Aircraft Accidents and Sense

Amtrak’s Empire Builder de-railed

On September 26, 2021, at 4:00 PM Mountain Daylight Time, a scheduled Amtrak train called the Empire Builder, a daily run from Chicago to Seattle, derailed near Joplin, Montana. The accident claimed three lives and seven were hospitalized. The suspected fault, per the New York Post, was “… near a switch on tracks in the middle of vast farmland in far northern Montana.” Was this a fluke or a reality check that the Federal Railroad Administration (FRA) has been chasing CVD-19 instead of assuring Rail Safety? What if the next ‘event’ is a capsizing ocean liner or a wide-body full of passengers pancaking in a neighborhood, reminiscent of American 587?

To misquote Mario Puzo, “It’s not political, it’s simply Business.” We are not going to sail into the next year safer than we were before; if you believe that you are – you have been – gravely mistaken. The Federal government has not been overseeing industry as it should; they are in the vacc1ne business now, they are pushing a vacc1ne set to make billions. Where is the sense?

We are about twenty months into this CVD scare, yet few are concerned that the Federal Aviation Administration (FAA), the Federal Maritime Administration (FMA), the Pipeline and Hazardous Materials Safety Administration and the Federal Highway Administration are spending less and less time in their offices or in the field chasing safety violators and more time chasing CVD bad guys.

The FAA’s Mission Statement (MS) is: “Our continuing mission is to provide the safest, most efficient aerospace system in the world.” The MS says nothing about policing vacc1nes; berating and banning 2-year-olds for refusing to wear a mask or making sure those crazy diversity numbers are up to Progressive levels. The MS does use words like ‘safety’ and ‘efficiency’, throwbacks to a time when that was the oversight agency’s job, their purpose of existence: Public Safety and Industry Efficiency. If it took the aviation industry three years to recover to pre-9/11 safety and efficiency levels after a five-day lockdown, how long will it take after two years of CVD confusion? How many aircraft accidents will have to happen before we wake up? How many lives, that will be erased in one second, will exceed the 2021 Delta variant victims? Do you think those families will say, “Well, at least they didn’t die of CVD”?

President Theodore Roosevelt said, “Patriotism means to stand by the country. It does not mean to stand by the President or any other public official save exactly to the degree in which he himself stands by the country. It is patriotic to support him in so far as he efficiently serves the country.”

Let us look to what is happening in the next month. All Presidential Cabinet Secretaries are firing non-vacc1ntaed personnel. The Post Office escaped the termination process (more on that later); they are the only government entity with a spine to defy the President’s Executive Order (EO) 14043. Meanwhile, the offices of Treasury, Attorney General, Labor, Education, Defense, etc. including all of Transportation will be terminating skilled employees … for refusing an unapproved vacc1ne. This is true, the vacc1nes are still under ‘emergency approval’. If you think the interruption of services two years ago during the government shutdown was an inconvenience, then buckle up folks!!!

What does that mean for those who had previously taken the vacc1ne in good faith or who folded and took the vacc1ne against their own better judgement? There will be paralyzing distrust for the Industry and Government management; doubt of those who put loyal employees’ jobs in jeopardy, used the employees’ families as hostages. Front line management will be the Judas Goats. Imagine how employees will react after being threatened with unconstitutional terminations, to go against religious and medical Facts to keep their jobs. Does anyone believe those who are left behind will be able to, will want to, will be inspired to, do their jobs as they did before? Will they gladly train those coming in to replace their friends and trusted coworkers who were forced out? How many will recognize the fact that their Unions betrayed them? Will they know their liberties and freedoms were lost?

EO14043 will also demand that all businesses employing more than 100 employees must have all their employees vacc1nated by December 8, 2021, or each company will be fined up to $700,000. Many will lose irreplaceable specialists in their respective fields. Between government and private business, the interruptions will affect, e.g., Aviation Safety, Defense, Food Inspection, Commerce, Trucking, Bridge Inspections, Rail Improvements, Homeland Security, Border Security, Medical Equipment, Medical Services, Unemployment Benefits, Law Enforcement, Firefighting, Auto Repair, Teaching, Social Security, Emergency Response, Buying Appliances, Food Supply, Fuel Reserves, Welfare Checks … Check out how much containerized freight is sitting outside California’s ports right now, goods that are not – will not – be getting to your stores; food that is spoiling; companies going out of business.

