Aircraft Accidents and a Dangerous Precedent

Bele and Lokai of the planet Cheron in Start Trek TOS, Season 3, Episode 15: Let This Be Your Last Battlefield

In the late 1960s, the television show Star Trek (aka, The Original Series) showed us our future; the diversity of the human race in a professional environment: The (White) Captain; First Officer/Science Officer (Alien); Pilot (Asian); Navigator (Russian); Communications Officer (Black Woman); Engineer (European) and Physician (Southern Doctor). These characters interacted every week; they displayed how these different folks could work together towards common goals. Even the villains and antagonists were interracial men and women, so no group escaped praise or being booed or hissed at. What made the show so appealing was that race and gender played no part in any character’s qualifications or the storylines; each character was qualified to do their job. As Star Trek played out for the next half century in spinoffs and movies, the diversity factor never quit; Captains, Bridge staff, Chief Engineers, Medical and Security personnel were all represented by each race and gender, again, because these characters were qualified to hold their positions in the show. Even aliens were both racial and gender blind.

According to an April 13, 2021, Washington Post article, “… [Unnamed] Airlines said last week that it had set a goal to train 5,000 new pilots, at least half of them women or people of color, at its new flight school over the next decade.” The article goes on saying that this will improve safety.

How disingenuous for an airline that is now focused less on safety and more on theater. The article revealed a ‘woke’ airline management’s trivial agenda. More importantly, the airline set a dangerous precedent. Question: How does one reconcile hiring practices based on skin color and gender – to aviation safety?

The aviation industry is diverse; the Facts, e.g., applications, seniority lists, training records, can prove that out. For those who understand this, Facts are not necessary. A few less informed (inexperienced?) individuals commented on the airline’s announcement, praising the airline’s ‘brave move’, by comparing non-safety sensitive occupations, like tech company managers, to pilots; they likened someone who sits at a desk in a large office to a pilot who flies multimillion-dollar aircraft … full of people. The airline’s ‘woke’ practice was lost on many aviation enthusiasts; these individuals put political correctness first, the flying public’s welfare, second. For these people, no Facts will ever be enough.

And then there were the head-scratching comments, such as the pilot of many decades and (allegedly) former air operator manager who commented that in his X number of years in the cockpit, he saw many pilots with ‘borderline’ quality – and that no one spoke up. He continued by saying that “… as more women and people of color occupy the cockpit, the safety profile will improve”.

And there lies the rub. The first problem with this gentleman’s statement was that he saw many pilots with questionable skills in the cockpit and … that no one spoke up??? Did he speak up? As a member of management, was the welfare of the flying public not his responsibility too? Those ‘borderline’ pilots lacking in flying skills, whether white, black, green or purple, should have been trained harder or given a non-safety position in the company. That is Airline Management and Safety 101.

But then he said that “… as more women and people of color occupy the cockpit, the safety profile will improve.”  How does one square that circle? How does an airline’s safety profile improve when the racial or gender numbers change? How does one equate Aviation Safety to the quantity of melanin in one’s skin and/or how many X chromosomes one has? Does that even make sense?

This speaks volumes to how meaningless the airline’s announcement was. It obviously appealed to some shortsighted political correctness warriors. Perhaps they feel the Federal Aviation Administration (FAA) should require operators to focus on diversity instead of safety. Maybe the National Transportation Safety Board (NTSB) should revamp its critical mission; spearhead industry studies that direct more women away from running tech companies to running air cargo. Perchance the Departments of Transportation, Interior, Commerce, Defense, etc. will refocus on diversification instead of wasting time on safety, security and wellbeing.

Over these last few years as each new politically correct concept took center stage, companies fell over themselves to be seen as in line with each new concept, as if the topic du jour was foremost on every American’s mind. The problem is that with each politically correct concept – aka Distraction – someone else becomes the new target: the police, the military, political parties, religious groups, age groups and, of course, people of certain race or gender. We become numb; it becomes easier to ignore the static, to allow the bullhorns to blare and the sarcasm to fly. Question: Is airline management that bored that they now waste our time with self-served posturing? Weren’t their post-COVID Stimulus payouts large enough?

To serious aviation folks: Is there a gender or racial problem to begin with? One could ask the airlines, since they suggested that diversity numbers were a problem, what are the actual ratios? Maybe, the numbers are not as bleak as the progressive airline makes them out to be. The FAA, as an unbiased source, could get those numbers. That way, America can go back to the important issues.

