Aircraft Accidents and a Qualified Ten Percent

Emmett Kelly ‘sweeping’ up the spotlight

In an interview, actor John Cleese said he asked a psychiatrist friend how many in the psychiatric field honestly knew their job counseling the emotionally challenged. Cleese’s friend replied, “About 10%.” Cleese then asked other specialists from other fields and found the highest qualified percentage response was 20 – 22%. It makes one wonder what the percentage would be for those in aviation oversight.

A good friend of mine, a former Federal Aviation Administration (FAA) aviation safety inspector (ASI), recently spoke with some FAA managers. Throughout the conversation, he became painfully aware of a troubling fact: The FAA had become ‘woke’. For many of us who made – and many loyal ASIs still making – the FAA the greatest safety agency, that FAA upper management pushes Diversity, Equity and Inclusion (DEI) programs is sobering. Like critical race theory (CRT), DEI is not fact-based. Its implementation in the FAA’s safety-intense environment is a serious problem simply because of its negative effects on safety.

Is it accurate to say the FAA is woke? The FAA’s Jobs website delivers phrases like, “Our inclusive culture …” and “Because our diversity is so critical …”; along with the Department of Transportation’s own war on Racist Roads are clear indications of woke-ism. What is DEI’s intent? As a nation, we’re becoming deaf to government corruption. Most Federal agencies are out of control, which is why DEI and CRT thrive in the common sense vacuum. Like weeds in a garden, DEI and other perversive programs only benefit con men and bloated politicians who divide our industry along non-existent lines.

It’s right to say that DEI is not for every industry. If DEI is ever necessary, then reserve it for vacation resorts, like Disney that can hire per DEI dictates. If Disney hires a bearded man to play Cinderella only stockholders get hurt, not the general public. Resorts don’t represent safety issues, nor do the News, Entertainment, Auto Sales, Banking, Real Estate, Marketing or any other non-safety intensive industry.

DEI, as the second word suggests, is a push for ‘equity’, but to whose definition of the word? Lily Tang Williams, a Congressional candidate from New Hampshire’s second district and a Red China survivor, said ‘equity’ is a communist tactic. It demonizes certain classes as the cause of all this country’s troubles. She said, “I fear the country I love is becoming the country I left.”

What does that have to do with the FAA? The FAA is one government agency among many that is pushing DEI, a push directed by politicians. It’s a platform that emphasizes gender identification and sexual preference. It’s impossible to find a more safety irrelevant topic than what one’s sexual preference is or how one acts in private. What DEI has to do with aviation or being safety motivated is anyone’s guess. Professionals, both gay or heterosexual, never advertise their preference because sexual preference was never anyone’s business, and it never should be.

DEI lumps valid race and gender issues with gender identity to boost the latter’s credibility in a bold attempt to make DEI look factual … to use as a hiring skill. Are there race and gender biases? I haven’t seen bias in my forty years. I worked side-by-side with women and men of every race as a mechanic, manager and safety inspector. Gay or heterosexual issues never came up because – nobody cared! Yet, the only ones showing any bias are those promoting DEI. They think qualified men and women, gay or heterosexual, should be grouped with those suffering sexual dysphoria. They’re convinced sufferers from sexual dysphoria are maligned. But by whom? Who cares about sexual identification?

Here’s the rub. In a professional world, race and gender are as obvious as can be. In contrast, dressing contrary to one’s born gender is a choice that flies in the face of professionalism. No matter how accepting an airline is of cross-dressing or ‘finding oneself’, passengers find a bearded man in a dress unsettling. If one can’t dress professionally, why would one be expected to act professionally in an emergency? In safety, professionalism and trust are synonymous. Forcing passengers to accept ‘woke’ policies deprives them of their right to what every airline and the FAA guarantees: A Promise of Highest Level of Safety. Sexual identification? It’s not professional. Never has been. Why? Because nobody cares.

DEI dictates pilots should be hired for sexual identification, gender or race, not whether the pilot can safely fly an airplane or if the flight attendant can handle an emergency. Some airlines now employ Diversity counselors in the pilot interviews. Are these Diversity counselors there to assure job candidates’ qualifications or to make sure DEI policies are followed? What training do Diversity counselors receive that show their priority is safety? If DEI hiring practices don’t improve safety, the FAA should confront the airlines to remove the DEI policies from hiring practices for safety’s sake.

If the FAA is biased, then pre-DEI numbers would reflect clear data and fact-based trends on why DEI policies were needed. If not, then millions of taxpayer dollars are being wasted on a scam. What were the White-versus-Black, Hispanic, Asian, etc. flight attendant numbers like in 2017? How many women pilots were rejected for bias in 2017? Be clear on the facts. If the allegation is the FAA is racist, then show, with conclusive proof, that the FAA was racist. Otherwise, let the FAA worry about aviation safety.

The government is a mess. They’re still litigating vaccine mandates that, in the past proved ineffective at the least and dangerous at best. What happened to the FAA’s mission: “… to provide the safest, most efficient aerospace system in the world”? Doesn’t it seem the FAA is just phoning this DEI stuff in? Sure, their website points to DEI with, “Our inclusive culture …”; “Because our diversity is so critical …”; and “The mission of the FAA involves securing the skies of a diverse nation,” but these are political word-salads, buzz words – not an FAA commitment to DEI orthodoxies. Where does it say the FAA commits to DEI policies as a hiring guideline? It doesn’t because the FAA can’t take the DEI policies seriously. Instead, ‘woke’ folks are played for fools. The FAA sounds woke, so that it has deniability. Unfortunately, the FAA must continue the ruse, so they force DEI ‘training’ on their professional ASIs.

Unfortunately, this acknowledgement of DEI is costing the FAA credibility. FAA ASIs remain safety professionals, but they’re being forced to conduct their jobs as upper management dictates. Since FAA management jumped the shark, so must every ASI suffer the indignity as the safety agency is destroyed from the inside. These mistakes lead the public to ask about the FAA’s real job of certificate holder oversight and why so many years of providing, “… the safest, most efficient aerospace system in the world,” ain’t been happening.