Why would industry’s upper management buy into such a counterproductive move? For one, EO14043 relies on fear to force people to take the vacc1ne. The ones who do not submit, create shortages. By creating shortages, businesses super-inflate prices. How much has the cost of meat gone up in the last six months? Gasoline? Construction materials? Microchips? Do you think upper management cares if people are laid off due to shortages? No, because they raise prices with less overhead costs, less manpower. Their Personal profits increase! Shortsighted fools. Who will be able to afford their goods and services?

More telling are the effects recent ‘illness outbreaks’ and ‘weather’ had on Florida’s air traffic control and Southwest Airlines last week. This was a wake-up call to all industries – not just the airline industry. Can any company, no matter what type, survive if they suddenly had to do without a large percentage of their workforce as the President is requiring? If the mandates push for companies to terminate a large number of non-vacc1nated employees, how many others will quit, sick-out, retire or take emergency leave in sympathy with their coworkers? Are the numbers of stubborn non-vacc1nated (and their sympathetic coworkers) much larger than the untrusted Media is reporting?

Another question must be asked: what does this mean for Safety if all the experience is being shoved out? I understand why someone with no experience would stay; they need the money. Those with experience have had time to plan and save; they can retire. Who will work on airplanes for the near future? Will the remaining airline mechanics have the necessary experience? Will airline pilots be lacking training? What about the remaining flight attendants? Air traffic controllers? The FAA inspectors who stay; will they know what to look for? For that matter, the remaining FRA or FMA inspectors?

As per Joy Pullman of The Federalist, “It’s all a mirage. [the President]’s so-called vaccine mandate doesn’t exist — at least, not yet. So far, all we have is his press conference and other such made-for-media huff-puffing. No such rule even claiming to be legally binding has been issued yet.” This means Families are being devastated … for nothing. People will lose everything; Innocent families will become homeless; Dreams will be shattered. Why? Because neither political party will fight for their constituents.

If the vacc1ne is valid and works as promised, why force it? Has the media been repressing medical information that shows the vacc1ne is causing major concerns; are they silencing the voices of medical experts, like Doctor Peter McCullough, who has been warning against the vacc1ne? He and his colleagues have been published in The American Journal of Medicine. Their research finds that the vaccines, “… have an injurious mechanism of action in that they cause the body to make an uncontrolled quantity of the pathogenic spike protein from the SARS-CoV-2 virus.” In addition, “The spike protein itself has been demonstrated to injure vital organs such as the brain, heart, lungs, as well as damage blood vessels and cause blood clots.” Doctor McCullough and his colleagues are pushing for a halt to vacc1nations until further study can be made, especially into its use on children. Are we being played? Is Industry forcing vacc1nations on their employees and blaming the President? Will that backfire?

But there the damage to America does not end. Consider, for the first time in medical history, a vacc1ne’s uselessness is being blamed on those individuals who have researched its dangers and decided not to take it. What new division will this mandate reap? Is this an opportunity for others to look down on the unvacc1nated as the present age’s lepers, the unclean, the undesirables; to sneer at people of aviation, of engineering, of medicine … of Science? These people are not zealots. They have learned to think, to question and possess the ability to use analytical views that will allow survival where those who are less cautious, might not. When – not if – that day comes, those who are being cursed, medical professionals, the military, public servants will not withhold help to anyone.

To our national shame, other targets have been under fire. The Border Patrol, who protect our sovereignty from those who would invade, are ridiculed, slandered with assaults on their character and integrity.

The military, Heroes, every single one, are threatened with a Dishonorable Discharge if they do not vacc1nate. The Navy SEALS have joined the fight against the vacc1ne, because it is so wrong.

First responders, e.g., police, fire department and emergency medical, threatened with losing their jobs and their benefits for refusing the vacc1ne and for doing their jobs. These professionals understand the dangers of the vacc1ne more than anyone, they are being fired for their knowledge and experience.

We must stand with our Military, Medical Professionals, Border Patrol, Law Enforcement, Fire Fighters and First Responders. What will we do without them? We must have their backs because they have ours.

