Aircraft Accidents and a Trip to ‘The Hill’

On November 10, 2021, the Miami Herald published an article from the Seattle Times ’s Dominic Gates titled: FAA says Boeing is Appointing People Lacking Expertise to Oversee Airplane Certification. It was strange that Mr. Gates wrote a Hit Piece on one of Seattle’s largest employers. As one reads, it remains unclear what experience Mister Gates has with Federal Aviation Administration (FAA) matters. The article’s picture showed a contrite FAA Assistant Administrator outing Boeing to Congress, saying Boeing built aircraft employing inexperienced engineers to oversee certifications. Yet, it was the FAA management’s actions and not Boeing’s, that stood out in the Hearing and the article. What was discussed caused great harm to FAA management’s reputation, raising serious questions about what FAA management has been doing – or not doing – these last two years. Mr. Gates should take note of that.

Was the FAA Assistant Administrator’s trip to ‘the Hill’ voluntary or was he called on to answer questions? The article was not clear. The article opened: “The Federal Aviation Administration this summer found Boeing had appointed engineers to oversee airplane certification work on behalf of the agency who lack the required technical expertise and often ‘are not meeting FAA expectations.’” This suggests the Congressional Committee heard from aviation professionals that the FAA had lost control of Boeing and their certification processes, that FAA management gave Boeing too much freedom in policing themselves. After all, whose job was it to vet these engineers? Mr. Gates heard Boeing …  Boeing … Boeing, but aviation industry professionals heard FAA … FAA … FAA. Safety integrity was at risk and FAA management needed to explain why.

Is this interpretation a stretch? Consider that a week later, on November 19, 2021, a Reuters article was published in US News: U.S. House Panel Seeks Review of FAA Oversight of Boeing 787? Reuters said that the FAA’s oversight – not Boeing’s – will be scrutinized by Congress’s US House Transportation and Infrastructure Committee, likely an Inspector General (IG) investigation. It was not chance that an IG investigation closely followed the FAA Assistant Administrator’s testimony.

In April 2008, FAA Assistant Administrator Nicholas Sabatini testified on ‘the Hill’, answering questions about Southwest Airlines. The FAA’s approach to their ‘customers’ – aka certificate holders – came into question. The IG felt the line had greyed between overseer and the overseen, which led to unsafe practices. Ironically, for years prior Mr. Sabatini had diligently spearheaded the most effective overhaul of the FAA’s greatest problem: Standardization. The FAA had become International Organization for Standardization 9001 – ISO-9001 – qualified. Mr. Sabatini’s management team had been proactively uniting all FAA offices across the globe with scheduled internal audits that guaranteed standardized certificate holder oversight with new safety programs. It worked great until January 2020 when the audit program fell victim to COVID shutdown overkill; FAA inspectors were forbidden to perform internal audits and certificate holder surveillances that were required.

It was during the FAA’s COVID shutdowns that Boeing allegedly employed inexperienced engineers for certificating aircraft, apparently without the FAA noticing. Would the overlong COVID shutdown prevent FAA inspectors from seeing? Would FAA upper management consider what benching FAA inspectors might lead to; what would happen when the shutdown extended into two years? Certificate Holders, like Boeing, went from being the Cause to being the Effect.

Meanwhile, the media continued to cry Boeing … Boeing … Boeing because they could not understand. A moot Bloomberg Business Week article claimed: Boeing Built an Unsafe Plane and Blamed the Pilots When It Crashed. How irresponsible. No facts supported that headline. It was strictly opinion built on accident reports that applied no effort to get to the root causes; no focused investigation into maintenance and inspection to base the reports’ findings on. The Komite Nasional Keselamatan Transportasi 18.10.35.04 accident report (Lion Air 610) and the Aircraft Accident Bureau of Ethiopia AI-01/19 accident report (Ethiopian Airlines 302), each had maintenance-finding holes large enough to drive an A380 through. Each showed what inexperienced investigators brought to investigations. Meanwhile, uninformed reporting damaged reputations.