The International Civilian Aeronautical Organization – ICAO – cannot be taking the FAA seriously anymore either. With airlines now choosing ‘woke’ policies over safety, how long before international travelers read about these airlines’ ‘woke’ policies and start avoiding the US major airlines like the plague? The FAA will become the poster child for how not to be an oversight agency. They will become the Emmett Kelly of aviation, left only to ‘sweep’ up its own dwindling spotlight.

An excellent article by Janice Hisle (not an aviation journalist) called ‘Woke Airline Policies Threaten Safety, Workers Say’, related stories of major airline pilots and flight attendants being fired or harassed due to ‘woke’-ness. The FAA’s silence on this is deafening and they won’t engage these ‘woke’ airlines. Last month, a former Southwest Airlines (SWA) flight attendant won a $5 million lawsuit against SWA. How embarrassing for SWA that they fired her for anti-‘woke’ opinions on her personal Facebook page and not for safety violations. Following this decision she stated, “I think there are a ton of cases out there just like mine.” Does this mean other major airlines terminate safety professionals for woke reasons, like the lawsuit judge said SWA did? This should alarm all FAA Principal inspectors, that airline safety persons were terminated for non-safety reasons. These Principals should audit training records and flight attendant criteria, to determine if safety is at risk. The flying public should demand action.

To further highlight the insanity of DEI hiring, Ms. Hisle wrote that the industry actually follows something called environmental, social and governance (ESG) scores, an airline industry-wide rating of how ‘woke’ airlines’ ‘woke’-ness compares to other ‘woke’ airlines. ESG advisory groups exist, working behind the scenes to push diversity and inclusion – not safety – on the airline industry. Practices of this kind are why I don’t fly anymore.

Are safety ‘experts’ participating in the ‘woke’ agenda? Listing one’s pronouns on social media just demonstrates that even aviation folks are giving credibility to the ’woke’ agenda, which looks like promoting ‘woke’ is more important than promoting safety. How can they be taken seriously? Is the use of he/him or she/her a surrender to the latest fad? Are they now in with the ‘woke’ crowd? Maybe these woke aviation ‘experts’ can factually explain how being ‘woke’ makes us safe.

But perhaps the long-range goal is to make government so incompetent as to be irrelevant. With the push to defund police or accusing the Department of Justice and Federal Bureau of Investigation of political bias, it appears that the goal is to trivialize government’s efficiency and deprive its front-line personnel from any interdependence, divide and conquer the agency’s mission. True victim? Public safety.

There’s an old saying in aviation, “There isn’t enough lipstick to make a pig look pretty.” The DEI policy is abusing those susceptible to racism or bias against women. Capitalizing on legitimate folks’ issues just to promote one group’s own unpopular agenda is just ugly. No matter how hard DEI policies try to force otherwise, they can’t be made appealing… and they hurt safety.

Safety isn’t selfish. It’s colorblind and is applied evenly across both race and gender. Safety could care less who one is attracted to. Safety does need to be taken seriously because it is the prime mission of aviation folks everywhere. We’re witnessing the beginning of the end; the pendulum has reached the end of travel in one direction and will soon swing back, but not before the FAA’s integrity gets crushed under ‘woke’-ism. The FAA is losing its footing in the 10% of qualified aviation organizations that know what they’re doing. The industry knows it and the flying public knows it. It will be interesting to see if FAA upper management figures it out.

Aircraft Accidents and Catch 22

The 1970 movie Catch 22 is based on the Joseph Heller novel of the same name. It is an exceptional tale of Yossarian, a B-25 bombardier during World War II. His attempts to be grounded from flying missions are confounded at every turn by the Army-Air Force’s Catch 22, and this leads him on a vicious circle of reconciling his dwindling sanity in an increasingly insane world. The movie and novel are listed as both drama and comedy, but there is absolutely nothing funny about it.

Catch 22 can be analogous to what has been going on these last two years (going on three years); no one in their right mind would have conceived of such a far-fetched tale as believable. Yossarian symbolizes the struggles of Every Man. In the story Every Man is a B-25 bombardier whose commanding officer keeps raising his allotted missions before he can cycle out. His efforts are blocked by feckless religious leaders (Chaplain Tappman); medical personnel (Doctor Daneeka) who are afraid to draw attention to themselves by challenging the inept leadership (Colonel Cathcart); an opportunist (Milo) who impassively makes money off the demise of others (Nately and Snowden) and numerous colleagues who accept quietly what is going on. The story begins as satire, almost quirky, before it rapidly descends into dark gloom.

All actions produce consequences that must be dealt with; sooner or later, they cannot be ignored. In a complex twist of fate, one could only call ‘bizarre’, life imitated art; the US Federal government moved towards weakening its moral fiber by dismissing civil liberties for the purpose of pushing a vaccine even the Federal Drug Administration refused to approve. During this two-year-plus comedy of errors, less qualified physicians damaged the reputations of more experienced doctors and nurses who were protecting their patients; these selfish physicians ignored studies that showed the vaccine’s safety had come into question, pushed the vaccine on children, all the time ignoring the science. Religious leaders of all denominations deserted congregants, abandoning them to crises of faith. Members of the Military and first responders were demonized. The media, on both sides, turned the nation into a 24/7 battlefield for ethical superiority while the opportunists watched their bank accounts swell. In aviation, safety was dismissed for capitulation.

As we moved towards summer 2021, the Federal Aviation Administration (FAA) aviation safety inspector (ASI) position became unrecognizable. For over two years, vital internal FAA office audits were discontinued; this was the FAA quality assurance program in place for over fifteen years. Flight Standards offices remained all but empty of personnel; enroute inspections were minimized to ineffectual levels; certificate holder surveillance was conducted from a desk at home; FAA management forbade onsite inspections; safety investigations were executed from hundreds of miles away and visual inspections were reduced to the 90˚ angle of a camera.

My job conducting investigations required onsite surveillance, mainly with issues demanding impartiality. In June 2021, I investigated an operator’s ground operation. It took weeks for permission to enroute to the destination and physically visit the ramp, something I did normally before COVID. When I arrived onsite, I was not allowed within 100 feet of the airplane, and I could not talk to the pilots because of COVID restrictions, not even through plexiglass. How is onsite surveillance conducted without access to the gate or the airplane? How does an inspector understand the issues without talking to personnel?