What about the Chosen Ones the President excused from the vacc1ne?

  1. United States (US) Congress and the Legislative Branch
  2. US Congressional Staff
  3. US Judicial Branch
  4. White House Staff
  5. Centers for Disease Control (CDC) employees
  6. US Federal Drug Administration (FDA) employees
  7. US Postal Service employees
  8. National Institute of Allergies and Infectious Diseases (NIAID) employees
  9. Pfizer employees
  10. Moderna employees
  11. Illegal Aliens

This list makes no sense; the first four on the list are the centers of government. Are they not in danger from the CVD? Why excuse the CDC, FDA and NIAID employees? Vacc1ne manufacturers; are they afraid to take their own medicines? The Post Office? Their management and union look out for their employees, but they are in contact with the public more than anyone. This list does only one thing: it creates an emotional argument devoid of Facts and Logic; it divides Americans.

It is unclear where we are going … or why. Some fear government conspiracy, but what many don’t understand is that US government officials are too ignorant to plan this – on their own. Some fear the New World Order, Globalization. Some warn the Book of Revelations predicted this, while still others warn of power grabs by the Elite, who are more evasive and less and less tangible.

I believe what we are seeing resembles a quote from the movie, The Dark Knight: “Some men aren’t looking for anything logical, like money. They can’t be bought, bullied, reasoned or negotiated with. Some men just wanna watch the world burn.” It is the only explanation that makes the one kind of sense out of this, which is no sense at all.

Aircraft Accidents and Aviation Lessons Unlearned LIV: Southwest Airlines flight 812

Southwest Airlines flight 812, aircraft N632SW

On April 1, 2011, around 15:58 (3:58 PM) Mountain Standard Time, Southwest Airlines flight 812 (SWA812) experienced a rapid decompression during climb out at a flight level of 34,000 feet. The flight diverted to Yuma International Airport (NYL) in Yuma, Arizona. The aircraft, registration number N632SW, a Boeing 737-3H4 (-300 series), serial number (S/N) 27707, landed safely. The National Transportation Safety Board (NTSB) assigned the event accident number DCA11MA039; the Accident Brief – NOTE: not Report – AAB-13/02, was adopted on September 24, 2013.

The NTSB determined, “… the Probable Cause of this accident was the improper installation of the fuselage crown skin at the S-4L lap joint during the manufacturing process, which resulted in multiple site damage fatigue cracking and eventual failure of the lower skin panel.” The cause of the accident was attributed to a rapid decompression because fasteners and a skin panel at the crown were improperly installed by the manufacturer, resulting in cracking and eventual failure. The NTSB was correct in stating that a structural problem may have been built into the panel. However, clearly the blame for preventing the panel anomaly was Southwest’s inspection abilities and its maintenance program – specifically the structural inspection task cards – not a Boeing manufacturing error.

There were two problems with SWA812: For one, there were no fatalities. As indelicate (cynical?) as that sounds, nobody would notice an aviation event unless there were more horrifying consequences. This is human nature; after all, why be concerned if there was no threat of death. The NTSB decided an Aircraft Accident Brief (AAB) was adequate, not an Aircraft Accident Report (AAR); they did not feel that the SWA812 deserved anything more. This NTSB error led to the second problem, which was ignoring the fact this was not the first time this happened, albeit not on the scale of the previous event/accident.

On April 28, 1988, Aloha Airlines flight 243 (Aloha243), a Boeing 737-297 (-200 series), S/N 20209, suffered rapid decompression and a catastrophic structural failure of the crown from the forward bulkhead at Body station (BS) 360 to the manufacturer’s splice at BS 540, just forward of the wings; from the left-side floor to the right-side floor. S/N 20209, became infamous when the disfigured airliner’s pictures were splashed all over the media for weeks. Everybody knew. Aloha243 also suffered a fatality; a flight attendant was killed when the crown separated; she was pulled out of the aircraft and lost at sea near the Hawaiian Islands.

Why was the Aloha243 accident significant to the SWA812 event? NOTE: Serial numbers will be used as opposed to registration numbers, which can change when an aircraft is sold from operator to operator. First point: S/N 20209 was a 737-200 series; S/N 27707 was the next series, the -300 series, designed, approved and flying before Aloha243 occurred. Both aircraft were also Maintenance Steering Group (MSG) -2 certificated.