Mr. Gates’s article continued: “The need for those recent appointments arose because during the downturn from the pandemic Boeing offered early retirement to many more senior FAA-authorized safety engineers.” Did Boeing’s qualified engineers just decide to leave? Unlikely that a company, around since 1916, would so carelessly deplete their engineer ranks; it made no sense. Was there another reason the qualified engineers suddenly felt the urgent need to leave in large numbers? But no one said anything about large numbers. Or did they?

No one cares what side of the vaccine mandate (VM) conversation anyone falls on. However, all actions – including the enforcement of the VM – have consequences. That is a fact. The VM fallout has yet to be realized. Why would there be a fallout? Because experienced professionals, who remained suspicious of the vaccines’ safety, would rather quit or retire than surrender to the VM. Mr. Gates’s article never stipulated that the VM pushed people to leave. But consider what an FAA representative said in the article, “… that in one [Boeing] certification specialty, more than 20 such Boeing engineers left in a single month.” 20 certification engineers left – in one specialty – in a single month. That is a large number. Are professionals leaving their jobs over their principles?

Per Mr. Gates, when asked about the VM’s effect on the FAA, The FAA Assistant Administrator said the FAA was focused directly on VM compliance. Why? VM compliance is not the FAA’s mission – Safety is. What does the VM have to do with aviation safety or overseeing certificate holders? “I do not expect to lose a significant portion of our workforce,” he said, “We have robust contingency plans in place.”Contingency plans for what? What is a “significant portion of the FAA workforce”? Are skilled inspectors leaving? How are they distributed by specialty? Will any offices lose high percentages of airworthiness or operations inspectors? How much lost skill and knowledge would FAA management consider ‘irreplaceable’? Do they even know? “At this point in time, I’m not seeing any impact on safety …” This Boeing “impact on safety” happened with the FAA at full capacity. FAA management drove its inspectors to comply with the VM, but not to conduct aviation safety on-site surveillance. That is an impact on safety.

Why would the media think Boeing is alone in this? What about other aircraft manufacturers of the fixed-wing and rotary varieties? If other manufacturers were like Boeing, how many would hire the inexperienced to save money? What about government contractors that provide military equipment or airlines with more than 100 employees providing Civil Reserve Air Fleet support; are their people leaving because of the vaccine? Is this a prelude to a mass exodus? With thousands of experienced professionals separating, how long before manufacturers and air carriers return to quality?

The FAA found the deficiencies at Boeing during visits in July and August when it interviewed some of the new appointees. Since then, the FAA has introduced new procedures to address the problem.” July and August were over three months ago. Committee members were assured that since the B737-MAX accidents, the FAA had Boeing “… under intense scrutiny.” Those two accidents happened over two years ago, in 2019. If FAA management just found out about Boeing’s inexperienced engineers three months ago and FAA inspectors’ movements have been restricted for two years, how intense would this scrutiny have been?

According to the article, “New rules are scheduled to take effect before year end that will require every proposed appointee to be interviewed by the FAA and then either approved or rejected by the agency.” From July and August, that would be four to five months just to get the rules enacted – not enforced.

Where is the US Secretary of the Department of Transportation (SDOT), the cabinet member responsible for the FAA and all five transportation disciplines? SDOT took two to three-months of Paternity Leave, and no one even realized he was gone. Question: How crucial is one’s job if no one knows you are missing? Allegedly, he is trying to resolve a major nationwide supply chain breakdown and striving to redo Racist Roadways, whatever they are. Tweeting about the 1.5-trillion-dollar Infrastructure Law, SDOT said, “People who care about transportation have been waiting a long time for this day, and @USDOT is ready to get to work.” Are any “people who care about transportation” more worried about mythical Racist Roadways than whether airplanes are not properly certified and/or aviation safety is improved? It is good to hear SDOT “is [now] ready to get to work”. What has he been doing all this time?

The last two years did not reflect the dedication to safety that FAA inspectors and safety advocates possess. Unfortunately, the travelling public – even our elected officials – do not see the real dedicated safety specialists on the front lines. Instead, they are treated to officials who point to someone else’s mistakes while defending poor choices. We are headed for hard times in aviation, starting with needed IG investigations from ‘the Hill’. The B737-MAX is back in the headlines; the B777-X is now under suspicion; the B787 is now on the IG’s radar. This is just the beginning. A hands off/eyes off approach to safety is going to be the IG’s focus. Government officials may yet learn what the travelling public thinks about shutting down safety oversights for what could amount to … absolutely no reason at all.