In late summer 2021, when a return to normal was still pending, the government employee became the second of many to be ordered to take the COVID vaccine. The first were the military – take the vaccine or face dishonorable discharge. The third were any government contractors – take the vaccine or be fired. After that it was open season for any and all workers in any industry whose employers were ‘woke’ enough to think that taking unapproved vaccines was wise, because politicians and opinion media said so. ASIs started saying that ‘FAA’ stood for ‘Forgot About Aviation’. Upper management’s arrogance and indifference reached critical mass, so I put in my retirement paperwork.

To be clear, the vaccine was mandated while government employees were still working out of their homes – and would continue to be – without any threat of exposure. Many contractors, again, worked out of their homes and would remain doing so through spring 2022. Just like Yossarian’s missions, the number of months were extended – again – before the COVID ‘crises’ would end. The vaccine was proving to be ineffective and enforcing the mandate far exceeded government powers; it was more intrusive than the futile mask requirement. Bureaucrats were forcing professionals in all industries and citizen protection to comply with the mandate or lose their livelihood and benefits.

In direct violation of the Nuremberg Code of 1947, Constitutional rights were violated. First responders in many states were threatened with termination if not vaccinated, while politicians and celebrities socialized in direct violation of the federal and state governments’ laws. Many favorable to vaccination argued that decisions, such as the Jacobson versus Massachusetts (J vs M) Smallpox epidemic case (1905), gave authority to force vaccination. However, smallpox vaccines were developed by Edward Jenner in 1796. Smallpox vaccines were effective, while all COVID vaccines were still unapproved and experimental. They were superseded by the Nuremberg Code of 1947. J vs M did not apply.

Religious exemptions were left up to review and acceptance by government officials, who felt they could override the doctrines of conscience between the faithful and their Creator. After submitting a religious exemption from my Diocese, FAA management stipulated the Request for Religious Exception to the COVID-19 Requirement questionnaire be filled out, which infringed on religious confidentiality.

While my retirement was being processed, FAA’s upper management believed that each FAA ASI, analyst, engineer, lawyer, etc. would eventually succumb to ‘vaccine logic’, roll up their sleeves, take the COVID vaccine and the boosters, then move on. FAA management shut down conversation; division meetings were non-existent and were replaced by deliberate silence. Medical privacy became the new threat, either download a program that gave management access to all an employee’s personal medical information or face disciplinary action, including termination.

The results of these actions caught management off guard. Despite warnings from past managers and experienced executives, FAA’s upper management pushed on like bulls in china shops, shrugging off the employees’ concerns. Instead of a dispirited workforce, those who could not separate lost all trust in their management teams because management had demoralized all their experienced professionals.

One month after I officially separated, I was asked to answer a post-retirement survey questionnaire. After I submitted my questionnaire, the reply came back thanking me for the input, despite the delay in getting the survey to me over a month late, because “The volume of the separations was so high.” The letter continued, “We lost so many good inspectors due to the [COVID] mandate.”

To those who feel that these FAA persons were nothing but self-centered children whose choices should never have been tolerated, you missed the point. No matter where one comes out on the validity of vaccines, this wasn’t a walk out, e.g., the 1981 PATCO strikes. These separations were not the result of union demands for higher pay; there were no exigences for quality-of-life improvements; these retirements and returns to the industry were not the results of negotiation breakdowns. The Federal government’s position was, ‘If you do not take the vaccine, we do not want you. Your medical condition is irrelevant. It is unimportant if you suffer vaccine after-effects, fear for your family’s well-being or you have a conflict of faith, leave now or we will fire you.’ This was an echo of what had already been faced by the military, medical first responders, law enforcement and fire rescuers.

How safe will aviation be since the FAA forced many of its best people out? The mandate was the one straw too many; separations began long before autumn 2021. Why? Because FAA upper management disingenuously focused attention away from aviation safety and redirected the mission to being diverse and inclusive, two unqualifiable topics that cannot further aviation safety. Wasn’t the FAA diverse before? Yes, the FAA – and the industry – were diverse since before I entered the industry in 1982. FAA upper management created a problem where no problem existed, just to be ‘woke’.

However, to be open-minded, what does Inclusive mean? Not just the definitions we pick and choose but all of them, even the inconvenient ones. According to Merriam-Webster, the second definition of Inclusive is “including everyone, especially: allowing and accommodating people who have historically been excluded (as because of their race, gender, sexuality, or ability).” I’ve been in this industry for forty years and have not seen anyone excluded for race or gender. As to sexuality, who gives a flying leap through a rolling donut about anyone’s sexuality? That leaves ability. Questions: Can a blind Asian woman be a Quality Control inspector? A deaf Hispanic man fly the left seat? Does race and gender eclipse physical handicap? I admit I may not understand, so if anyone knows how diversity and inclusiveness equal aviation safety, please explain it to me, and please do so factually.

How safe is aviation? ‘Experts’ say, “No major accidents – we’re super safe.” While an aviation mass formation exists that says, “Everything is O-K,” we ignore reality like we ignore flight attendant safety briefings. Since 2020, the FAA reduced onsite visits to almost zero, isolated regulators from certificate holders and ended FAA office internal audits. FAA management’s new task? Hiring new-hires to replace – not only workers who left due to the vaccine mandate – but to account for normal retirements every month. Will the FAA lower its experience and industry knowledge standards for manpower needs? Will new hires get paid as much as those who separated? How will industry react to the FAA being understaffed and in a perpetual state of training? How safe is aviation now?

Bureaucrats on both sides of the aisle have created a self-destructive environment; by their actions we now have consequences that they cannot – will not – fix. Those pressured to separate, will not return. To those forced to remain behind, they know that they were demoralized; upper management has dismissed the workforce; citizen rights were too easily disregarded. Threatening loyal professionals with the ability to care for their family was the weapon of choice. Attacks on the civil liberties of the military, first responders, law enforcement and professionals who protect us, only cultivated complacency.

In Catch 22, one pilot, Orr, told Yossarian he would take care of him, but Orr was the one pilot Yossarian wouldn’t fly with. Why? Yossarian thought Orr was crazy. Ironically, Orr had solved the Catch 22 enigma and spent the rest of the war safe in Sweden.

