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 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. 

Aircraft Accidents and 2020

A scene from the 1951 MGM movie Quo Vadis

The beauty of reading: an ability to immerse oneself in the pages of classic literature. Arrogance makes us assume that novels from the 1800s and earlier are not applicable to today, but that … is incorrect. Ralph Waldo Emerson wrote, “Fiction reveals truths that reality obscures;” Henryk Sienkiewicz’s book, Quo Vadis (1896) is just such fiction, set against Emperor Nero’s reign. ‘Quo Vadis’ is Latin for ‘Where are you going?’; Saint Peter asks this in a vision. The back story has Nero authorizing Rome’s burning in 64 AD. Faced with a furious citizenry, Nero used propaganda and influence to blame the fire on the Christians, a defenseless religious people. Soon, hundreds of innocent Christian men, women and children were slaughtered in the most brutal ways. Quo Vadis is a timeless tale that demonstrated how false narratives destroyed civilizations, just like today, in the year 2020.

In March 2019, the Boeing B737-MAX was grounded after two high-profile air disasters: Lion Air 610 and Ethiopian Air 302. In what could only be described as an international kangaroo court, Boeing was dragged into the media’s hysteria and subjected to inept opinions – lean on knowledge, fat on ignorance. The MAX was exposed to inept analysis from investigators with no access to – let alone knowledge of – Boeing’s designs. Finally, the maladroit conclusions of the Ethiopian and Indonesian accident investigators, proved prejudicial and unqualified. Did anyone read reports KNKT. and AI-01/19? Did anyone understand the mistakes that could not be concealed?

How biased: government-run airlines investigated by government employees. Aside from the fact these government employees were not discerning about the latest technologies, governments are opposed to finding blame in themselves and less likely to admit blame when confronted. Ethiopian and Indonesian government investigators were woefully unqualified to analyze the Boeing’s latest designs of digital-based turbine engine aircraft. In addition, the investigators were engineers, ones who did NOT … could NOT … understand what they were looking at.

What was myopic was that engineers do not play active roles in aircraft maintenance, airline operations or take part in day-to-day airline activities. How many pilots on delay tell Operations to send out an engineer? How many mechanics rely on engineers to troubleshoot everyday system problems? Adding insult to injury, these accident investigators/engineers were bureaucrats who shifted blame from their airlines’ deficient training and antiquated culture practices, i.e., from themselves … to Boeing.

Then it got worse. In stepped the media and their non-aviation news ‘experts’, who amassed confusion and stoked public fear. Armed with hearsay, the media discredited Boeing and set the industry back twenty months before the Federal Aviation Administration rescinded the 737-MAX’s grounding order on November 18, 2020. By then Boeing’s reputation took a crippling hit in public trust; they lost billions in redesigns. Who did this was irrelevant; What they did was imperative, followed closely by Why.

How did industry ‘fix’ the MAX? Did they turn to mechanics experienced with digital aircraft technology or pilots with thousands of flight hours in digital aircraft? No, industry trusted the very work group that designed the ‘problems’ into the MAX: the engineers.

It was evident from both reports (and to those paying attention) that the investigating engineers, the media and the ‘experts’ did not understand the technology.

The inexperienced accident investigators, reporters and aviation ‘experts’, those who could not explain the B737-MAX’s technology to themselves, lacked the ability to explain the technology to others. And yet, these people seized control of the conversation and drove the narrative. Why were we so quick to accept the incompetent media’s word, let them steer us to the cliff’s edge and over?

The destructive mainstream media strategies of, e.g., CNN, Fox News, MSNBC and other major news channels and publications, can so easily destroy reputations that take decades to rebuild. Have any of these reporters ever turned a wrench; landed in zero visibility; taught up-and-coming aviation people? Did they play us – all of us – as fools?

The year 2020 marched on, and suddenly we had run out of pocket change; stores across the nation could not even break a one-dollar bill. Had the United States Mint run out of cupronickel or was someone trying to force us to pay with credit cards or debit cards? How curious.

The COVID-19 tally of those infected had risen. However, the COVID death toll had flattened. Because of available testing we were now receiving accurate numbers of those who contracted COVID … and lived … or had been unwittingly living for months as COVID-positive. Why, then, are we still wearing masks; avoiding restaurants; listening to politicians about COVID safety? Are we no longer concerned about the 2020-21 strain of the annual flu or does the annual flu season not happen anymore?  

Cynical tactics were never more evident than with the November 3rd election night. It does not matter who each of us voted for president: President Trump, Senator Kamala Harris or Mickey Mouse. Who we voted for was irrelevant; What we voted for was imperative, followed closely by Why.

What transpired on election night should scare the living hell out of every American citizen. We can no longer trust that a two hundred-year old, reliable voting system is still used. Even if we believe – or do not believe – fraud occurred, the question of fraud was raised with convincing evidence. That demanded that a serious investigation be run.

Late night comedians assured us that the election was legit; Daytime talk show hosts laughed at the suggestion of any fraud. Their years of questionable political superiority aside, the concept of fraud should have even made them shudder; indeed, they did not know the difference between criminal lawsuits and civil lawsuits, when searching for the truth. As these personalities focused on the distraction instead of the election, celebrities, e.g., singers, movie stars and other entertainers, assured us with their trustworthiness, that all was well, that we needed to move on. Any one of these people who balked at the possibility of fraud with disdain and sarcasm was not looking out for the People.

Meanwhile, the media seemed unusually quiet; they stood with hands in pockets, staring at the floor while shuffling their feet, intent to ignore all that was going on. On November 10th, the New York Times said, “Voting fraud is extremely rare.” Extremely rare?! Just how rare is ‘rare’? How extreme is ‘extremely’? Why would fraud be allowed at all, even when extremely rarely?

A week after the election, the Michigan Secretary of State’s spokesperson stated emphatically that “We have not seen any evidence of fraud or foul play …” Can his analysis be believed? Where is his proof? Another politician said, “… it would be nearly impossible to do voter fraud.” Nearly impossible is not a denial; it is a distraction. Perhaps these politicians did not understand the technology. Or, perhaps, they did. Perhaps they knew how easily the technology could be corrupted to sway the election.

Who promised to fix the ‘broken’ election system? The very group that broke the system: Politicians, whose agenda-driven power brokers divided this nation along racial, gender, demographic and income lines, were now going to save us. Government bureaucrats would, again, ‘fix’ the mess they made.

Then there were corporate executive officers, like Mark Zuckerberg (Facebook) or Jack Dorsey (Twitter), who manipulated social media to allow only the news they wanted us to hear. Two men, who made their billions without discipline, who somehow tripped and fell face first into billionaire status, provoked the political outcome of their choosing and played their customers in the process.

Other bad actors played more damaging strategies. They demonized Police Officers, called them ‘racists’, despite minority police officers in, e.g., New York City, making up 57% of the police force. Domestic terrorists burned our cities, looted businesses and unashamedly annihilated our way of life. While these terrorists launched unprovoked attacks on innocents, Hollywood and sports figures bailed them out, lifted them up and supported their rampages. This action was allowed, encouraged and applauded.

The media and politicians have desensitized us. We shrug off the assaults and victimizations of Mexican children smuggled across the borders by Coyotes. The shocking drive-by gang-related shootings of adolescent children attending birthday parties or barbeques became lost amid calls for defunding the police. We ignored at what point a life is valued. Our immunity to all that is shocking … is shocking. Have we become so apathetic? Does our nation’s upheaval not interest us anymore?

As in the novel, we should all be asked, “Quo Vadis;” “Where are you going?”. As the story played out, corruption and fraud turned an entire civilization against itself, led the average Roman citizen to betray his or her neighbor for power. How different are we? It is becoming a crime to want the same successful principles our earlier generations lived and died to defend. The year 2020 may have shown us – hopefully, not too late – that we are in danger of a decline of our decency and morality towards one another. So, should we ask ourselves, “Populus autem Americae, Ubi Sumus Iens?”