Aircraft Accidents and Lessons Unlearned LV: Loganair flight 670A

Loganair Flight 670A post crash

On February 27, 2001, a Loganair Ltd. Shorts Brothers SD3-60 Variant 100, registration number G-BNMT, flight 670A, crashed near Birnie Rocks, Scotland, shortly after taking off from Edinburgh Airport. The aircraft, which had two Pratt and Whitney PT6A-67R turboprop engines, impacted the waters in the Firth of Forth at a 6.8˚ attitude in six meters of water.

The investigation found, “… following a selection by the crew of the anti-icing systems on the aircraft, specifically the selection of the intake anti-ice vanes, the subsequent movement of the vanes precipitated the near simultaneous engine flameouts. Interaction between the moving vanes and the residual ice, snow or slush contamination in both intake systems is considered to be the most likely cause of the engine failures.” The investigators felt that “A significant amount of snow almost certainly entered into the engine air intakes as a result of the aircraft being parked heading directly into strong surface winds during conditions of light to moderate snowfall overnight.”

Although there were six Causal Factors identified, these factors never verified Root Cause; indeed, the investigators did not even come close to determining Probable Cause using their own words. Though there stands the chance that the causal factors, as identified, led to the accident, the list of causal factors are plagued with terms, like “A significant amount of snow ALMOST CERTAINLY [capitalization added] entered …”; The flow characteristics of the engine intake system MOST PROBABLY allowed …” and “At some stage, PROBABLY AFTER engine ground running … slush ALMOST CERTAINLY migrated …” This type of analysis did/does not generate confidence in the accident report’s quality. In keeping with the effort made during this investigation, the investigators MOST CERTAINLY missed some important information and PROBABLY did not put effort into investigating the accident beyond the only questionable theory pursued, demonstrative of a languorous attempt at the fact-finding.

What was missing from the report was any effort to determine cause. Considering the aircraft and both engines were recovered in a reasonably unmolested condition – meaning no post-accident damage was encountered – the post-accident investigation and inspections of the engines alleged to have been subjected to, “… the near simultaneous engine flameouts,” any analysis quality was non-existent. The report notes found under 1.12.2.1 Powerplant did not describe any internal engine damage that led to the simultaneous flameouts; the report was absent of any information about the intake stages’ condition, even though both engines were on-site. Instead, the report delivered useless information about the crash site terrain and water temperature (at the crash site), all of which had nothing to do with the accident.

There are two reasons to look again at this flight. First, associating icing of any kind and maintenance. The second reason is, though not seen many times in more technologically advanced airplanes, aircraft like the Shorts SD3-60 are out there and we ignore them at our own peril. What the report failed to focus on, though aviation accident knowledge demanded it, were alternative possibilities of accident cause.

The British investigatory authorities, the Air Accidents Investigation Branch (AAIB) assigned four people to the investigation: the Investigator-in-Charge (IIC), an Operations investigator, an Engineering investigator and a Flight Recorders expert. It is unclear what expertise the Engineering Investigator had in both Maintenance and Engineering and, if the Engineering Investigator was an Engineer, what was his/her specialty: Systems, Powerplants, Structures or, even on the slight chance, Maintenance? This is a valid question because when reviewing accident reports, such as the Lion Air and Ethiopian Airlines B737-MAX accidents, Mechanics are called Engineers in certain countries. Either way, the Engineering Investigator failed to show any expertise in either area.

Before other possible causes are examined, it is important to understand how the aircraft lost control during the last minutes of flight, what obstacles the flight crew faced, even with a double flameout, which might have been survivable. Normally for ground operations, such as towing, many aircraft are equipped with an alternate means of hydraulic power that would not make use of the engine-driven hydraulic pumps; whether the ground hydraulic pumps are electric or reversible, they are controllable from inside the cockpit, though, they may require AC power. The accident aircraft lost power in both engines during take-off, a critical phase of flight where things tend to go wrong in spectacular ways.