It is telling that those who saw the mandate’s insanity for what it was were called ‘crazy’, that in spite of all the disparaging names thrown around, the vaccine’s safety is now under question. Prestigious medical professionals like Doctors Peter McCullough and Robert Malone are breaking through with information. Joe Rogan was attacked for challenging the status quo with questions. Now, with possible war with Russia, a new question should be asked: “With the military having been forced out by the mandate, are we ready anymore?” Multiple vacuums left by the loss of experienced professionals, military personnel and first responders will become obvious.

How safe is aviation now? Time will tell.

Aircraft Accidents and The Return

Is There a Return to Normalcy?

Now that I am in my own house again after six years, I am beginning the process of reengaging in activities that I enjoyed when I mailed in my last mortgage check seventy-two months ago, one of which is to take part in a local 5K. There is something to be said for building up your endurance from a few ¼-mile laps around the track to 3.1 miles of non-stop running; it tests your mettle, challenges persistence, dismisses procrastination and forces one to realize the most soul-searching fact that one must face at least once in life … Man, am I getting old.

It is difficult to slide back into the game, especially when you make life-changing moves across the country and back again, while some changes hardly affect your life, like going on vacation across the country and back again. But when your job alters dramatically, restricts your effectiveness, with no return-to-normal date in sight, it is unsettling to say the least; the Return becomes the Goal, when you can again do what you do best, be what your career has developed you to be: a Positive Force.

To the average Federal Aviation Administration (FAA) aviation safety inspector (ASI), it is their career to be a positive force for safety. Telling ASIs they cannot – will not – conduct certificate surveillance or when on-site inspections are required, do them virtually, is the equivalent of hobbling them. The FAA ASIs I have worked with do not drive a desk; they are in their environment: on a plane, in a hangar, walking the ramp, chatting it up with certificate holders, promoting safety; that is what they do best.

The FAA has stated that it will be going back to pre-COVID services, very likely in March – fingers are crossed. After two long winters of COVID-19 (shouldn’t it at least be COVID-21 or -22 by now?), regulators are cautiously raising their heads out of a management-imposed underground existence. Like Gobblers Knob’s Punxsutawney Phil squinting in a February early morning dawn, looking for his own shadow, the FAA managers will arise from the bunkers and allow inspectors to reengage the industry, face-to-face. And then, like the famous Sciuridae marmot, many FAA managers will back down their home office holes, overflowing with M&Ms, Hostess Cupcakes and disposable Keurig K-cup coffee; the managers will sigh, taking solace in the current Administration’s ‘sit-back-and-wait’ approach that communicates that everything will be, “… just okey-dokey, fine” – even when it won’t.

Is this an exaggeration? It may be cynical, but not far from being accurate. Since the aviation community became engulfed in COVID scare tactics as a means to ‘save us’, regulatory agencies like the FAA have practiced a torpid attitude toward their responsibilities. Will the FAA’s two years of ‘be-COVID-safe-and-engage-as-little-as-possible’ approach to aviation safety have long term negative effects on the aviation industry and safety? You betcha. Any agency with as much responsibility as the FAA has cannot pull back without crippling the progress it made and stunting its forward progress.

In a recent symposium I attended – virtually, of course – the general agreement was that we have the safest aviation industry … EV – ER; it would be impossible for us to slide backwards from this lofty position. Yet, FAA inspectors on the front line, as well as some that have retired, share my uneasiness. They, too, feel something will shake this industry to its core, that this mislaid self-congratulatory back slapping with the harsh reality of safety … or lack thereof … is all a facade.

We were fooled; we have been hushed into false refuge, a complacency that has duped us into thinking that the skies will always be safe and that we are beyond reproach. Why? Because people in authority said so, that’s why. Is this reality? To be clear, the FAA has been on a two-year self-imposed hiatus, hiding from COVID boogeymen, as if concealing oneself in a basement or home office, retaining six-foot separations and porous masking, could ever guarantee protection from microscopic viruses. The FAA was unseen; they have not been ‘kicking the tires’, diligently keeping the aviation industry on its toes.

The 4th century Roman military writer, Vegetius, once stated in his work, Epitoma rei militaris, “Si vis pacem, para bellum,” translated: “Let him who desires peace, prepare for war.” What is missing is the word ‘always’ before “prepare for war.” If Vegetius were alive today and worked for the aviation industry, he’d say, “Let he who desires safety, [always] prepare for danger; carelessness; complacency; ignorance; etc.” In other words, we can’t walk away from our responsibilities and not expect an opposite reaction. We should have been, must always be, diligent … always.

The industry has also been lulled into a false notion that since accidents had decreased, all is well in Aviation Land; no worries; move onto other business. It is highly likely that, while the aviation industry rested on its collective self-confidence, the unwatched in the industry have continued to cut corners, replacing safety with saving money. That is the reality that has evaded regulators and accident investigators for decades, that human nature will find a way, will fill the oversight vacuum with strategies they would not employ if the FAA were 100% attentive. Passenger traffic down? Lay off ramp people needed for safety. Never realized storing aircraft for three months would result in pickling them for two years? We’ll just get some exemptions or get with engineering. Training put on hold for months? The Training department will figure out something.

It is beyond the pale that anyone, associated or unassociated, with aviation could think that the last two years of distancing from the industry, allowing industry to be ‘on its own’ would not, could not produce any kind of safety environment but one of deep concern. Regular on-site surveillance has become almost non-existent due to mismanagement … and I do mean mis[sing] Management, for regulators and the certificate holders. Where investigations that demanded face-to-face interviews, first-hand observations and personally checking important documentation, such as training records, revised manuals and tool tracking, the FAA workforce were expected to conduct these oversight responsibilities virtually, trusting to the certificate holder to be forthcoming with all questions and concerns.

Two years ago, trust without verification did not, would not, could not, happen; this approach defied everything the FAA stood for. Investigations demanded ASIs’ physical presence; paper documents necessitated visual verifications that could not be performed over a teleconference or virtual meeting format. Trust was earned – often daily – not meted out in place of performing one’s obligation. The FAA’s role was as the regulator, a tremendous responsibility that should never be compromised for any reason. Did FAA management make itself obsolete by requiring ASIs to do their safety-intensive jobs from miles away, jobs for which each ASI is, and always have been, passionate about?