What made the dismissal of SWA812’s importance more egregious were the number of flight hours and flight cycles accumulated. A flight hour is measured from engine start to engine shut down or how many hours the aircraft is operated. A flight cycle measures how many flights an aircraft takes, from wheels off to wheels on the ground. An aircraft may fly five flight hours in one flight, but that is only considered one cycle. A cycle records how many times the aircraft is pressurized and depressurized, which places stresses on the aircraft skin and structural members, how often it expands and contracts. The Boeing 737 was originally designed as a short-range aircraft, resulting in a closer number of flight cycles to flight hours and that was an important issue that led to the Aloha243 accident.

At the time of its accident, S/N 20209 had 35,496 flight hours and 89,680 flight cycles for an average of 2.5 hours per flight; it had been operated in salt air conditions (Hawaii), which contributed to the accident. By contrast, S/N 27707 had 48,748 flight hours and 39,786 flight cycles, for an average of 1.2 hours per flight; it was owned exclusively by Southwest Airlines for fifteen years before the event. What both Aloha Airlines and Southwest Airlines experienced were failures in the maintenance inspection program; the NTSB caught this with Aloha243, but missed it completely with SWA812, twenty-three years later.

The NTSB website was referenced successfully for docket information, specifically the Maintenance investigation notes and ten attachments, including the NTSB Maintenance Group Chairman (MGC) Factual Report. A review of these documents confirmed that SWA812 was not a Structures accident, as the NTSB determined, but a Maintenance accident. The Structures Group could have been playing a supporting role in damage analysis, but this accident was not due to structural engineering and had less to do with manufacturer culpability. To record this event in a Brief demonstrated that the NTSB did not just miss the target, they missed the broad side of the barn the target was hanging on. It must be asked: Did the NTSB Board Members actually read the Accident Brief before adopting it?

AAB-13/02 used five of the Brief’s fifteen pages to elaborate on the structural testing accomplished on the failed panel, surrounding structure and fasteners; ‘good-to-know’ information that failed to address the accident’s Root Cause. This raised the question: At what point, e.g., flight hours, flight cycles, years, was an operator culpable for failing at its Inspection program? The Brief diverted attention from actual root cause to irrelevant issues. This made the industry less safe; nothing was learned.

Those five pages glorifying structural testing brings to mind one scene from the 1992 movie, My Cousin Vinny; the Prosecutor’s expert witness bragged about his tire testing equipment, “I have a dual-column gas chromatograph, Hewlett-Packard model 5710a with flame analyzing detectors.” In the scene, the illusion worked; the jury, unfamiliar with automotive jargon, were dazzled. However, the expert witness never answered the simple question: Did all the impressive testing information prove the case? No, it did not; it was a distraction … just like with the SWA812 Brief.

The NTSB has used distraction before. In the April 2013 National Air Cargo B747 accident where a military all-terrain vehicle (M-ATV) moved aft during takeoff, the NTSB’s Structures investigator’s report showed numerous color pictures of the M-ATV’s pallet, particularly the underside, where red paint scrapings scored the M-ATV’s pallet. Everybody knew the M-ATV pallet moved aft; the paint scrapes proved nothing. Worse, the investigator never answered the basic question: Why did the M-ATV pallet move aft? Ironically, Boeing answered in the report that the M-ATV pallet’s weight exceeded the floor’s structural strength. The pallet’s weight, exaggerated upon landing in Bagram Air Base, broke the floor; there was nothing to anchor the pallet in place; the pallet was free to slide aft. That was the answer: clear, simple, factual. The cargo floor failed on its previous landing – period! The M-ATV pallet slid aft when the aircraft rotated, nose up. Paint scrape pictures were irrelevant.