My perspective: For almost four decades I rode the cockpit jumpseat of various airlines, whether I was flying to fix one of my airline’s broken jets in the field or as an FAA inspector conducting enroute inspections. Throughout those four decades, I have flown with pilots of both genders; sat and talked shop with flight crews – both in the cockpit and in the cabin – of every known race. As an FAA and NTSB instructor, I taught pilots who were sister and brother; husband and wife; parent and child. The pilots I have known flew everything, from a Cessna Citation to a Bombardier Dash 8 to a DC10 wide body, both Parts 121 and 135. Lots of pilots; lots of diversity. So, is diversity even a problem these days?

On social media in March, how many all-female flight crews were celebrated; all black female flight crews; all Asian flight crews; mother and daughter flight crews. I am confused by these postings. Why? Because I see them all the time … every single day. No one cares anymore who has three-striped epaulets and who has four. These sights are the norm, not the exception. The airline industry is diverse – and safe – because it uses qualified individuals. The FAA and the NTSB are diverse, only because they hire professionals for their skills. Diversity results from these hiring practices; it does not cause them.

Diversity is subjective, it is open to interpretation. Safety is specific; something is either safe or it is not. What would be considered a diverse pilot group? When I was a hiring supervisor, we were tasked to hire as diverse a workforce as possible. The problem was the job drew mostly white guys in the airport I worked at. How do you hire to diversity when diverse populations do not apply? Should we alter the interview process; should we interview for diversity or for skill and experience?

When I went to airframe and powerplant school in New York City, the breakout of students in my class were: two women, one Asian guy, two Black guys and the rest were White guys. I attended on loans, State and Federal assistance because I was broke. Public transportation and major highways were very close. Everybody tested to be enrolled. How would diversity be forced into such a situation?

The question still remains: What does Diversity have to do with Safety? How does requiring an equal racial ratio or gender ratio make an airline safe to fly? How does racial equality across the mechanic workforce guarantee safe aircraft? Air Traffic Control? When a pilot, mechanic or controller works on their training and developing their skills, it is not to check a political box. It is to assure the persons in those positions are qualified. Would any airline suggest that, to keep the racial and gender numbers even, they would drag everyone across the finish line, equally? Compromise the qualifications? What about the people who cannot make the grade, pass the flight school; would the airlines fail them? Would their pilot financial investments result in failing those unqualified or pass everybody with a wink-and-a-nudge?

What effect would Diversity have on safety? Hiring for Diversity would negatively affect safety … period!

Ralph Waldo Emerson once said, “Fiction reveals truth that reality obscures.” The picture above is from a 1969 Star Trek episode called ‘Let This Be Your Last Battlefield’. Frank Gorshin and Lou Antonio played Bele and Lokai, respectively, two citizens of the planet, Cheron who were prejudiced against each other. In one memorable scene, Captain Kirk and Mister Spock tried to comprehend why the two Cherons hated each other. The Cherons said that, though both were half black/half white, the black and white sides were reversed on Bele and Lokai. Kirk and Spock still did not grasp the hate. The Cherons thought Kirk and Spock were fools for not seeing the racial disparity that they saw. But it was the prejudiced Cherons who were the ones obsessed with pushing racial divides. Sound familiar?

Americans have come through decades of faults and, along the way, each generation has corrected for the faults of the former. Women hold many influential jobs and powerful positions. Both genders of all races are prominent in every industry; it is hard to remember when it was otherwise. Yet some people agitate; they must stir up old bigotries; pick at the scabs; insist on seeing bias where bias does not exist. Their Emotions blind them to Facts. But, maybe the agitators are the bigots, finding racism in the aviation industry where it does not exist; placing Diversity over Safety. In aviation, Diversity is not the problem. Instead, making diversity a problem … IS the problem. And doing that to aviation safety sets up a dangerous precedent.

Aircraft Accidents and Lessons Unlearned XLVIII: TWA Flight 841

On April 4, 1979, Trans World Airways (TWA) flight 841, a Boeing B727-31, registration number N840TW, suffered an uncontrolled maneuver, beginning at 39,000 feet; the aircraft rapidly descended for seventy-one seconds before it stabilized at 5,000 feet near Saginaw, Michigan. The number 7 leading edge slat departed the aircraft, the tracks and actuator for the number 7 slat were substantially damaged.