Is this question an exaggeration? Hardly. The B737-MAX was splashed across headlines for months following the Lion Air and Ethiopian Air accidents. The MAX received more attention when the FAA was excoriated for approval failures. Then, after public condemnation receded, the FAA testified on the Hill last Fall that Boeing somehow used inexperienced engineers (OOPS!) for certifying aircraft a-a-and the FAA didn’t notice. What?! So, the FAA missed big certificate holder problems in its own backyard – Boeing. Why would anyone think that certificate holders’ airplanes, pilots, employees, contractors, etc. would receive adequate virtual oversight from ASIs half a country away?

Not only has the chasm between the regulator and the regulated become almost unbridgeable, but the FAA’s own inner checks-and-balance systems have fractured, and worse, vanished altogether. FAA management allowed safety programs that kept its own efficiency go stale or flatline. In 2007, the FAA became International Organization for Standardization (ISO) 9001 certified. Past FAA administrations managed to keep this ISO 9001 certification – not easily acquired – by regularly conducting internal audits that guaranteed standardization and efficiency. ISO 9001 ensured that seven regions of the FAA operated as one, not seven regions operating as seven FAAs, as it will return to. Have these programs survived? Were they shelved or simply eliminated because, you know … COVID?

Have the increasing number of inspector retirements or inspectors leaving to return to industry hurt? Are new inspectors being hired in time and numbers to replace the departing inspectors? Probably not. New inspectors have to be trained, beginning with a three-month indoctrination. Then there are months of on-the-job training events before an inspector can solo, all the while the industry gets further and further away from safety. Since departures outnumber hiring, when will manpower return to pre-COVID norms?

It was never clear, at least not to me, how maintaining the exceptional oversight of aviation safety had anything to do with COVID; there were – and are – ways to be careful and work around health concerns. People fly every day, in a confined metal tube, sitting inches from their neighbor with ineffective masks. But safety surveillance cannot be accomplished? Did restricting ASI ramp or hangar surveillance outside in the fresh air make sense? Those misuses of time and opportunity will be telling to see how aviation safety will suffer. Two years ago, the industry kept regulators busy, busy, busy. Can regulators ever return to that type of endurance again?

Aircraft Accidents and Lessons Unlearned LVII: Kenya Airways flight KQ431

Kenya Airways, flight KQ431

On January 30, 2000, at 9:09 PM (21:09) Greenwich Mean Time (GMT) Kenya Airways flight KQ431, an Airbus A310-304, registration 5Y-BEN, with General Electric (GE) CF6-80C2A2 engines, impacted the North Atlantic Ocean 1.5 nautical miles south of Port Bouët Airport (ABJ) in Abidjan, Côte d’Ivoire, where it had departed from 33 seconds prior; Abidjan, Côte d’Ivoire is in the GMT time zone. KQ431 was the first flight leg through Lagos, Nigeria (LOS), terminating in Nairobi, Kenya (NBO). The accident occurred over two hours after sunset, 6:39 PM (18:39) GMT; the Moon, which rose four hours later, was in a waning crescent, with 25% illumination. The meteorological conditions: eight kilometers (five miles) visibility; clear with scattered clouds at 390 meters (1280 feet) and the ocean leading to the point of impact was dark against a dark sky, giving the flight crew no exterior point of reference of the horizon. Instruments were found not to be an issue.

Per accident report 5y-n000130, the Ivorian Commission of Inquiry (ICI) concluded, “… that the cause of the accident to flight KQ 431 on 30 January 2000 was a collision with the sea that resulted from the pilot flying applying one part of the procedure, by pushing forward on the control column to stop the stick shaker, following the initiation of a stall warning on rotation, while the airplane was not in a true stall situation.

To be clear, per the report’s cockpit transcript, the accident occurred when a stick shaker – a warning that alerts the pilots to a stall situation – activated nine seconds after rotation – not on rotation. The flight was committed, the gears were retracting and the aircraft was nose up in climb meaning; this meant engines were at takeoff power. Per the report’s conclusion, the first officer (FO) [pilot flying] did not complete required Flight Crew Operating Manual procedures during the stall event. Per the report, though he lowered the nose to escape the alleged stall, he failed to advance the throttles to the ‘Takeoff-Go Around’ position to increase thrust, despite the fact the aircraft was still taking off and in CLIMB.

There were too many concerns in this investigation report to speak to in one article, but three problems that stood out were:

  • Who had investigated the accident?
  • How the Maintenance investigation was conducted.
  • The captain’s actions (or inactions).

Who had investigated the accident? Per report 5y-n000130, “In accordance with Annex 13 of Article 26 of the Chicago Convention, the Ivory Coast, the State of Occurrence, launched an investigation.” The report stated, “… accident notifications were sent, in accordance with the provisions of Annex 13, to Kenya and France, respectively the State of registration and the State of Manufacture, as well as to the International Civil Aviation Organisation (ICAO). The investigation work itself began on Monday 31 January 2000 with the establishment of several working groups made up of Ivorian, Kenyan and French investigators. At the Ivorian authorities’ request, the French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) were deeply involved in the investigation and created the report.

It was unusual that, per the accident report, Airbus, GE and Kenya Airways were not listed as providing on-site representation. Organizations listed as contacted and represented, included the BEA, the French government’s investigatory agency, as the State of Manufacture. If Airbus, GE and Kenya Airways were represented, was there concern about the level of expertise on the ICI’s part? Was the ICI up to the challenge of a major accident investigation? How many major accident investigations had the ICI overseen in the past? Would their decisions depend on the integrity of the manufacturers?

Questions of design faults or inherent safety issues that cannot be investigated with objectivity meant that the causal factors would have been lost. If the ICI relied too heavily on Airbus, GE and Kenya Airways for answers, either they might have missed any questionable issues out of ignorance, or they may have overly trusted Airbus, GE and Kenya Airways to be candid with sensitive or proprietary information that aided the investigation. All organizations are self-protective, that was why objective team leaders with experience were important to the impartial flow of information and data research.