Translation: “People of America, where are we going?”

Aircraft Accidents and Lessons Unlearned XLIV: Korean Air Cargo 6316

Korean Air Lines MD-11

On April 15, 1999, Korean Air Cargo flight 6316 (KAL6316) crashed shortly after take-off from Shanghai Hongqiao International Airport (SHA). The McDonnell-Douglas MD-11 aircraft was operated as a scheduled international cargo flight between Shanghai and Seoul, Korea. The aircraft was airworthy; the flight crew was qualified and trained. This should have been an uneventful routine flight.

The accident report, 99-091-0, was accomplished as an investigation per the International Civil Aviation Organization (ICAO) Annex 13 provisions by the Civil Aviation Administration [the People’s Republic] of China (CAAC). Participating with technical support were the Korean Civil Aviation Bureau (KCAB), the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), Boeing (who had purchased McDonnell-Douglas at the time), Pratt and Whitney Engines and Korean Air. The report shows that the NTSB was tasked with reading out the flight data recorder (FDR) and the cockpit voice recorder (CVR).

There were three people on the cargo aircraft during the accident flight. The Captain had a total of 4,856 flight hours in the MD-11. The First Officer (FO) had 1,152 flight hours in the right seat of the MD-11. Both pilots had recently undergone training and were qualified to fly the MD-11. The third person was a technician (mechanic), flying with the aircraft; he had twenty years with Korean Air working their trunk aircraft, including the MD-11. The technician was not heard on the CVR; mechanics are not known to fly in the cockpit, even on cargo flights, so any input he might have provided was absent.

The CAAC made efforts to remove all other possible contributors to the accident: weather, navigation aids, communication, air traffic control, recent maintenance, long-term maintenance, aircraft airworthiness, fuel distribution, fuel contamination, weight and balance. All these possible contributors were eliminated, one-by-one, as unlikely causes. The CAAC report was thorough in this process; as the Arthur Conan Doyle quote stated, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” What remained was most improbable: two qualified pilots, who got so behind events, that they unintentionally crashed the aircraft.

Per page 10 of the report, the aircraft impacted the ground at a twenty to forty-degree, nose down attitude, wings level. All primary instruments on the MD-11 are digital; the ‘gauges’ are video displays that are fed data from the Flight Director, Air Data Computer, etc. Any FDR data captured during the accident flight was lost in the post-crash fire. The only analog instrumentation – the sole ‘snapshot’ recovered – were the standby gauges; the standby altitude/airspeed indicator was locked at 398 knots at time of impact.

All flight control components had been meticulously examined for proper condition and to determine no sabotage had occurred. The engines had no issues during flight. The aircraft was properly balanced; it had achieved an altitude of 1370 meters (4500 feet) during the 2-1/2 minute flight; the crew did not talk about control issues caused by being tail or nose heavy; there was no evidence of a stall. No mechanical or technical issues were discovered. By all evidence, the aircraft was in an airworthy condition. On page 48, the report stated, “The above mentioned evidences indicate that the accident airplane’s sudden dive was at the wish of the crew rather than other causes.” A most improbable truth.

On page 9, the report stated that the only usable recording device was the CVR; “… no useful information could be retrieved from the recovered portions of tapes of the FDR …”. The Korean to English translations of the CVR recordings were choppy; conversation, terms and sentence structure did not convert smoothly from the Korean pilots’ native language to English. Even so, the conversations were mostly recognizable, yet the tell-tale urgency and other voice inflections were missing, leaving the reader to guess at what the pilots were reacting to, indeed talking about. This is unfortunate; reactions, such as excitement, doubt, rises in pitch or volume would have been more telling. Another unfortunate fact was that the mechanic was not in the cockpit; the pilots [appeared to be] worried about instrument readings.

The report was correct in highlighting that the Captain did not conduct a pre-takeoff brief; the pilots did not run through the departure, including expected turn points or emergency plans. As it happened, this flight had unforeseen events that contributed to an increasing state of confusion. The report also stated that the root cause of the accident was confusion about altitudes; the air traffic controller relayed altitude in meters while the FO stated to the Captain altitude in feet – 1500 meters versus 1500 feet. This was unquestionably another contributor to the flight crew’s inflight confusion. However, there was more going on during the flight than questions about altitude.

At 16:03:06 (4:03;06 PM), the crew initiates a left turn, but the FO was confused about when to complete the turn. At 16:03:37, the Captain stated, “It might turn upside down. What’s wrong with this?” At 16:03:54, the FO said, “Slat, why doesn’t it work? Slat, slat up.” Finally, at 16:04:05, the Captain said, “Well, what’s wrong with this airplane today?” All three statements occur within one minute; the first is stated at one minute into flight and the last stated thirty seconds before impact. Through this, there were no communications with air traffic to report problems.

The flight crew never elaborated on what they were seeing. For example, was the ‘slat problem’ that the slats would not retract or was it an indication problem? What ‘might turn upside down’? What was the Captain seeing that he asked, “…what’s wrong with this airplane today?”

Even before takeoff and the ensuing confusion, the FO got meters-to-feet wrong. During engine start, with the towbar still attached, the Tower says to go to nine hundred meters; the FO tells the Captain nine hundred feet. This was not due to heavy workload; the pilots were loading data into the computer and they were entering the wrong information. Just like the later confusion of altitude, the Captain did not challenge the FO or tell him to confirm the numbers. Cockpit resource management (CRM) appeared to be non-existent; no challenges, no questioning and a lot of guessing took place.

On November 22, 1968, Japan Air Lines flight 2 ditched in shallow water in San Francisco Bay, two and a half miles short of the runway in heavy fog. The DC-8 landing was determined to be the result of poor flight crew communication during an Instrument Landing. The FO and Second Officer did not question the Captain, a result of cultural issues within the cockpit; the Captain would not … could not … be questioned. There was no CRM; it did not exist. In 1999, CRM should have been standard practice.

The FO on KAL6316 did not insist on a pre-takeoff briefing even though it was required by Korean Airlines procedures. The FO confused meters with feet of altitude, possibly giving the Captain the wrong altitude to enter into the Flight Management System. The FO became confused again, this time with the air traffic clearance before entering the information into the Flight Control Panel. Just like with the pre-takeoff brief, there was no challenge, no verification. Instead the pilots just changed settings without confirmation.

The CAAC was correct in its Probable Cause, but they did not go far enough. It was culture that brought down this aircraft. Complacency did not bring about the failure to perform a pre-takeoff briefing; culture made the briefing unimportant. This was evident because neither pilot pushed for the briefing; neither one questioned the briefing’s absence; neither one seemed to care. Every subsequent problem hinged on the briefing and the briefing hinged on a culture that demanded it be done.

Recommendation 4.2 spoke to the briefing, requiring pilots conduct them. This recommendation was good, even though briefings had been required for decades. Briefings should not have had to be recommended because this aircraft should not have crashed. Recommendation 4.6 was also good, requiring air traffic to speak to one measurement, metric or standard – not both.

The CAAC did a great job with this report; they hit every mark on the investigation. All investigatory bodies still need to accept the existence of culture as a root cause and study culture’s effects on safety. Until they do, culture will continue to elude the most efficient reports, thus eluding being addressed and fixed.