Just like National Air Cargo, the SWA812 Brief needed common sense and attention to analysis, not worthless technical jargon. The report should have focused on Maintenance and Inspection. The MGC did come close to Southwest’s Inspection problems in his Factual Report, but either his data was dismissed, or he did not understand it. In AAB-13/02, page five, was this throw-away statement, “… the Southwest Airlines maintenance records for the accident airplane were examined and contained no evidence of any major repairs or alterations performed on the accident crown skin or side skin panels.” Major Repairs? Alterations? That’s it? What about Inspections? Was the Inspection schedule given more than a hurried glance? The MGC identified himself as an Aerospace Engineer, which meant he possessed ZERO skills in various inspection techniques and how to follow the dictates of an Inspection program. The MGC did identify inspections conducted on S/N 27707 over fifteen years. On pages four through seven of the MGC’s 18-page Factual Report, the MGC referred to Southwest Airline’s Maintenance Inspection Program, recorded its heavy structural inspection intervals and dates they were accomplished, but the SWA812 Inspector-in-Charge failed to include any of this information in the Accident Brief.

Per AAB-13/02, “The fracture extended between BS 666 and BS 725 and through the lower row of rivets of the lap joint, intersecting 58 consecutive rivet holes at approximately 1-inch intervals.” The crown section, per Figure 3, was between BS 360 and BS 908; the left and right limits were between Stringer 14-Left over the top to Stringer 14-Right. As per the MGC’s Factual, this area had received several general visual inspections, which were limited by paint and primer not being removed.

The Southwest maintenance program for the B737-300 series required heavy inspection checks during S/N 27707’s lifetime leading up to the event. The original Maintenance program had upgraded from MSG-2 to MSG-3 in 2004, so the Maintenance program was improved for this model B737. The MGC’s Factual showed S/N 27707 had undergone several ‘C’ Check phase inspections and ten ‘Y’ inspections since 2004. During this time, there were more involved inspections marked ‘INSP’; the MGC did not document how detailed the INSP inspections were nor how much access to the failed panel area was exposed. This was crucial information to understanding the integrity of the Southwest Structural Inspection Program. Why did the NTSB not know about inspections or why dismiss this information?

It was relevant to these points that S/N 27707 underwent a Non-Destructive Inspection (NDI), most likely Eddy Current. The NDI was performed at the location of the failed skin panel on February 2, 2011, fifty-eight days prior to the SWA812 inflight event. The MGC did not specify what type of NDT was used nor did he investigate the NDT’s findings, which is why AEROSPACE … ENGINEERS … SHOULD … NOT … BE … LOOKING … AT … MAINTENANCE … ISSUES!

The ongoing foolishness, where unqualified NTSB engineers keep missing maintenance issues has been documented in almost every maintenance-related NTSB accident report reviewed on this website. The NTSB continuously avoids employing industry-experienced airframe and powerplant FAA-certificated technicians as Lead Maintenance Investigators; this guarantees that major investigation mistakes will persist and maintenance issues will not be corrected.

The whole purpose of an aircraft accident investigation, no matter how involved, is improved aviation safety; the industry benefits, lives are preserved. When I was the sole NTSB Maintenance Major Accident investigator, I would talk frequently with the Federal Aviation Administration (FAA) investigators I worked with. If the NTSB dragged their feet on maintenance issues, the FAA investigators would raise the issue(s) to FAA’s upper management – safety was improved. Former Member John Goglia, the only mechanic Board Member, was often frustrated by the NTSB’s inaction on maintenance issues; he would walk across the street and speak with FAA management himself – safety was improved. Industry knows investigations are error-filled; they also take the initiative. Boeing would have addressed National Air Cargo’s floor collapse to guarantee it did not repeat – safety was improved. Southwest and its FAA certificate office would have corrected the B737-300 inspection program – safety was improved.

It would be small consolation if the SWA812 Brief’s Probable Cause was close, but it was not. It could be argued that the structures investigator was right about the metal analysis; that might be true. The truth is, in accident investigation, there is a large difference between “being right” and “getting it right”; Accident Brief AAB-13/02 for SWA812 was neither.  

SWA812 faded from a lack of attention; no one saw it as a big problem; no one analyzed Root Cause; no one related it to Aloha243; no one at the NTSB felt – still feels – that Maintenance issues deserve the careful attention they deserve. In thirty-four years of existence – minus the time John Goglia and I were there – the NTSB still ignores the fact that over half the FAA workforce deals strictly with Maintenance; it is that important. Until the NTSB hires qualified mechanics, my Aviation Lessons Unlearned website will – unfortunately – have plenty of monthly accident reviews.