Aircraft Accidents and Recognition

NTSB Chairman Robert Sumwalt

Before there were a bevy of health gurus, there was Jack LaLanne. Jack, who died in 2011 at the age of 93, spent his lifetime spreading the values of exercise and good nutrition for thirty-four years on his show, The Jack LaLanne Show, where he not only helped those of all walks of life to better, healthier living, he was a living example of what he professed – the man had even skipped dessert since 1929. He performed 1,033 pushups in 23 minutes in 1950; on his seventieth birthday, while shackled and handcuffed, he pulled 70 rowboats, with a man in each, across Long Beach Harbor, CA. In short, he ‘walked the walk and talked the talk’. He was the health expert for many decades and never equaled.

This kind of dedication is what is known as being “qualified for the job”. Jack did not get elected health expert, he lived it; he showed by example that his insight worked; acknowledged by the international community as the model. And for his lifetime achievements he received recognition.

On the topic of aviation safety, there is no lack of contributors. It has taken me time to realize that though others who promote aviation safety may be in conflict with some of my views, they have spearheaded much needed conversation to the front, conversation that benefits all in aviation. I sometimes need to be reminded that I did not get into writing about aviation safety to just promote my arguments or sell a book. I – we – do what is necessary to increase safety – period.

Aviation safety is not a popular topic; it is, though, one of the most important subjects affecting, not just our industry, but civilization. Like points on a compass, investigator theories can veer off in different directions so dissimilar, one wonders if they are speaking to the same event. I have sat in Federal Aviation Administration (FAA) and National Transportation Safety Board (NTSB) staff meetings where I had to check my notes to make sure I was in the right room, that we were discussing the same accident/incident. That is why leaders are so important to advancing safety; a person who not only grabs the microphone but can challenge the others who line up against him or her to do what is right.

When I worked on NTSB major accidents and subsequent hearings, (then) Member John Goglia’s seat was to the Chairman/Chairwoman’s immediate left. Of the five Board Members, he always appeared cool and collective; he was in his element. His aviation experience as a Board Member was unmatched. His aviation maintenance knowledge was unlimited. There are or were not many NTSB politically appointed Board Members who deserved their place at the table more than John Goglia.

The single reason I was hired into the NTSB was because former Member (FM) Goglia used his influence to guarantee an aircraft mechanic, experienced in the maintenance field as he was, be hired into the NTSB and work on the major accident Go-Team. Prior to FM Goglia’s push for the position I would soon occupy, aircraft maintenance was – and possibly is again – investigated by engineers with no industry experience. FM Goglia recognized that investigations into maintenance issues had to be done right; the investigator had to understand every aspect of aircraft maintenance for a Part 121 commercial airline, Part 135 ten-or-more perspective and have a healthy understanding of Part 145 Repair Stations. In other words, to know the conditions mechanics worked under, problems they faced and even problems they created. FM Goglia knew the best way to fix problems was to be able to identify them, address them and determine a way to make sure they did not reoccur.

It was more than the raising of the investigative bar that FM Goglia brought to the NTSB; it was his tenacity. He understood an inarguable fact: that to make effective changes – post-investigation – solutions had to be properly communicated to all those who would affect change, including how the FAA interpreted NTSB recommendations. Employing common sense, FM Goglia would speak with FAA management about how to word recommendations so that the transition from recommendations to FAA regulation, policy and guidance would be flawless.

He also was there to guide anyone who wanted to benefit from his experience. FM Goglia, knowing that I had no one who could show me the ropes in maintenance accident investigation, was always a phone call away with advice – especially when on-site – and his office door was always open. He would go off script; his methods did not always appeal to management at the Board, but then he was not there for management; he was there for the investigators, those at the site. They were the ones who needed the benefit of his experience.

Lately FM Goglia has been sharing his experience at his website: with a look into past accidents. He continues to make the industry safer.

Former Member Goglia was one of few Board Members, present and past, that I knew of that could draw from personal experience and bring that to the table. Another is Chairman Robert Sumwalt. 

I never worked with Chairman Robert Sumwalt; I have seen him on social media updating the industry about the latest news of an investigation. I have known other Chairpersons in the past, but none stood on the front line as often as Chairman Sumwalt has. He did not stand on ceremony. In my career, indeed my lifetime, I cannot remember an NTSB Chairman – and very few Members – who has championed the NTSB or taken a more active role in spreading, not only the NTSB’s successes in all five modes, but infused his experience as a pilot into the discussion.