The Aroma of Deference

Captain Mario Jiminez flying the Intruder

ZERO dark thirty, Tongduchon Valley South Korea – minutes to target. Speed 420 knots, altitude 300 feet. A single carrier-based A6E Grumman Intruder points North surgically utilizing its terrain-following radar while threading rain-soaked valleys, fogged filled mountainous passes and low visibility scenarios on approach to the worlds’ most heavily defended border – the infamous 38th parallel. Aboard are 12 Mk-82 500 lbs. bombs. This is serious business; surface-to-air North Korean radars are active as real-world threats and imminent physical dangers. Massive geo-political turmoil awaits any navigational, procedural or performance errors. It’s been thundering since the beginning of the hi-speed/low altitude “live-fire” training mission (theoretically perfect weather for these aircrafts’ mission profile of low -level, interdiction), yet the closer the target (USAF Nightmare bombing complex) looms, the worse the weather becomes. Now continuous lightning bolts clearly illuminate the silhouette of the jet and its two aircrew. One of them has started to sweat. In the left seat is a young Naval Aviator, a relatively inexperienced, 26-year old who as the pilot and the only manipulator of the flight controls is operationally responsible for the overall safety of flight. In the right seat as the Bombardier-Navigator is the well-seasoned senior officer and Vietnam war hero. One prefers to terminate the flight in the interest of safety, adherence to existing rules and compliance with standard operating procedures. The other crew member through body language, grunts, hand signals and time-consuming silent deferrals intends to “press on and get the mission done”. It becomes obvious that a covert difference of opinion permeates the cockpit infusing in its wake the unmistakable aroma of deference.

Deference is the condition of submitting to the espoused, legitimate influence of one’s superior or superiors. It is a yielding or submitting to the judgment of a recognized superior, out of respect or reverence. Deference has been studied extensively by political scientists, sociologists, and psychologists. Yet, most cogent to our field of aviation this definition harvests a myriad of obscured cobwebs, mouse traps, and decision-altering hand grenades.

Ground zero for detonation is based on simple differences in expectation – “Is what I expect to happen what’s really going on – are we on the same page”? At specific critical moments in time and space, any misunderstandings, assumptions, incapacities or neglect will quickly, easily and forcibly impale chards of failure and loss. While these landmines can be potentially embedded in every flight we take, the mere fact that our judgments can be altered by an outside source (someone who either covertly or with brazen gusto applies undue pressure by enforcing early time constraints and task saturations) can easily deliver significant deviations from standard operating policies and procedures. Additionally, it sets a scenario where the breakdown of effective of communication will without doubt, alter the basic chemical composition of our own, personal decision-making process.

In my life-long professional quest to become more proficient at this human factor genre, I’ve called on my experience and research to label four of them. Analogous to petri dishes, they are perfect culture-creating trays cogent to the possible misapplication of deference: leader/follower relationships, communication skills, situational awareness and decision-making.

Leader/follower – It starts on day one and it continues on every single flight. As a participant on both sides of this equation I can clearly identify with the specific roles whose effective fulfillment will eventually dictate mission accomplishment and more importantly assure the safety of flight. I have always done my best to establish clear lines which unambiguously demarcate areas of responsibility and more importantly cement that final authority. These must be identified, understood, agreed upon and adhered to, “prior to leaving earth”. As the leader, I must set the tone from the very beginning and must be consistent – if I’m at the flight controls then I make that final decision. if I am not – then I willingly grant the authority to whomever is working the stick, rudder and throttles; ensuring that the pilot does feel completely comfortable with his/her own decision-making. Written policy and procedural manuals are useful tools that can be often referenced. Yet, I found out that for me, nothing beats: “Hey, just want to remind you that today our safety is in your hands, let’s do what’s right. If you have any questions, doubts or concerns, please speak up – let me know right away, don’t forget – I’ll back you up”. This simple phrase, spoken clearly and unequivocally at the beginning of each and every flight has been my decades-long number one countermeasure against the misinterpretation of deference.

Communication – Clear, concise, unambiguous, timely – solution driven. Remember – “The greater the stress level, the more difficult communication will be”. In the presence of improper deference, accident histories clearly identify breakdowns, misunderstandings and assumptions. Clear examples are “trial balloons” – these are generally ambiguous hints, dangling participles or incomplete statements issued by the individual with the concern (in hope that the person(s) they are addressing picks up on their trend and properly interprets their meaning, all along not getting their feelings hurt or not feeling disrespected). More often than not, those “trial balloons” are in fact either misunderstood or ignored. They also eat up precious time. Keep it basic, keep it timely, try your very best to offer solutions and/or proffer options regarding your past, existing or upcoming dilemmas. Don’t just state the problem, give yourself a way out! I have always utilized key phrases such as “I’m concerned or I’m uncomfortable” as sacrosanct statements which for me, identify serious situations. If those words are spoken, it’s time for all of us to pay attention. More importantly as the person at the controls, I have to know well before the firecracker has been lit, that I can speak up without being judged. Also be cognizant of verbal (tone/inflection/interruptions/volume) and non-verbal (body language/eye contact) feedback which may very well deliver a much stronger message. Make the message the luminous star of your statement. Focus on what is right not who is right! As the listener, I always make the extra effort to validate any concerns, it could very well save our lives.

Situational awareness – Is the perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their future status. It’s a mouthful for sure, and what makes it even more difficult to master is its ever-changing nature. In simpler terms, it’s just “pattern recognition, a been there-done that” mantra. In familiar territories, we can easily, quickly and accurately adapt. Yet in unchartered waters or at the crest of a tsunami (despite our valiant and best efforts to “find our way”), the very last thing we need is the feeling (perceptive and/or real) that an aroma lingers potentially affecting our final outcome, especially an aroma that has a direct effect on our livelihood. Interestingly enough accident histories show that nearly always significant clues are available (in time) to recognize and recover – they also clearly identify errors in judgment as the leading cause of accidents, followed closely by those that are skill-based. Furthermore, the cognitive nature of the analysis required in gaining and maintaining S.A. utilizes both short-term and long-term memory banks, both of which are finite. Both are negatively affected by the bilateral stresses of criticality and time. The more complex the solution to the puzzle is, the more difficult the process will be. And as discretionary time counts down, the malignancies of “tunnel vision” are sure to yield their results. Accurate S.A. is useless if it cannot be converted into proper action, and that action has to be applied, at the right time, at the right place and in the right manner by the one “behind the wheel”. The thought that lingers is who truly is the author of that situational awareness at the moment of truth?

Decision making – Have you ever noticed how easy it is to know when someone else is making a bad decision?  We find it easier to assess someone else’s choices because we all have two views of the world – an outside and an inside view. When you think about someone else’s situation you are able to consider it from the outside – using the rational side of your mind. But when “the shoe is on the other foot” and it is a decision affecting your life the emotional side does take over. Reality is everyone’s mental “default setting”. The role of emotion in decision making is grossly underrated in the aviation community – no doubt as “real men don’t talk about such things”. Yet there is an over-abundance of evidence that emotional decision making might very well be hard at work when we are listing our options in flight. It is emotion – how we feel – that “closes the deal”, that makes that final choice. The emotional reward will be the (perceived/real) approval of his/her peers and superiors will send his/her way after one has “hacked the mission” though the going was tough. As a leader, have you ever placed undue pressure on whomever is working the flight controls and throttle? Let us not forget that “good stories are often about bad decisions”. Emotion consumes logic and drives behavior, in all of its’ righteous glory often transforms into the enemy of analysis affecting how we do process information. We then are prone to misinterpret facts, commit framing errors, take shortcuts and align ourselves with confirmation bias.  Emotion’s first cousin – subjective confidence – is the probability of being correct. It is not a judgement – it is a feeling – so, coherence of a story equals acceptance, while incoherence of a story equals denial. Surprisingly acceptance of a story (as gospel) actually requires very little quality and/or quantity, it’s much more about the strength of the delivery, emotion, passion, energy, confidence and enthusiasm with which it is transmitted. The landmine here is believing that it is actually true or correct. Trusting the validity of a story solely based on the confidence of self or others is a poor indicator of accuracy. Statistically you might as well flip a coin. So now, someone has made their mind up. Why are they saying what they are saying? Dissect it, get to the bottom of their reasoning. Ask yourself, if in fact you are in over your head. How really important is it to be right here, right now? Specifically what price are you willing to pay? It’s exactly these replies to each and every one of my questions that did in fact keep us safe on that pitch-black Korean night.

Forty-three years later this old and crusty Intruder pilot hammers away at these keys, and the sweat does come back. Why is that? Because even with amazing technological advances and modernization of aircraft, as well as a much greater skillset required of our aircrews, accidents still happen, and they do so for the same basic reasons. The dangerous aromas of deference are still taking their toll. Let us not allow those things that matter the least, affect the things that matter the most.

