts?

It is to be noted by reviewing the AAR-75/09 report that the NTSB, in these early days, made a great impact on aviation safety with less arbitrary input; focus was on both quality investigations and quality investigators; they used their qualified resources wisely, their experience constructively. These early investigators demonstrated that, like some cockpit warnings and alerts, less might be better.