And that is what makes the difference: Experience. To ‘separate the chaff’, remove media sensationalism and rationalize the investigation. Chairman Sumwalt’s experience streamlined the Operations side of an investigation, a major part of any investigation that needed a practiced eye. That is what pilots need for safety to be improved, especially in the Part 121 world. Part 135 nine-or-less operations are far different than Part 121; crew scheduling, fatigue, recovery flights, flying Part 91, all the important factors taken for granted by the less experienced in a major accident investigation, play vital roles in safety; they and other factors are the difference between determining cause and best guesses.

As per his NTSB website bio, Chairman Sumwalt was a pilot for 24 years with Piedmont and US Airways. During this time, he experienced mergers, equipment changes, thousands of hours of training, long days, conflicting schedules and every hurdle a line pilot could deal with, all factors that affect the safety of the flight crew, passengers and the aircraft. At US Airways, he served on the Flight Operational Quality Assurance monitoring team, which assured procedures and policies were followed by both pilot and management. Experience – Experience – Experience!

After leaving US Airways, he ventured into management at a Fortune 500 company; chaired the Airline Pilot Association’s Human Factors and Training Group and acted as a consultant to the National Aeronautics and Space Association’s Aviation Safety Reporting System program. It was his choice to step out of the left seat and pursue other safety avenues that make him stand out as an investigator and a Board Member. Not just that he was a commercial pilot, but that he broadened his effect for all aviation.

I felt the most influence Chairman Sumwalt had was his role as Chairman for the NTSB. He used his position and social media to keep the aviation community informed about the latest news of NTSB investigations. It was this function that he served aviation most notably; he took the NTSB out of the meeting room and broadcast their investigations for all to see, not just in Aviation, but Rail, Highway, Marine and Pipeline, as well.

Somehow, it is hard to imagine that Robert Sumwalt, upon his pending retirement, will simply fade into aviation history. I do not foresee him pulling a ‘Jack LaLanne’ and strong arming a B737 across a ramp on his birthday, but like John Goglia, it is expected that Robert Sumwalt will find new ways to improve aviation safety. And that is good – that is real good – because aviation needs him, needs both of them, desperately. These two aviation professionals, from opposite sides of the aviation ‘tracks’ – Operations and Airworthiness – deserve recognition for their continuing contributions, leadership and drive.

Aircraft Accidents and Lessons Unlearned L: The Wright Flyer Model A

The Wright Flyer Model A after it crashed on September 17, 1908.

On September 17, 1908, at 5:14 PM, local time, Orville Wright was conducting a demonstration for the United States War Department; he flew with United States Army First Lieutenant Thomas E. Selfridge. Wright was conducting a proving run for the military in a modified version of the Wright Flyer, the upgraded Model A. About twenty minutes into the demonstration, after three successful laps over the Parade Grounds outside Arlington Cemetery, Wright heard a light tapping. Being wary, he began to shut down the engine and attempted to glide from a height of 150 feet. Before the engine could be shut off, per Orville’s testimony, he heard, “… two big thumps, which gave the machine a terrible shaking.” A piece departed the aircraft before the airplane swerved to the right; the aircraft would not respond to his inputs. He shut off the engine, while working to regain control.

Per the accident report, Wright said, “I continued to push the levers, when the machine suddenly turned to the left. I reversed the levers to stop the turning and to bring the wings level. Quick as a flash, the machine turned down in front and started straight for the ground.” Witnesses said that at seventy-five feet, the machine began its nose-dive into the ground.

Lieutenant (Lt.) Selfridge had the sad distinction of being the first person to die in a heavier-than-air powered aircraft, a unique fatality for, at the time, only balloon and dirigible occupants were known for being aircraft fatalities. Even so, Lt. Selfridge’s unfortunate death had nothing the do with the accident; he neither affected airworthiness nor unexpectedly contributed to the accident. Aside from mentioning his unfortunate demise, Lt. Selfridge did not have a place in the investigation. However, Lt. Frank Lahm played an important role.

At the time of the Wright Brothers first flight and subsequent work with the military, the term, ‘Powered Aircraft’ was locked up by dirigibles, balloons and other lighter-than-air machines. Per, Gliders – one of the first heavier-than-air attempts – were receiving initial attention when Otto Lilienthal, with his brother Gustav, of Germany, “… built his first [heavier-than-air] man-carrying craft, with which he could take off by running downhill in the wind.” The Lilienthal brothers had experimented with wing camber and Bernoulli’s Principle; they studied stabilizing tail surfaces that would evolve into horizontal and vertical stabilizers, rudders and elevators. It was not until 1903 that power and aircraft were successfully married in the Wright Flyer.