Mario Jimenez grew up in Colombia – South America and several Latin American countries. He has a B.S. in Business Administration from The University of Texas, El Paso. Additionally, he has attended numerous military and civilian schools in pursuit of professional development.

• From 1973 until 1983 he was a United States Marine Corps Officer as well as a Naval Aviator flying the A6 Intruder, the T2 Buckeye and the A4 Skyhawk in both land and sea environments.

• From 1983 until 2016 he was employed as an Airline Pilot with FedEx.

He led as a Captain for 24 years and facilitated as an Instructor Pilot for 12 years.

With FedEx he flew the Boeing 727, the McDonnell Douglas DC10 and the McDonnell Douglas MD11 freighters.

He has served as an advisor to Utah Valley University’s Professional Pilot Program on training and educational philosophies.

He has been a guest speaker at the Marriott School of Business – BYU

He has a 38 + year flying career.

15,000 + flight hours

During a 5-year period at FedEx he led the Human Factors Performance Group within the Air Operations Division, responsible for specific cognitive training and evaluation of 4500+ pilots. Concurrently he served as a member of the Pilot Applicant Selection Team. He is the founder of Jetstream International – a consulting firm specializing in the circumnavigation of human error. He has been married to Barbara Bluth for 45 years, they have 3 children & 11 grandchildren. He and his family have resided in Utah since 1999.

Aircraft Accidents and Lessons Unlearned XLIII: JetBlue Airways Flight 292

JetBlue flight 292 during emergency landing in Los Angeles airport

On September 21, 2005, JetBlue Airways, registration number N536JB, flight 292 landed at Los Angeles International Airport (LAX) with its nose gear wheel turned ninety degrees from center. The Airbus A320 departed Burbank airport headed for JFK airport in New York. The flight crew flew the aircraft for close to three hours to burn off fuel for the emergency landing; the decision to divert was made after the unsuccessful retraction of the nose landing gear (NLG) because the NLG tires blocked the gear from folding into the wheelwell. The two main gears, meanwhile, operated normally.

National Transportation Safety Board (NTSB) accident investigation, LAX05IA312, did not go through the normal investigatory process – it is assumed – because there were no casualties; the aircraft was not destroyed. As soon as the media blitz ended, complete with helicopter vantage point coverage of the edge-of-one’s-seat landing, the accident was put to the back pages. This was an unfortunate mistake; an aircraft that survived an accident would have been a teaching tool like no other. Six years earlier, a US Airways Airbus A320, flight 1549, survived its accident mostly intact. However, just like JetBlue 292, the NTSB missed important information in that accident and then failed to follow up on crucial findings that were instrumental to the industry.

The report was confusing; the terminology was ambiguous. Because of Airbus’s excessive use of sensors in the NLG steering and positioning, the reader, in order to understand what was happening, should have had a better narrative. For instance, when describing the proximity sensors, the report states, “There are a pair of proximity sensors and targets on the NLG that detect if the gear is extended (airplane in air) or if the gear is compressed (airplane on the ground).” When a gear is deployed in flight, it is considered ‘extended’, ‘retracted’ when up in the well. Instead, the report used ‘extended’ to describe the strut as extended, not the gear. Also, the ambiguous use of, “… a pair of proximity sensors and targets …” does nothing to aid understanding of what sensors/targets, how many sensors/targets are used, when during the deploy sequence are they required and for what purpose.

In 1966, Star Trek (the original series) relied heavily on storyline, not limited technology computer graphics (CG) to be successful. Common sense overrode technology. In contrast, 2017’s Star Trek: Discovery relied heavily on CG – not storyline. Technology replaced common sense. The successful franchise wasn’t broken, so why did they ‘fix’ it?

Today, technology has become the digital aircraft’s prominent characteristic, while reliable decades-old technologies are dismissed. The extensive use of technology does not make aircraft systems unsafe – it makes the systems unpredictable. For instance, the JetBlue 292 accident report mentioned that the A320 employs a device called the Brake Steering Control Unit (BSCU); it electronically controls the aircraft’s steering system. One BSCU function is to perform four bite tests – four deflections of the NLG steering through five degrees of travel … left to right … in flight … before touchdown. Why? Why test the steering before landing? Could this bite test have contributed to JetBlue 292’s misaligned nose strut?

Before digital wire technology, steering was simple; it was accomplished via a series of cables, pulleys and bellcranks. The steering system was not heavy because it ran from the NLG to the Captain’s steering tiller directly above. This system always worked; there was no need to test the steering in flight. The fundamental steering system design wasn’t broke – why fix it? Airbus, by employing numerous sensors and targets, ‘corrected’ a system that worked; they fixed the system beyond all repair.

Meanwhile, NTSB investigators were so caught up with the technology, that they forgot to check a most important factor: Was the NLG strut properly serviced? The gear’s integrity was intact – the strut, uncompromised; they could have checked. The NTSB docket for LAX05IA132 had nineteen specialty reports and documents; not one answered the simple question of strut servicing. The JetBlue 292 accident report did not answer that question either. Why, then, is strut servicing important?

NLGs, since the dawn of tricycle gear use (a nose gear and two mains) have used a mechanical device called the centering cam. The NLG shock strut has three main parts: a piston (chrome strut), an upper cylinder body (the sleeve the piston slides in; it connects to the aircraft) and the scissor links, which, among other things, prevent separation of the piston and cylinder body. Centering cams, also called locating cams, are mechanical devices located inside the strut. A locating cam (LC) is a simple design; each pair resemble two sine waves that slide together when employed. There are two LCs: an upper and a lower. As the aircraft rotates, weight comes off the NLG. The strut’s nitrogen pneumatic charge immediately pushes the piston away from the upper cylinder body. The upper LC on the piston engages the lower LC attached to the cylinder body, which aligns the gear to the aircraft centerline. Simple.

The A320 has centering cams. They work … but only as long as the strut is properly serviced with nitrogen to force the upper and lower LCs to engage. The accident report did not verify JetBlue 292’s NLG had the proper nitrogen charge. The centering cams would have made the sensor/target technology irrelevant in lining up the NLG to the centerline. Was the NLG strut properly serviced?

Unfortunately, in its inexperience, the NTSB did not understand this. Instead, they focused on cracks found on the NLG’s upper support assembly’s four lugs; damage from NLG stresses during landing. The four lugs did not contribute to the gear strut turning ninety degrees from the centerline, so this begs the question: Who cares? Why examine damage made after the landing? The purpose of an accident report is to highlight the cause(s) that led to the accident, not what was incurred after.

Furthermore, the NTSB spent great effort analyzing sensors and targets that – maybe – contributed to the accident yet did not produce a viable solution to any problems they may have caused. To slightly alter an Abba Eban quote, “The [NTSB] never misses an opportunity to miss an opportunity.”

Here are two examples of why maintenance-experienced investigators – specifically, airframe and powerplant certificated maintenance investigators with experience working in the industry – are critical to the NTSB investigatory process. First, a practical problem: It appears (because the NTSB did not provide NLG strut servicing evidence) that important clues were missed prior to flight. Was the strut ‘showing chrome’; in other words, was the strut flat, deflated, not serviced properly? This would have been caught by (hopefully) two individuals: the mechanic assigned to the flight and the first officer during his/her preflight walkaround. A flat strut would have been evidence of the strut requiring servicing or a leak. If the strut was properly serviced, again, the inflight emergency may not have happened. This would amount to an operational problem at JetBlue, a procedural revision of their manuals.