The flight left JFK Airport for Minneapolis roughly fifty-five minutes before the event began.  This meant the aircraft had been at cruise for close to an hour, meaning no secondary flight controls, e.g., four sets of flaps, eight slats, six Krueger flaps or ground spoilers would have been extended. The first indication of a problem, per the pilot interviews, was that the Captain’s altitude director indicator – ADI – showed a right bank of twenty to thirty degrees. From this indication to the recovery at 5,000 feet, the flight crew were in reaction mode.

The National Transportation Safety Board (NTSB), in report AAR-81/08, determined that the Probable Cause of the inflight upset was, “… the isolation of the number 7 leading edge slat in the fully or partially extended position after an extension of the numbers 2, 3, 6 and 7 leading edge slats and the subsequent retraction of the numbers 2, 3 and 6 slats, and the captain’s untimely flight control inputs to counter the roll resulting from the slat asymmetry. After eliminating all probable individual or combined mechanical failures or malfunctions which could lead to slat extension, the Safety Board determined that the extension of the slats was the result of the flight crew’s manipulation of the flap/slat controls.” Report AAR-81/08 went on to say, “Contributing to the captain’s untimely use of the flight controls was distraction due probably to his efforts to rectify the source of the control problem.”

The NTSB investigators’ statements bordered on accusatory – without evidence – that the flight crew introduced the slat extension by their, “… manipulation of the flap/slat controls.” Unless the flight crew stated that they extended these secondary flight controls, no one should have assumed that any slats were extended at cruise. However, NTSB investigators held that the flight crew either deliberately or unintentionally extended flight controls due to the erasure of all but nine minutes of the cockpit voice recorder (CVR) recording. Report AAR-81/08 called this action ‘a distraction’; he said, “… the Captain’s untimely use of the flight controls was a distraction due probably to his efforts …” Use of the word ‘probably’ was not in relation to probable cause; it was used in lieu of fact. The ‘probably’ was not a definitive statement; it was not analysis. It demonstrated that NSTB report AAR-81/08, while supposedly based on Factual information, had been founded on an allegation.

On the B727, the CVR erase button is on the second officer (SO) station’s side panel. The allegation meant that, not only were the Captain’s actions suspect, but that the two copilots: the first officer (FO) and the SO, would have been complicit in the ‘distraction’, otherwise the Captain would have had to set the brakes, get out of his seat and hit the ERASE button, if the SO refused. The allegation would have also assumed that CVR transcripts were indisputable, which gets to the heart of many accident report confusions, that CVRs were 100% reliable for determining accident cause. The CVR is, and was, never 100% reliable. CVR recording quality has always been compromised by any and all cockpit noises, e.g., aural alerts, wind noise, conversation overlaps, etc. If, in this case, the pilots did erase the CVR, was this an acceptable action? Questionable. However, after reading the NTSB’s reaction in AAR-81/08, it would have been understandable why any pilot would remove ambiguous CVR information. In AAR-81/08, the NTSB investigator assumed – without fact – misconduct on the Captain’s part. Furthermore, NTSB Board Member Francis H. McAdams agreed with this line of thought. He wrote a dissent that disagreed with the Board’s findings and questioned how they interviewed the Captain. It was important to note the four other Board Members did not question the Findings. What did this say about how the other four political appointees grasped the nature of the allegation?

AAR-81/08 was, as are all accident reports, vital to industry’s understanding of what happened, to prevent reoccurrence. AAR-81/08’s Probable Cause never addressed the Root Cause. The pilot’s actions, during the event were responsive to the probable cause: the uncontrolled maneuver. However, the Root Cause should have answered the question: Why did the number 7 slat come out of the stowed position in cruise?

On page 18 of the report, titled: History of B-727 Leading Edge Slat Problems, the report stated, “According to FAA service difficulty reports (SDRs), from the beginning of 1970 through the end of 1973, seven cases of a single leading edge slat extension and separation on B-727’s during flight were reported without mention of whether the extensions were scheduled or unscheduled.” Pause here to direct attention to the use of the words ‘scheduled and unscheduled’. Fifty-seven minutes into cruise, the wings were ‘clean’; lift-augmenting flight controls, i.e., the slats, had been stowed for nearly an hour; there would be no reason to extend them until Approach. It would be dangerous and counter to design.