How the Maintenance investigation was conducted. Per the report, the investigations were conducted in the following titled areas: Operational aspects, Air Traffic aspects, Aircraft, Site and Wreckage, Readout of Flight Recorders, Testimony, Meteorological aspects and Medical/Pathological aspects. It is presumed – though unknown – that ‘Aircraft’ meant Systems, Powerplants, Structures and Maintenance. Questions raised by KQ431’s unusual last minutes required that the ‘Aircraft’ be investigated by each specialty. While the Causes of the Accident focused on alleged pilot error and their purported failure to follow procedures, what the investigation did not properly convey was why the airplane had a stall warning on climb-out to begin with. The maintenance investigation into the accident was so undeveloped, it bordered on non-existent. Why did the stall warning go off on a routine flight? Was the angle of attack vane stuck? What did the attitude instruments say? Were they cross-checked with the standby indicators?

The investigators concluded that the inadvertent activation of the stall warning was not due to known possible causes, e.g., uncommanded spoiler or thrust reverser deployments; center-of-gravity issues; slat retraction out of sequence; improper speed indication; insufficient thrust per aircraft attitude or aircraft improperly configured. In the report, a list of past events where false stall warnings occurred without a traceable reason was included in Appendix 16 in French; it referred to several different airliners, which made the subjective list inapplicable.

Instead, the ICI referred to a ‘selected scenario’ to explain events that led up to the accident. How was this scenario arrived at? Why did the ICI defer to it? This is where the ICI’s – or any investigatory group’s – aircraft knowledge and experience was vital because a complete reliance on the manufacturer to be candid meant the ICI report’s quality solely depended on the manufacturer holding itself accountable. It was not about blame; it was about cause.

The report stated, “The Commission of Inquiry concluded that this malfunction [stall warning activation] existed before the last departure from Nairobi of flight KQ 430 but that the inoperative condition of the FDR had no connection with the accident.” The ICI made this statement without any basis in evidence. How did they arrive at this conclusion? Did the Maintenance investigation find any reason for this? Systems? Was there anything in the maintenance log to suggest this happened?

Nowhere in the Causes of the Accident or the Contributing Elements were any aircraft or engine concerns addressed, questioned nor even raised. Instead, the three Contributing Elements bullets wandered off on a tangent, calling out trivial issues that did nothing to find the cause. All focus was on pilot, pilot, pilot, bells and whistles – not aircraft. This attention to pilot error raises the third problem:

The captain’s actions (or inactions). A major investigation’s greatest myth is that the cockpit voice recorder (CVR) is effective, that it is productive and should be depended on for accuracy. A CVR is a tool. To unqualified investigators it is a go-to device; a crutch for the inexperienced; a distraction from other evidence that confuses more scenarios while answering less questions. The only thing more unwise would be to install cockpit cameras. But then, where in the cockpit would they be installed?

The CVR’s uselessness was noted by the report when referring to the different flight crew responses that could not be determined in KQ431. Between the first sounding of the stall aural warning until impact, 27 seconds passed. Were the captain’s and FO’s instruments giving conflicting information? Those listening to the CVR could hear aural alarms, but few words spoken; no sense of the speakers’ urgency, no recognition of what the captain was doing. In those 27 seconds, why did the captain not say, “My airplane,” then take control? Was the captain busy with the gear and flaps?

It is hard to believe, with the cacophony of aural warnings, the captain was unaware of an unfolding emergency. He had 1664 hours in the A310 while the FO had 5768 hours. Even though the FO was qualified, hours-wise, and was the pilot flying, the captain was in command.

The report itself may have inadequately portrayed the investigation. Perhaps some things were missed in translation from French to English. However, the conclusions were specific, the findings ambiguous. It is difficult for the interpretations to have missed important information when the conclusions were focused on pilot error and little else.

It is said that a pilot’s greatest friend is altitude; the higher an airplane is above the ground, the more time and room the pilot has to recover. The true frustration with KQ431 was that pilot error was never proven to be a factor; even though the captain did not assume control, the FO had checked out on the A310 and had the flight hours to prove his ability. More concerning, an Airbus A310 takes off on a routine flight before it plummets into the sea in under 30 seconds and the aircraft and its maintenance received minimal attention. Where was the industry on this? Did anyone reading the report ever ask the obvious questions?

Aircraft Accidents and Batteries Not Included

Robert the Robot from Fireball XL-5

I recently went Christmas Shopping for toys … no, not toys for adults; we call those power tools. Most everything that glittered and awed came marked with what battery type was required. These toys came preassembled, pre-decaled and, for the most part, pre-thought out – no room for imagination. Toys and games that required inventiveness were ignored, thickly coated in dust, like: Stratego and Risk, that taught organization and planning; Puzzles, that honed problem solving; Dolls and Tonka trucks, that allowed children to have fun … for the fun of it. Batteries not included. Heck, batteries? Who needs ’em? You can imitate any truck sound without them.

I pity the child who plays with nothing but the latest super-zoomie gadgets; whose entertainment relies on a full charge or a closet full of triple-As. They will never understand why teamwork is essential in little league baseball or the ingenuity of turning an old appliance box into Luke Skywalker’s X-Wing fighter, hand drawn gauges and all. They will not exercise the most important muscles available: their minds. Will they comprehend bicycle repair shop aircraft design; learn how to explore the Cosmos from a wheelchair? Will they learn not to serve the computer or will the computer forever think for them, after they long ago parted out their self-reliance?

ALPA – the Airline Pilots Association – the union representing most airline pilots, sent out an article two weeks ago called Why Two Pilots are Better. The theme is self-explanatory, ALPA is obviously worried about the growing push for single-pilot airliners, so they are pushing for memberships now to counter the effects of the decreasing pilot population, right? Hmmmm! I don’t think so. With all that is going on with Boeing’s B737-MAX or Airbus’s financial A380 overreach (Airbus will have to recoup that loss), do we rea-ea-eally trust manufacturers to build an aircraft with one or less pilot?

The case is made early in ALPA’s article with the observation: “Those who think the industry can save money by having only one pilot on a flight – while not jeopardizing safety are just plain wrong.” There is no need to go further, the point is clearly made: Safety is Paramount. To reduce the pilot numbers to save money is a recipe for disaster. ALPA knows what they are speaking to – no one knows better.

At one time there were four cockpit flight crew members: the Captain, First Officer (Co-pilot), the Second Officer and the Navigator. As technology evolved, the flight navigator was phased out. This was more of a technology driven change since the computer proved to be quicker and more accurate.