Second, a technical problem. The NTSB identified an unknown number of sensors and targets that track just the NLG’s movements, such as deployment, retraction, inflight steering tests, up-and-locked or down-and-locked. The consequence of the technology, as stated, “… a failure condition can exist that results in the NLG system sensing ‘ground/compressed’ when the gear is extended and a mechanical failure allows the NLG wheel to rotate to a position greater than 6 degrees.” The report confused ‘extended’ with down-and-locked/ strut at full travel; the “NLG wheel to rotate” should have been written “strut turned – or steered –  to a position greater than 6 degrees”. One can see how JetBlue 292’s strut turned ninety degrees from centerline; the still rotating wheels caused vibrations that helped the airstream turn the strut beyond the allowable six degrees in a few seconds.

With numerous sensors and targets, Airbus created multiple-point failure opportunities. There are too many sensors and targets, which lead to: (1) countless chances for computer error, and (2) numerous occasions for these sensors/targets to become damaged in day-to-day use, which, again, leads to computer error. The fact that the strut was able to rotate beyond six degrees should have raised multiple flags. It should have caught an experienced eye and acted on.

No accident, whether survivable or not, is too small or insignificant. What information was lost and could have been learned by JetBlue 292 cannot be emphasized enough. Investigations large and small demand qualified investigators that can identify problems and fix them. The traveling public deserve better.

Aircraft Accidents and Family

Ken Burns’, The Civil War Series, Episode Four, ‘1863: Simply Murder’, Narration: “In Texas, General John P. McGruder captured a Union flotilla at Galveston. After the bombardment was over Confederate Major A.M. Lee went aboard the badly hit USS Harriet Lane. There he found his son, a Federal Lieutenant, dying on the deck.

That is a sobering historical account; imagine being the instrument of a family member’s destruction. Even fiction, like O’Flaherty’s The Sniper, remind us how, even the most noble of causes, can be damaging to our community, or metaphorically speaking, our family. We, as co-members of this industry, might take a lesson from this, to choose our words – and battles – wisely.

Some weeks ago, there was an article written for the Travelers Weekly’s website titled, “THE FAA WAS TOLD TO SET PLANE-SEAT STANDARDS. THAT WAS NEARLY TWO YEARS AGO.” The lead paragraph stated, “A Congressional mandate for the FAA to set minimum standards for seat width and pitch passed 22 months ago. But the agency still isn’t saying when it will move forward with those regulations.” The Writer’s Bio says he is a travel reporter; it does not mention his aviation regulatory or design experience; per the Bio, the Writer (He) has none. His allegation suggests the FAA is in the comfort business – not regulatory and oversight. The Writer’s article is based in conjecture, clouding the FAA’s vital role by confusing those outside the aviation industry who look to the FAA for safety.

Per the article, “The FAA last November conducted a series of evacuation tests designed to inform its decision on aircraft cabin configurations.” It further stated, “… the agency has not updated its evacuation assessment standards since 1990,” that, “… airlines have increased the number of seats on planes, squeezing rows closer together in the process.” The Writer is correct; the standards have not been updated or, as industry says, ‘revised’. Why should they be? What did the Writer’s experience suggest needed changing? Is he saying the airlines intentionally violate the regulations; that FAA inspectors have averted their eyes from safety? Beyond the Writer’s stated opinion, what evidence did he present supporting his conjectures? Why did he choose to skillfully employ the verb ‘squeezing’, to employ an exaggeration for how passenger seating design has changed? He could have used ‘reducing’, ‘decreasing’ or ‘shortening’, but then that would have had less dramatic effect. With regards to design, the Writer’s use of the verb ‘squeezing’ is dishonest; it only appears clever by introducing a futile emotional argument.

The article then called out another violator of the Congressional mandate, the Office of Inspector General (OIG); “In May 2019, the OIG’s office said it would complete the audit last fall [Fall 2018 or 2019?]. However, that timeframe came and went. An OIG spokesman this week [August 2020] said the final report is on track for delivery by late September [2020].” Was the Writer suggesting the OIG violated Congress’s direction? Did the Writer understand how long effective testing can take? Does he realize the five-year long process required to change a regulation? Portraying the OIG and FAA as disobedient agencies that ignore Congressional mandate, only serves to divide the industry. The Writer’s uneducated opinions sew distrust in government agencies, whose job is to guarantee safety … not comfort.

I do not read travel magazines, but someone in the aviation safety arena I belong to, does. A reader of Travelers Weekly, an aviation lawyer (AL), added his opinion, that the FAA failed to follow through on the Congressional ruling. He stated, “… a provision in the FAA Reauthorization Act of 2018 that calls for the FAA to report to Congress (Sec.337) on evacuation certification, including changes to width and pitch of seats to facilitate evacuation.” (It felt like an ‘Harumph!’ was missing). He added, the Congressional committee heard from, “… safety advocates that jamming as many seats on a plane was compromising safety,” Jamming? More exaggerated verbs, as if seats were forced into seat tracks against their design to restrain them. More dishonesty and useless emotional babble.

The AL wanted wider seats in Coach, that’s clear. Who doesn’t? However, these complaints sound like the type of misinformed insinuations the National Transportation Safety Board (NTSB) make against the FAA, e.g. not doing their job, etc. The NTSB, like the AL, does not understand the FAA’s job either.

Coincidentally, the AL’s opinion was echoed by a former NTSB Board Member (BM), who took derisive shots at the FAA, saying, “Amazing how some folks still think the FAA is there to support the industry and not the taxpayers and passengers paying the bill!” (Harumph! Harumph!) His comment was unnecessary churlish disdain; very unprofessional. This particular BM had no transportation experience and, thus, no cause to be acrimonious. In addition, he should have known better. After dropping out of the NTSB, this BM continues to make a stink.

I have great respect for lawyers; some good friends of mine are lawyers; some lawyer friends are also piranha fish … but I digress. A lawyer with practical industry experience, knows the regulations; he does not look at them myopically. Experienced aviation lawyers know, despite following the same regulations, United is not like Delta and, just as important, American does not operate like a regional airline. They fly different equipment in different environments with different passenger requirements, e.g. seating. Let us be honest, this seat argument was not about safety; it was about comfort. Any reference to safety was purely hypothetical. What’s the next Congressional Mandate for? More peanuts? Fluffier blankets?

Incidentally, didn’t the AL mention safety advocates addressed the committee? How did these safety advocates determine that safety was at risk? What Data did they provide that spoke to these risks? Did they conduct testing? How did they conclude the 1990s standards were out-of-date? Some aviation schools have the resources to provide such testing. Were any employed? What qualified these safety advocates to speak on this subject? Were they engineers who spent years designing safe seats? Did they generate manufacturer’s procedures for evacuation standards? Or, maybe, they were Board Members who left the NTSB and became … Consultants. The safety advocates’ credentials should have been qualified.

The FAA did comply with the Reauthorization Act of 2018’s requirements; seating questions were answered many years earlier. Title 14 Code of Federal Regulations (CFR) Part 25 Appendix J: Emergency Evacuation and Subpart 25.803 were revised, based in testing and reliable data – not opinion. Even the former NTSB BM should have been familiar with these regulations.

Did the article Writer or the AL think that all aircraft models would be tested; that the MD-80, B737, Airbus 330, Embraer 135, etc. would each be analyzed? Would each operator’s fleet be pulled from service, towed to a hangar and reseated for mandatory measuring? More likely, average seating arrangements, i.e. one standard fuselage, would be tested to qualify all models … together. What the Congress failed to realize was that, when analyzing aircraft seating designs, one size does fit all.

Average career politicians, who sit on oversight committees, are not chosen for theirexperience; they are chosen because of politics – just like NTSB Board Members. Committee members have no experience; they only care about votes. If they can secure a vote by promising to nail a wave to the shore – or force the FAA to ignore its mission – they would do it. When they are voted out, career politicians leave their government positions to become Consultants – and Safety Advocates – with zero experience. Perhaps Congress’ time would be better used looking at safety advocate qualifications.