Documented information on the accident was extremely limited; the unexpected disaster was witnessed by military personnel and some media; no one expected to see anything beyond the trial runs of some of the latest aircraft. The consequences of heavier-than-air flight were unknown, perhaps as alien to the people observing as those fearing a ship going over the horizon’s edge a millennium ago. It was clear from Wright’s comments that the accident was a surprise, that the modified mounted propeller upset the flight as it had; the result was completely unanticipated.

Per the website, First Lt. Frank Lahm, after freeing Orville Wright and Lt. Selfridge from the accident aircraft, immediately began investigating the wreck. He would submit his report to the War Department five months later. Lahm had flown with Orville Wright a few days earlier and was familiar with the Model A; he had witnessed the accident and helped rescue the occupants. Lt. Lahm had access to all witnesses and the wreckage was available to analyze.

Before his demonstration for the War Department, Orville Wright had replaced the original 104-inch propellers on the Flyer with 108-inch propellers to increase aircraft speed. During the demonstration, the aircraft had reached a top speed of forty miles-per-hour and an altitude of 100 to 150 feet above ground.

When Wright heard the tapping sound, he was confused; his subsequent actions were not fast enough to prevent tragedy. The aircraft nosed over and lost 125 feet of altitude before Wright recovered, but he did not have enough room in the final 25 feet to pull adequately out of the dive; the skids – landing gear – dug into the earth and the aircraft crashed with what one reporter described as “frightful force”. Wright later commented, “A few feet more [of altitude], and we would have landed safely.”

During interviews, several witnesses had confirmed what Lahm had seen: a piece of one of the Flyer’s propeller blades had separated from the end of the propeller, causing a propeller imbalance. Lahm’s report stated, “… excessive vibration, this guy wire [securing the front rudder] and the right-hand propeller to come into contact. The clicking which Mr. Wright referred to being due to the propeller blade striking the wire lightly several times, when, the vibrations increasing, it struck it hard enough to pull it out of its socket and at the same time to break the propeller.” The term ‘guy wire’ may have been used in error; a guy wire is used to stabilize, brace or stiffen. The rudder was a moving flight control. However, the function of the wire was irrelevant, as was the title assigned to it; that it was in a position to be struck by the propeller was critical. It was not clear if Wright’s control movements moved the rudder wire into the propeller’s path or whether the amount of wire tension allowed it to swing into the propeller.

Was this accident preventable? Not likely; there were no previously similar situations for Wright to have learned from. The Model A did not have gauges to monitor the propeller or the rudder movements; all sensing of flight controls and engine monitoring were rudimentary, limited to sight, sound and feel. Even if Wright had identified the problem with the propeller, it would have been unlikely he could have shut the engine down in time to prevent the accident.  

In today’s aviation, what would have been the norm for Wright’s propeller modification. First, as the Model A was a redesign … of an aircraft without a type certification, the Model A would have been classified as an ‘Experimental’ category; it would have been operated under a special airworthiness certificate (SAC) and it would have been subject to the limitations according to its category. Per the Federal Aviation Administration (FAA) website, experimental category aircraft SACs are issued today to aircraft used in Research and Development – for which the Wright Flyer Model A qualified. Other limitations of Experimental aircraft include: Showing compliance with regulations; Crew training; Exhibition; Air racing and Market surveys.

The 108-inch propeller Wright changed to would have required testing as a either a modification or a complete redesign. The change in manufacturer design would have required checking to assure a clear path for the blades – no airframe in the blades’ paths. The blade materials would be tested for structural integrity. The propeller would be rated for safe operation with the Model A’s engine and that there was engineering paperwork to assure the propeller was a safe addition to the powerplant. Assuming the propeller was constructed of wood, the blade angles, symmetrical uniformity, the bonding of propeller to hub, balance and effects of air on the propeller’s structure would have had to be engineered as well.

Even in 1908, there were lessons to learn – and some to unlearn – from early heavier-than-air powered-aircraft of the day. Even politics played a part in the demonstration of the Model A; Wright had reason to believe that Selfridge was friends with and would show favoritism towards, Doctor Alexander Graham Bell, an aircraft builder and rival for the War Department’s aircraft contract. However, on that fateful flight, there was nothing dubious about Orville Wright’s intentions, which was to make an aircraft to the War Department’s specifications.

Perhaps the only lesson to be learned that day was to maintain aviation safety, no matter what; to think outside the box and to anticipate … anything. A lesson not to be unlearned over a century later.