The next cockpit position to be eliminated was the second officer – flight engineer – position. It was debatable if this was strictly a pilot position; a mechanic or engineer could perform the second officer’s duties without a pilot’s certificate. This flight crew member would attend to aircraft systems monitoring and control. Duties included assuring fuel distribution and burn were within limits; paralleling generators and performing the preflight walk around inspection. This second officer was not meant to handle flight controls as part of their regular duties, but instead to learn the airplane. It was a critical step. I cannot tell how many second officers asked me, the mechanic, to point out components or systems on the airplane.

In 1963, Boeing built what would be the last three-man narrow body cockpit, the B727. Also, in 1963, British Aircraft Corporation (BAC) introduced an early two-pilot cockpit jet airliner, the BAC1-11; Douglas in 1965 began manufacturing the DC-9 and Boeing, in 1967, the B737, very similar to the B727. These models proved that in the narrow-body, limited range airliner, the third pilot could be phased out.

Wide-body airliners like the B747, DC-10 and L-1011 (1969 and 1970 respectively) kept the third pilot in place until later versions of the B747 (-400 and -8) and DC-10 (MD-10 and MD-11). The Airbus A300B4 was originally designed with three-pilot cockpit; some were built, but the A300 was later converted to two-pilot. The B757 and B767 were originally conceived as three-pilot – especially the B767 as a wide-body – but were instead delivered with a two-pilot cockpit. This was the end of the three-pilot cockpit.

The two-pilot cockpit, however, was not originally a move specifically to reduce pilots, it was a natural evolution; technology had made a third pilot unnecessary. Since the second officer was never a proper piloting position, no piloting duties – hands on flying of the airplane – were eliminated. This was where the necessary streamlining of airline pilot duties should have ended.

Those who wish to change the dynamic that has existed in airliners since the DC-7, fail to understand why the cockpit is more efficient with two at the controls and not one or, God forbid, less. Aircraft accidents that resulted from poor communication amongst its pilots and the result of these accidents had forced vital lessons that led to the most important flight crew evolution: Cockpit Resource Management (CRM). What is being forgotten in this drive for ‘less-than-two-pilots’ is Why CRM was so vital.

CRM cemented the reliance between Captain and First Officer. The two pilots are symbiotic; they depend on the other. Also the First Officer adapts to, becomes comfortable with the aircraft, increasing hours, and benefiting from the Captain’s experience. It is a professional relationship; every First Officer is in training to move to the left seat through a necessary progression. In a single pilot cockpit, who and how does one learn to command?

Interestingly, one thing lost with the second officer’s removal was airplane familiarization. Although the position no longer existed, the systems and aircraft functions that a second officer monitored did not disappear. Just as many, if not more, attention-seeking systems could still fail, some terrifically. Though the technology has improved greatly, the need for pilot airplane knowledge has never vanished. Thus, a single knowledgeable pilot is weaker alone than two knowledgeable pilots together.

Though there were those without foresight who thought technology solved everything, emergencies continued. Dangers increased because pilots were losing real-event experiences faced by their pilot ancestors, events not covered in the simulators. This was evident with accidents where not knowing the aircraft resulted in tragedy, where each accidents’ probable cause concealed root cause, e.g., Air Midwest 5481, National Air Cargo 102, Colgan Air 3407. They each demonstrated that even with two qualified pilots at the controls making joint decisions, much would have been gained by learning what a second officer’s duties were, by knowing the airplane, that could have prevented the preventable.

To replace the pilot with technology that, whether the cockpit is occupied by one or no pilots, the thought is that efficiency will increase and, as a result, safety; plus, costs will go down. However, we ignore, at our peril, the lessons of relying too much on technology. Were the B737-MAX accident lessons ones of too much technology or were they lessons of too much reliance on technology? Have we trained pilots to become so dependent on the computer that we forgot that Humans Designed the Computer? Were the fatal mistakes that led to both accidents – and possibly others – have been because pilots no longer actually fly the aircraft, so they failed to recognize the signs?

Or is it more likely that the accident reports were not in proper context? For instance, what were the report writers’ qualifications? What were the airline cultures like? What was pilot training like? Did these events occur with United States pilots? Why, when the systems were worked on, no one called Boeing?

How can we trust our industry to computers when we do not understand their limitations? We want to completely phase out all fallible human presence in the cockpit and replace it, completely, with an infallible device programmed by a fallible human, saving money at the cost of safety. No, we risk so much on the quality of the computer, that we do not even recognize our own complacency.  If we kick pilots and their experience to the side, when the first inevitable accident happens, who then would be responsible for what occurred in the cockpit? There should be no one left – but ourselves.

Aircraft Accidents and Lessons Unlearned LVI: N47BA – Payne Stewart


On October 25, 1999, at 12:13 central daylight time (CDT), a Sunjet Aviation Incorporated Learjet 35, registration number N47BA, impacted an open field in Aberdeen, South Dakota. At some moment amid the last recorded direction from air traffic control (ATC) at 08:27:18 CDT and 08:33:38 CDT, contact between ATC and N47BA was permanently lost; in that six minutes and 20 seconds, it was believed that N47BA suffered a rapid cabin depressurization that incapacitated the flight crew and everyone else onboard. Four air national guard (ANG) F-16s – two Oklahoma ANG and two North Dakota ANG – were diverted to intercept N47BA’s trajectory to assist and/or communicate with the crew. All attempts were unsuccessful; N47BA’s flight crew was unresponsive and unanimated. One ANG pilot followed N47BA as it spiraled to ground impact. The flight was operated under Title 14 Code of Federal Regulations (CFR) Part 135 Air Taxi and Commuter; the accident was assigned accident number DCA00MA005.

Often, in addition to major accidents, the National Transportation Safety Board (NTSB) has launched a major accident group to investigate a government official’s accident and, sometimes, an accident involving a celebrity. In this case, six fatalities resulted from the accident, including pro golfer Payne Stewart; the use of the letters ‘MA’ in the accident number DCA00MA005 denoted a major accident investigation. For this case, six NTSB major accident investigators were assigned to cover Recorders, Operations, Human Performance, ATC, Maintenance Records and Airworthiness. Possibly, one of the NTSB’s assignment confusions was to separate Maintenance Records (MR) from Airworthiness (A/W); both were the same subject; MR and A/W were investigated by non-maintenance investigators who wrote two separate reports that should have been organized into one. It was unclear who the Inspector in Charge (IIC) was, but he/she should have led the investigation and managed the efforts.