No one is happy sitting in an airline seat these days; the cabin-wide first-class seating of Midwest Express Airlines is gone. There are alternatives: car, train or boat. I travel a lot, so I drive … a lot. Let us be clear: the FAA cannot force an air operator to change their seat design because they are uncomfortable … UNLESS, those seat designs are unsafe – and only unsafe for flight, per Title 14 CFR Part 25. Airlines make seat design decisions to increase sales … period. They are, after all, a business. If one does not like an airline’s seats, then don’t fly with them. The power lies with the consumer, not the FAA.

The rhetoric of the article Writer and the AL serve no purpose but to sow derision into the aviation safety process, making others question the integrity of those consigned to advancing safety. The disregard for these facts is demonstrated in NTSB accident reports, a politician’s pandering to special interests or the occasional lawyer’s frivolous lawsuit. The FAA and the OIG exist to fix safety problems – real ones, not the emotional kind. Reporting otherwise irreparably damages the integrity of the aviation family.

Aircraft Accidents and Lessons Unlearned XLII: TAM Flight 3054

TAM A-320

On July 17, 2007, Táxi Aéreo Marilla (TAM) Linhas Aéreas flight 3054 (TAM3054), an Airbus A-320, registration PR-MBK, crashed while landing on Runway 35L at São Paulo/Congonhas airport (airport identifier: SBSP). After touching down, the aircraft did not slow; it veered to the left, overran the southwest side of the runway, crossed over Washington Luis Avenue and struck both a cargo building and a fuel service station at ninety-six knots. It caught fire; the aircraft was destroyed. The investigation was conducted by Brazil’s Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA), [translated] the Aeronautical Accidents Investigation and Prevention Center. No archived evidence could be located on the investigation agency’s website to review; all information presented here is taken straight from the report: RF A-67/CENIPA/2009.

There are problems analyzing accidents written in a language that is not native to the reader. It was important that the Findings/Recommendations had received the proper interpretations to other languages, such as English. How does anyone benefit from the analysis if the translation was poor? Even the manufacturer terminology can baffle the investigator, cascading into more confusion. Consider the old game, Telephone Line, where a message spoken to the first person in line is drastically different when it reaches the fifteenth person. Confusion can result from simple terminology; the General Electric CF6-50 engine had a Constant Speed Drive that drove an engine generator at a consistent speed. On a later model, the CF6-80 engine, the device was called the Integrated Drive Generator – same purpose, different name. When an investigator is unfamiliar with the terminology differences from Boeing logic to Airbus logic, the end report becomes gibberish.

On page 52 of the TAM report, such an uncertainty exists, “… Aeronautical Accident Prevention Program (PPAA) of the company [TAM] for the year 2007, those accredited professionals were not considered for the development of accident prevention actions.” The Operations and Maintenance departments, by definition, subscribe to accident prevention in every action they perform; an accident prevention program would be redundant. What was an accident prevention program? Were investigators experienced in airline cultures? Other problems could arise, such as an overreliance on the manufacturers and the airline to fill in the blanks for them. How likely were manufacturers and airline to expose their own weaknesses? The A320 was/is a popular airliner around the world; the importance of a lost opportunity to learn cannot be stressed enough, especially if lost in translation.

A curious report problem: the number of recommendations. This report had fifty-two Conclusions and fifty Recommendations– an incredible number of recommendations for a single-aircraft accident. In the accident report, Quantity ≠ Quality. Recommendation numbers are not proportional, are not indicative of safety value. Some recommendations were valid, insightful; unfortunately, good information was lost in the commotion.

There were three focuses for the final report: Runway Integrity, Training and Mechanical Anomalies. Of the twelve possible (probable) causes, there were five the report considered ‘contributors’ to the accident: Training, Cockpit Coordination, Management Planning, Little Experience of the Pilot and Management Oversight. Any reference to the ‘pilot’ was ambiguous. Were both pilots considered inexperienced, or just one? Runway integrity should have been considered a contributing factor and the factual information about this should have been exploited. The report spent resources analyzing the runway’s condition, but the report did not list it as a contributor nor as an undetermined factor.

The aircraft was operating with a deferred #2 engine thrust reverser. This meant the right engine could not be used to stop the aircraft once it touched down on the runway. Thrust reversers are not required to stop the aircraft, but this scenario, exacerbated by the wet runway, created a landing challenge. The #1 engine thrust reverser would be deployed on landing, thus introducing a yaw effect, where the aircraft will pivot left in the direction of the deployed reverser. On the right engine, the thrust lever (TL) was set out of configuration (to Climb), which provided forward thrust to further drive the aircraft left.

Per the flight data recorder (FDR), at touchdown, the number one TL was at ‘IDLE’ while the number two TL was at ‘CL’ (Climb). The report stated on page 67, “If one lever stays at the “CL” position during landing, it deactivates the actuation of the ground spoilers, significantly reducing the aircraft braking capability (between 45% to 50%)” Did the pilots mistakenly misconfigure the aircraft for landing, essentially deactivating the autobrakes and ground spoilers? Why were the TLs not moved together on landing, why the split? Did they pay attention to the Minimum Equipment List (MEL) procedures for the deferred reverser? How did this reflect in their training? Was this pursued with TAM post-accident?

Maintenance was not listed as a contributor, an unfortunate oversight. The investigators failed to interview members of Maintenance, especially at Porto Alegre, the airport TAM3054 had departed from. The #2 reverser had been deferred since July 13, 2007, mechanically locked out to prevent inadvertent deployment. Any pilot concerns in Porto Alegre may have been discussed with the mechanic who launched the flight, including pilot/MEL procedure compliance issues.

Both the cockpit voice recorder (CVR) and the FDR confirmed the ground spoilers did not deploy. Autobrakes also did not function on touchdown in SBSP. These issues should have been explored with Maintenance. The mechanic could have provided insight into why the pilots’ actions led to the spoiler problems. Were the MEL procedures understood before launching the accident flight? What about anti-skid? Page 42 stated, “The Anti-skid system, in turn, functioned normally, preventing the blocking [locking?] of the main gear wheels during the braking.” PR-MBK was launched out of Porto Alegre with an allegedly functional anti-skid system … or was it?

According to information provided by the operator, several of PR-MBK’s last maintenance records from Porto Alegre were destroyed in the accident; they were being transported to Congonhas for entry into Maintenance’s database. Why were there no copies kept in Porto Alegre? Were TAM maintenance log pages normally duplicated and, if not, why not? Did an investigator pursue this point?

One good point made, though lost in the recommendations, concerned training on page 95. “The theoretical qualification of their pilots was founded on the exclusive use of computer interactive courses (CBT) which allowed a massive training but did not ensure the quality of the training received.” Anyone who has received CBT for maintenance or flight, understands the problems associated with this method, that the computer is the sole instructor during an important phase of the training. CBT is a poor instructor in that it cannot answer questions as thoroughly as a trained instructor. Quality depends on a distraction-free, uninterrupted learning environment, one that does not add to confusion.

Concerning the second in command (SIC) pilot’s experience, per the report, page 10, “The SIC had recently been hired by the company as a captain [When?]. He did not have previous experience in the A319/320 airplanes and did his A-320 training (already as a captain) at the very company.” If correctly translated, the SIC – first officer – had a captain’s rating with no previous experience before TAM, in the A-320. The SIC had 14,760 total flight hours, 237 flight hours on the Airbus A-320.

The report’s Findings pointed to credible administrative and cultural issues with TAM that were not pursued, while drifting into unproven findings, such as the Captain’s ‘mild headache’ (page 95), saying it, “… may have influenced his [captain’s] cognitive and psychomotor capabilities during the final moments …” A migraine would have been debilitating. A mild headache?

Recommendation 172/A/07 suggested, “… a warning system to allow the crew to identify a wrong setting of the thrust levers …” Another alarm or warning? The fallacy of overregulation and/or overengineering, taking the responsibility from the pilot and giving it to the aircraft. How does removing the pilots’ responsibilities to aircraft system monitoring benefit safety? How does adding another alarm help?

The TAM3054 accident report was confusing. Worse, it wasted resources on irrelevance and ignored issues that could have benefited safety. It was not that CENIPA missed the important safety mistakes, it was that CENIPA did not shine a bright enough light on the very important problem of inadequate pilot training, coordination and flight management.