The first problem was electrical; if the engine driven generators went offline together, power to ground hydraulic pumps was lost. It was unclear if the Shorts SD3-60 had a ram air turbine or air driven generator to power the pumps. Although the crew transmitted a MAYDAY, the radio could have been powered by the battery.

The Shorts SD3-60 had climbed out of Edinburgh; per the report, flaps and landing gear were retracted. Even so, these two items, with the activation of primary flight controls, are regular taps to the hydraulic pressure and quantity reserves. When the engines quit, hydraulic pumps were lost, hydraulic pressure would drop quickly, even depleting any hydraulic accumulators that may have been there to assist.

The lower an aircraft is to ground when trouble starts, the less likely successful emergency maneuvers can take place, especially with no hydraulic reserves. Starting descent from 2200 feet, the flight crew soon found room for wingtips and empennages decreased. An aircraft’s exaggerated glide ratio never achieves the advertised numbers based on conditions, especially during climb. Descent rate was sacrificed to gravity, drag, weight and balance. The loss of hydraulic power would result in a reduction in primary control authority; any tab-driven flight controls would also be difficult to ‘fly’ due to lower airspeeds at climb as opposed to cruise. This explains how quickly the flight crew could lose control of the aircraft.

The reason given above for giving this accident flight a second, more thorough, look was “associating icing of any kind and maintenance.” The Shorts SD3-60 was equipped with two Pratt and Whitney PT6A-67R turboprop engines; these engines operated on Jet-A – Jet Fuel – which has a lower density than water; anything will ‘float’ on water as long as its density is lower than that of water. The density of jet fuel is around 0.81 kg/L while that of pure water is 1.0 kg/L. Thus, jet fuel rises in water – it floats.

The Shorts SD3-60 employs a high wing with fuel tanks. Per the report, 1.6.3.4 Fuel System, “Each tank group [of which there are four] gravity feeds, via non return valves, a filter and a negative ‘g’ valve, into its own small, dedicated collector tank. Each of these two collectors incorporates its own boost pump …” To be clear, the jet fuel is gravity fed to the boost pump – not from the boost pump – before getting to the engine. The report stated that the aircraft was fueled the previous night, fifteen hours before actual flight. The aircraft sat longer than four hours, which is the average time it takes for jet fuel suspended in water, to separate into water on the bottom of the tank and jet fuel on the top; any agitation caused by the fuel pump was after the gravity feed piping.

The temperature on the field at midnight was +1˚ Centigrade and continued to drop … overnight. When landing, the aircraft passed through an ice layer, supercooling the wing … at night. The accident aircraft then sat with moderate snowfall covering the wing surface … overnight.

The wing was below freezing; any chance of the wing warming above freezing was frustrated by snow covering the wing, which blocked sunlight. A more probable cause of the accident was that the aircraft crashed because the engines were simultaneously starved of fuel due to fuel tank icing that would have fouled the gravity feed tubes, the filters or both.

Any opportunity to check the wings for water were disregarded by investigators, even though both wings were intact. The investigators also ignored the fuel station that provided the accident aircraft with fuel to check fuel integrity. Was the fuel farm supply contaminated with water? Could other aircraft have been affected by contaminated fuel? These questions will never be answered. More importantly was the wasted opportunity to generate useful and effective recommendations, such as introducing a simple fuel draining measure, called ‘Sumping’, into the Maintenance program for Loganair and other operators. A sumping program that required daily or weekly draining of fuel samples from the wings could have discovered high levels of water, if found, in the fuel tanks. That was where a Maintenance specialist would have added to the accident investigation to make the report a quality report.

As earlier stated, the second reason is, though not seen many times in more technologically advanced airplanes, aircraft like the Shorts SD3-60 are out there and we ignore them at our own peril. The solution to the fuel icing problem was one that plagues most technologically advanced aircraft as well as the older analog models and helicopters. The missed opportunity demonstrated in this report showed that it is still important to get the accident investigation right; to find out root cause and determine solutions – no matter how inconvenient it is.