The NTSB provided the following Probable Cause:“The National Transportation Safety Board determines the probable cause(s) of this accident to be Incapacitation of the flight crewmembers as a result of their failure to receive supplemental oxygen following a loss of cabin pressurization, for undetermined reasons.” The report provided no data. Worse, it provided no viable probable cause.

There were two reasons this non-probable cause stood out. For one, the use of the term, “… as a result of their failure to receive supplemental oxygen”. What did this mean, their failure? The inability to ‘receive supplemental oxygen’ could have been due to no oxygen being available – a fault in the oxygen system; the rapid decompression occurring too quickly for the pilots to have donned their masks or the pilots delayed too long in donning their masks. Either way, it was presumptuous to apply ‘their failure’ to the pilots without considering equipment failure or making an effort to prove ‘their failure’.

The second concern was the phrase: “… for undetermined reasons.” For a major investigation, this made no sense. Title 14 CFR Part 135 is a large presence in the aviation industry. Separated into ‘nine [passengers] or less’ and ‘ten or more’ operators, Part 135 includes, but is not limited to: helicopter medical services, air tours, air taxi, cargo contractors, corporate aviation, and others that far outnumber airline certificate holders (Part 121). Part 135s often work hand-in-hand with Part 121 operators. The lack of attention to such an accident was dismissive of Part 135 operators.

To be fair, the NTSB report stated, “The full report is available on the NTSB Web site. See for details. However, a search of this address opened an NTSB page that stated, “Page Not Found. The page you’re looking for doesn’t exist.”

There was a docket for DCA00MA005, but the documents showed no coordination between the final report writer (the IIC?) and the separate specialty groups. The final report contained nothing from those specific areas. What was the point of an investigation when what was discovered was never included?

The Operations report shed little light on the event aside from what the various manuals and procedures dictated that were followed. The Federal Aviation Administration (FAA) Principal Operation Inspector had been found to be engaged in the operator’s surveillance, so no FAA problems. The function of certificate holder surveillance and accident investigations is to understand what was right, what went wrong and to document both for safety advocates to build upon. Their purpose, however, is to learn moving forward; how to avoid repeated mistakes and to develop safeguards to protect aviation’s future.

The Operations report shed little light on the relationship between the FAA and the operator, Sunjet Aviation. Were there training issues with donning masks during emergencies? If everything was positive, why did the IIC fail to report it? Why did the IIC assume the flight crew failed to receive supplemental oxygen? Why was the Operations report ignored? The Operations information became a wasted opportunity, a lost chance to improve. Any mistakes missed were likely to be repeated.

It is necessary to remark upon a detail noticed by the ANG pilots as they flew in close proximity to N47BA, that was the cabin and cockpit windows were frosted and obscured any view into the aircraft, an indication of rapid decompression. When the cabin pressure was ‘dumped’ in a moment, the humidity, having been exposed to a sudden drop in temperature (at altitude) in the aircraft, went from suspended droplets to a gaseous state abruptly; the rapid temperature drop caused the water vapor to freeze to any surface, including the windows, which were described as “opaque” with frost. If it was assumed window heat was selected ‘ON’, was it working? Would window heat have affected the inside of the window, or would the cabin’s sub-zero temperature have canceled out the window heat’s effects?

This rapid decompression could have been caused by another catastrophic event beyond a valve failure. The decompression could have been attributed to a structural failure, perhaps a repair patch to the pressure vessel or a blown pressure seal. The ANG pilots said they did not notice exterior damage, but that does not mean a repair concealed by a fairing could not have failed. ATC’s last direction to N47BA was to climb to 39,000 feet but per the report, ANG caught up with the aircraft at 44,000 feet. Was the altitude selected in error or did the flight director exceed the targeted ceiling? Low oxygen at that altitude equaled an oxygen-deficient cabin, quick disorientation, blackout and suffocation. It was unlikely anyone survived, even unconscious, 2-1/2 hours without oxygen before the crash.

The final report was brief, especially for a major accident. It consisted solely of a recap of the last flight – nothing else. It was not an accident report, it was a play-by-play reminiscent of a documentary. Nothing useful from any of the specialty reports made it to the final report.

The MR report was wanting; the investigator did not appear to know aircraft maintenance. Questions in the MR report concerning a specific outflow valve airworthiness directive (AD) was valuable but detailed maintenance going back to 1979 was elaborated on in explicit, useless detail. This type data filled pages with irrelevant information. Specific outflow valve AD data (the valve was installed) and the altitude limit tied to the valve (which was still enforced) should have been pursued. Needed attention should have been directed to other possible failures for the decompression. The focus of attention Maintenance demanded, but did not receive, became a point of frustration; the MR report was Quantity, not Quality. The MR should have been integrated into the A/W report where better analysis was performed.

The A/W report was well written and researched. The A/W investigator invested Systems knowledge into the A/W Chairman’s report, important data that should have made DCA00MA005 a positive effect on aviation safety. The A/W report’s information was more instructive on the possibilities, a lot more helpful to understanding what happened. However, the IIC’s final report ignored the A/W report.

All accidents are important; none should be discounted due to aircraft size or fatality numbers; no person of fame should demand more investigatory diligence than a private pilot. That being said, when a notable circumstance occurs; when a catastrophic event this uncommon transpires, one that called attention to both Operations and Airworthiness; to allow this investigation to close with a weak sigh was inexcusable. Was there no more conclusion for the IIC to put forth beyond, “for undetermined reasons”? Did the pilots err? Maintenance? Component manufacturer or overhaul facility? Was it a maintenance manual procedure written incorrectly? Even a guess or blindly throwing a projectile at a dart board would have produced a more constructive probable cause. The aviation industry will never know. They should have cried out or perhaps they fixed the problem in spite of the report. DCA00MA005 was a result of minimal effort. Operations and Airworthiness created two paths to follow but the IIC’s inexperience left the most important information ignored.

Aircraft Accidents and a Trip to ‘The Hill’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned LV: Loganair flight 670A

Loganair Flight 670A post crash

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Sense

Amtrak’s Empire Builder de-railed

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Southwest Airlines flight 812, aircraft N632SW

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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