Aircraft Accidents and Unfortunate Responses

A Greek, a Hindu and an Egyptian meet in the desert … No, that’s not the lead-in to a joke. It is the first chapter in the complete and unabridged novel by Lew Wallace, Ben-Hur: A Tale of the Christ. In the story, Judah Ben-Hur becomes consumed by vengeance against the Roman government; the thought of retaliation occupies his mind. It is only in his second meeting with the Christ that he understands his self-destructive ways and forgives those who wronged him. Judah learned to understand before he acted and let fall the sword from his hand. He learned to think … before he spoke.

Recently, the National Transportation Safety Board (NTSB) announced online that the July 14, 2020, Atlas flight 3591 NTSB accident Hearing “a success”. All the NTSB findings and recommendations would make the final report. At last, the NTSB would inform Industry what went wrong. This news generated talk and … some unfortunate responses.

Atlas 3591 crashed into Trinity Bay on February 23, 2019. The NTSB first updated the investigation on their website: on March 5, 2019, ten days after the accident, where they announced an initial Cockpit Voice Recorder review. Then – NOTHING. For 289 Days – Forty-One Weeks – Nine Months – nothing but chirping crickets. A review of the NTSB website showed that there were no other major aviation accidents in work. Then on December 19, 2019, the NTSB posted Atlas 3591’s Hearing would be on July 14, 2020, which was still another Seven Months later. The docket was finally open. Important updates? Go look in the docket.

This needs to be clear: the B767 (accident aircraft) is one of the most popular Widebody passenger airliners in the world, certified to fly 3 to 4 hours away from land on one engine. As per the Boeing website, One thousand and ninety-one B767s of all versions have been sold to air operators and the military around the world – 1255 with those ordered. Some major airlines brag upwards of 70 to 90 B767s in their fleet. The B767 can carry upwards of 269 passengers (not counting crew) onboard. Yet, it took 497 days to learn anything substantial about this popular airliner. It was unthinkable to have a 497-day information blackout, to leave industry in suspense for 1.5 years. It was a disservice to safety.

In response to the July 14th Hearing announcement, I commented online, “I find it troubling that an accident involving one of the industry’s most popular airliners, the B767, took almost ten months before the Public Docket opened … that seventeen months passed before the hearing was conducted.” A widebody airliner pilot responded to my comment, “Amazing how the Kobe Bryant crash investigation has been expedited, but this [Atlas 3591] took 1.5 years?” The airliner pilot’s observation was accurate. The Kobe Bryant (KB) helicopter accident investigation’s docket opened in 143 days – two times faster than Atlas 3591’s.

However, the airliner pilot’s response challenged the mindset of today, that no one should question government agencies, like the NTSB, even when they put public safety at risk. An NTSB manager responded to the airliner pilot, “Not a bad idea to get your facts straight before posting ridiculous accusations. The accident which claimed the life of Kobe Bryant and 8 others has not been completed. And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” This … was an unfortunate response. The manager’s statement was condescending. It was indicative of an NTSB that treats public reaction with indifference.

This is a problem. To dismiss a derisive comment is understandable, but to show disdain over a factual statement, albeit with some cynicism, is another. The airliner pilot’s skepticism was the result of his frustration at the NTSB’s ‘slow-to-action’ attitude towards Atlas 3591’s investigation. The purpose of safety recommendations and reports is to generate conversations among those in industry, to encourage research and development. Dismissing an aviation professional’s voice discourages this vital dialogue.  

No person should believe that government agencies are always right; to suggest that they can never be wrong, would be absurd. “Not a bad idea to get your facts straight before posting ridiculous accusations”? How unnecessary. An accusation? It was not. Furthermore, the manager’s response was sarcastic and unprofessional. The NTSB is a government organization, funded by taxpayers. The general public’s comments are expected and welcome, especially when based in fact.

It is true that government does not create jobs or prosperity; government also does not improve safety. Only government believes otherwise. Government is a referee, an umpire, a neutral outsider whose job is to assure everyone follows the rules. What rules? The regulations industry helps to write. NTSB labs do not create safe products; NTSB recommendations do not generate aviation safety. Manufacturers, air operators, repair stations, pilots, mechanics, flight attendants, aviation schools, air traffic controllers and the flying public; these folks make aviation safety possible. They are the check and balance. Because of their safety contributions, we are assured industry will survive with integrity.

Look at the timelines: the KB helicopter accident docket opened in only 143 days. The Ethiopian Air 302 B737-MAX accident investigators presented their FINAL report in twelve months (March 10, 2019 to March 9, 2020). The NTSB provided findings and recommendations for Ethiopian 302 and Lion Air 610 within that timeframe. Why? Neither 737-MAX accident was an NTSB investigation. Where was the urgency to improve safety with Atlas 3591? Why did it take 289 days to open Atlas 3591’s docket? Aviation professionals should have asked why.

In May 2002, as an NTSB investigator, I assisted Taiwan’s Aviation Safety Council (ASC) with the China Airlines 611 investigation, a B747 that was in pieces on the China Sea floor. An NTSB Structures investigator quickly discovered the root cause, relayed the information to the ASC. By August 2002, the ASC told industry and safety fixes were expedited. Information was delivered in a timely manner.

What about the next part of the NTSB manager’s unfortunate response? “The accident which claimed the life of Kobe Bryant and 8 others has not been completed” is odd. Not for using Mister Bryant’s name. Often accidents refer to their celebrity victims, e.g. JFK Jr or Payne Stewart. It was the, “… and 8 others …” that was odd. What do accident fatality numbers have to do with fact-based analysis?

Since my days working NTSB major accidents, I have found it strange that accidents involving cargo or with low profiles, e.g. low victim count, receive insufficient attention. For example, in 2001, Emery 17 (three pilots) took almost two years to reach a limited Hearing. Colgan 9446 (two pilots) was not given a full Go-team or Hearing. National 102 had an investigator-in-charge with zero previous major accident investigation experience. Fine Air 101 (four crewmembers) had unqualified investigators. Why?

By exploiting the death count, the NTSB manager assumed (incorrectly) that emotional disputes are relevant. Were the “8 others” helicopter victims more important than the three in Atlas’s B767? What about the unnecessary risk to the thousands who flew on B767s with possible unknown problems for 1.5 years? Emotional disputes had nothing to do with either accident. To use the “8 others” to somehow justify the Atlas 3591 delay was absurd. Emotions have no investigatory substance; they are devoid of facts. Did pontificating about victim numbers help find root cause or were they just a distraction? 

Take a look at the emotional arguments for destroying history by removing statues of our Nation’s Founders. Why? Will it erase the sin of slavery? Won’t the memory of former slaves and abolitionists be erased as well? Should the Pope push to have the Roman Colosseum leveled for the Christians that were slaughtered there? Should Jewish leaders raze Auschwitz or other Nazi labor camps; remove Passover from its calendar, just because they are reminders of suffering?

The NTSB manager then dug in his heels: “And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” Was this defensive slap because the NTSB’s authority was questioned? “… digging through muck?” Another unfortunate response.

I make no secret of my criticisms of NTSB investigations. But the NTSB investigators I worked with, those investigators on-site, whether qualified by industry standards or not, chose to ‘dig through muck’ because that is what accident investigation is. Whether on a mountainside or in a field in Kansas, all accident investigations, by the NTSB or any other organization, are the pursuit of facts and truth; the pursuit of root cause; the pursuit of aviation safety, no matter the effort or conditions.

For every emotion, there is an equal and opposite counter emotion (apologies to Sir Isaac Newton). The NTSB manager demonstrated that emotional overtones are not welcome in professional discourse. His unfortunate responses devalued those NTSB investigators’ efforts who put forth some good work.