The Probable Cause stated, in part, “… after an extension of the numbers 2, 3, 6 and 7 leading edge slats and the subsequent retraction of the numbers 2, 3 and 6 slats …” Aside from the unusual insinuation of extending slats in cruise, the report suggested that the crew isolated one lone slat – number 7. This suggestion demonstrated that investigators had a fundamental misunderstanding of the B727 slats’ operation. No slat on the B727 operated independently, therefore, there could be no ‘scheduled’ extension of the number 7 slat – the flight crew could NOT do that. Slats 2, 3, 6 and 7 are deployed together when the flap handle is placed in the Flaps – Two Degrees detent. Slats 1, 4, 5, and 8 plus all six Krueger leading edge flaps all deploy when the flap handle is placed in the Flaps – Five Degrees detent and beyond to forty degrees. The problem with AAR-81/08 was that investigators kept referring back to a single slat deployment, which the pilots … could … not … do; even activating the flaps manually using the electrical system, the crew could not – could not – deploy a single slat, by itself. The number 7 slat deployment was unintentional and unexpected. The report went on to say, “… we recognize that if the No. 7 slat did not extend as the consequence of some series of failures and malfunctions in the slat system, then it must have been extended as a result of flightcrew action.”

Did NTSB investigators ask if a slat deployment would have triggered a warning? Actuation of any slat would have resulted in an illumination of the leading-edge device (LED) deploy/unsafe light indicator on the pilots’ instrument panel. Each of the B727’s eight slat LED switches is internal, meaning the switch is inside the actuator. The LED indicator light is Extinguished when the slat is stowed; Yellow when the slat is in transit and Green when the slat is deployed. This fact should have led investigators to ask the pilots: “Did you see an LED indication prior to the event?”

Consider that with all the LEDs retracted in cruise, for the captain to extend slats, he would have had to reach over the throttle quadrant and pulled the flap handle out of its ZERO detent – or – actuated the manual electric controls over his head. An out-of-configuration alarm, e.g., a takeoff aural warning would have sounded. The FO and/or SO would have questioned the action. Even if the Captain recklessly did all this, the FO and/or SO would have reported the incident to the Chief Pilot, who, with the Federal Aviation Administration Principal Operations Inspector, would have acted.

Did the NTSB investigators conduct a thorough maintenance investigation? The number 7 slat was missing, its slat tracks and actuator were severely damaged. The right wing displayed impact scratches and the righthand outboard aileron had been hit by the departing slat. The NTSB performed some basic inquiries into N840TW’s maintenance history and the slat system’s inspection and maintenance, but it was not deep or broad enough; the past maintenance examination was cursory. As the probable cause stated, “… if the No. 7 slat did not extend as the consequence of some series of failures and malfunctions in the slat system, then it must have been extended as a result of flightcrew action.” This meant that the investigators made ineffective explorations into why the number 7 slat was out of configuration.

In addition, the NTSB depended too heavily on Boeing to analyze their own aircraft. This raises the question: Should any manufacturer be expected to fairly review its products, especially when the determination could devastate said manufacturer? This cast doubt, not just upon the NTSB’s AAR-81/08 report’s quality, but also upon Boeing’s ability to be forthcoming about their airplane’s safety. It would have also allowed Boeing to fix any problems without any consequences.

One last item suggests the investigators’ unfamiliarity with the B727 slat system. On page 25, where the investigators justified faulting the Captain, the report stated, “… the air loads on the slat would have subjected the slat actuator rod to a compressive load of about 700 pounds and about 9 percent less if the outboard aileron was floating.” It was unclear what the investigators meant by ‘floating’, but the problem with this scenario is that the outboard ailerons are locked out at cruise – they do not move; they do not unlock until five degrees of flaps are selected – the numbers 2, 3, 6 and 7 slats extend at two degrees of flaps. In addition, the slats do not unlock the outboard ailerons, the flaps do; the mechanical device that unlocks the outboard aileron comes off the flap transmission, not the slat actuators. Therefore, the investigators should have tested, not only all eight slats but the four flap systems as well. If the slats were extended intentionally, the flaps would have moved as well.

The aviation community needs to trust the investigatory process, be convinced it is legitimate. The NTSB must not just expect quality and impartiality from the five transportation mode agencies it investigates, it must rise to the same standards itself. We will never know the Root Cause for what happened to TWA flight 841 on April 4, 1979; it is small consolation that the B727 has limited presence today in the United States, if at all. But the B727 still flies; other Boeing products have similar, if not identical, slat systems to the B727. If only the Root Cause had been found.