The government is not the answer to safety. Aviation safety’s only hope in this everchanging technological world will come from timely facts, entrepreneurship and those who make safety improvements each day. Aviation safety does not pivot on government intervention. That point being made, it is our obligation to question all government analysis, especially when it comes to safety. In addition, free and open dialogue among influential aviation professionals should never be discouraged by government bureaucrats who spout … unfortunate responses.

Aircraft Accidents and Lessons Unlearned XLI: Atlantic Southeast Flight 529

Atlantic Southeast Airlines Embraer EMB-120RT

As per National Transportation Safety Board (NTSB) accident report AAR-96/06, on August 21, 1995, Atlantic Southeast Airlines flight 529 (ASA529), an Embraer EMB-120RT, registration number N256AS, crashed during an emergency landing attempt near Carrolton, Georgia, 31 minutes after departing Atlanta Hartsfield International Airport. The flight, operating as a scheduled flight to Gulfport, Mississippi, had experienced a separation of five feet of a single left (#1) engine propeller blade during climb through 18,000 feet of altitude. The blade, one of four, departed the engine propeller, immediately introduced an out-of-balance condition in the still turning engine, which contributed to existing damage on the engine, cowling, remaining propeller assembly and wing until the propeller came to a stop.

The NTSB determined, “… that the probable cause of this accident was the in-flight fatigue fracture and separation of a propeller blade resulting in distortion of the left engine nacelle, causing excessive drag, loss of wing lift, and reduced directional control of the airplane. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered by Hamilton Standard because of inadequate and ineffective corporate inspection and repair techniques, training, documentation, and communications.” It further stated, “Contributing to the accident was Hamilton Standard’s and FAA’s failure to require recurrent on-wing ultrasonic inspections for the affected propellers.”

The NTSB’s decision to blame the Federal Aviation Administration (FAA) for reasons not-accident-related, diverted necessary attention away from the accident’s root causes. The NTSB’s probable causes demonstrated their fundamental misunderstanding of the FAA’s responsibilities of active oversight of the manufacturer/repair station, as well as Hamilton Standard’s own obligations. The NTSB’s repeated allegations that the FAA was directly to blame in many other accidents remains a problem and demands note. The theory that ‘casting a wide net’ generates more causes only confuses the Findings and does nothing for safety. This NTSB practice inhibits actions that can lead to improvement by placing blame where it serves no benefit, in other words, a counterproductive ‘cry of “Wolf”’. It is not because the FAA had no culpability for its certificate holder’s actions – the FAA did. But to categorize all safety issues as “FAA failures” is irresponsible and passive. It would be just as foolish to blame the NTSB for getting past probable causes wrong, which would be a more accurate Finding. Aviation safety would be better served with useful recommendations. Instead, an important issue was missed.

Recommendation A-96-143 stated, “… the need to require inspection (“buy back”) after the completion of work that is performed by uncertificated mechanics at Part 145 repair stations …” Federal Aviation Regulation (FAR) Title 14 Code of Federal Regulations (CFR), Part 145, Subpart E, Section 145.211 (c): Quality Control System addressed this topic for decades, yet the NTSB failed to research that fact. Since AAR-96/06’s publication, this Part had been revised twice as shown in Federal Register (FR) 41117 (8/6/2001) Volume 66 and FR 9176 (3/5/2018) Volume 79. Section 145.211 was not revised; the NTSB recommendation A-96-143 served no purpose.

This is the problem: NTSB engineers that investigate aircraft maintenance issues do not work with the FARs that deal with aircraft maintenance, in this case Title 14 CFR Parts 65 or 145. Engineers would not know how a repair station run by a manufacturer is divided into two separate entities: the manufacturer and the repair station. NTSB engineers do not comprehend the terms uncertificated mechanics, repairmen, inspectors, the roles each plays in a repair station or their limitations.

A second recommendation, A-96-149, stated, “Evaluate the necessary functions of the aircraft crash ax, and provide a technical standard order or other specification for a device that serves the functional requirements of such tools carried aboard aircraft.” This baffling recommendation referred to the first officer’s futile attempts to break through the cockpit window with the aircraft’s crash ax when the traversing window jammed from structural damage. The ax’s handle broke. The cockpit’s available space was not designed for swinging an ax with a longer handle. Furthermore, local first responders also failed to break through the window with larger axes and more swinging room. A-96-149 was irrelevant.

Was the unfortunate propeller blade’s departure the main contributor to this accident? It did contribute directly to the tragedy. Was the propeller’s overhaul to blame? Again, yes, this led to the tragedy. However, the NTSB should have studied whether the plane could have successfully landed with the damage it incurred, particularly how to survive a propeller blade separation at climb. The NTSB’s probable guesses did not address training and, worse, the NTSB never pointed to this training omission in the recommendations. The NTSB failed the industry.

Was this the first time that a propeller blade was thrown?  No, and probably would not be the last. The truth was confirmed nine pages into the cockpit transcript. The NTSB knew when it happened, why and how. What the NTSB did not do was to make this type of event survivable in the future.

The focus of an accident investigation is to prevent, not only the circumstances that led to an accident, but the repetition of history; that is the ‘product’ of an accident report. A key NTSB investigatory team on a major accident is Survival Factors, a group of professional investigators who determine what should change to guarantee the survival rate goes up in the next event, e.g. seat design, fire resistant materials. The purpose of the Operations investigators and the aircraft-specific investigators, e.g. Powerplants, Aircraft Maintenance, is to work towards surviving an accident when the unexpected happens. The ASA529 accident was similar to other accidents, like United flight 232, in that they were the victim of catastrophic failures, next to impossible for the pilots to anticipate.

Before United 232 crashed in Sioux City, Iowa in July 1989, the #2 engine failure had jettisoned engine metal, which cut into all three of the plane’s hydraulic systems, making the DC-10 uncontrollable. The solution was to assure that another #2 engine failure would not simultaneously damage the three hydraulic systems in the future; a hydraulic fuse was placed in the #3 hydraulic system. Simple, yet effective.

After the ASA529’s #1 engine propeller came apart, the pilots flew ASA592 for nine minutes before impact; the pilots made heroic efforts to maintain control and save the plane and all aboard. To protect future flights, the NTSB had a duty to lead the industry in analyzing the final minutes of ASA529 and generate solutions for how to survive a propeller failure in the future.

To do this, the NTSB should have taken the facts of the aircraft’s condition during the last nine minutes. What other damage was incurred when the propeller came apart? Were the flight control systems victims to the propeller blade’s damage? Why would that be important? With Southwest flight 1380, when the #1 engine threw a fan blade; the blade could have exited at any point within 180 degrees of travel, yet the blade was launched at the exact degree that resulted in tragedy; the plane remained manageable, but a passenger died.

AAR-96/06 did not report fuselage damage, e.g. flight control cables, pushrods, etc. affected by the propeller blade’s trajectory; the aircraft did not depressurize; damage was limited to the #1 engine, nacelle, propeller and surrounding wing structure, which was harmed extensively. Despite this, the pilots managed to continue on to Carrolton regional airport for nine minutes. The circumstances of the propeller coming apart in flight would be impossible for pilots to anticipate. Although aviation safety dictates that all is done to prevent a repeat of this event, it could be duplicated; it would be just as unpreventable.

The pilots successfully flew the wounded aircraft under extreme conditions; they did their best. But even with all they did, there were lessons to learn that could have been incorporated into pilot training. A good recommendation would have been for manufacturing, industry and the FAA to build a training program that, after studying the accident, would have figured out proactive measures to survive a similar event using knowledge taken from ASA529. It was encouraging for the industry to know that, in the aftermath of ASA529, the FAA, industry and aircraft manufacturers of both propeller and jet aircraft have categorized the circumstances, analyzed the contributing events of their actions and improved pilot training to learn from ASA529 and survive.

It would be hoped that the NTSB would focus on improving aviation safety by concentrating on solutions while avoiding casting subjective aspersions. The cost in people and machines is too great to waste time impugning the reputations of valuable organizations; it only serves to divert attention away from facts. ASA529 never should have happened. But will it happen again?