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.

Aircraft Accidents and the Imitation of Art

Count Dooku’s Realization

It would be difficult to find anyone from the age of five to one hundred and five who does not know who this movie character is or why he is in this predicament; from the 2005 movie Star Wars III: Revenge of the Sith (SW:ROTS), the one-time leader of the infamous Separatist forces, Count Dooku. In this scene, Dooku suddenly realized, at his end, how he had been betrayed and played for a fool by his Boss. In this moment, Dooku understood he sacrificed everything, gained nothing, and was to be blamed for all the galaxy’s pain and suffering; his pathetic death would only amount to the ignobility of being his ignorant successor’s first ‘kill’. The successor was a whiny Dark Lord who spent his entire professional career driven by his own emotions. No FACTS … just plenty of moodiness, better known as FEELINGS.

Sound familiar? Rarely has life imitated art more than it did with the Star Wars prequels. As each movie premiered, deceptions intensified; each character wandered further from their moral center. Fifteen years since the movie premiered, we, as a nation, to our peril, ignore the depths to which we are all falling. The crises we have nurtured to bring upon ourselves; the lengths we go to turn on our own; we are forgetting who we are as Americans. We have truly met the enemy, and they are us.

As awful as the 9/11 attacks were, we banded together as a nation unlike any other time since Pearl Harbor. Yet, with the recognition of the twentieth year since the 9/11 attacks, another generation has reached adulthood, unaware of the United States (US) before 9/11’s infamy. In that twenty-years, what have industries across this great nation forgotten? It is a valid question because we fail to remember what America was like before CVD-19. How will this generation survive? All industries, many businesses, will be devastated if the future does not correct. If, that is, we remain ignorant of what is needed to correct.

Take Aviation Safety: Do we honestly believe we are safer today than we were two years ago? With the CVD’s crippling effects on society, has the Federal Aviation Administration (FAA) been consistently conducting on-site surveillance of air operators, repair stations, aviation schools, manufacturing when FAA inspectors are not even allowed to be in their offices? How many FAA enroute inspections have been conducted? With an Airbus A350 being able to seat up to 369 passengers or a Boeing 777 seating up to 396 passengers, what numbers will be most prominent: a 0.25% or less CVD-related death rate over 18 months in many cities or the over 400 people killed in one second from a safety-related accident? How will the Count Dookus in the media spin those numbers?

Take the Aviation industry: How has the nation’s switch from energy independence to dependence on foreign oil benefited the US? Has the US’s tragic withdrawal from Afghanistan signaled to the Middle East that the US is now vulnerable to oil price hikes? During this brief pause in the two-year old CVD-19 scare, travel will (supposedly) pick up … for a while. The airlines will pass the rising fuel costs onto the flying public. Hotel and rental car industries will eventually suffer as travel slumps. When smaller airlines fold due to decreasing traffic, what is the first thing to go? Training and Maintenance. Safety will suffer. The numerous mechanics, pilots, etc. jobs will dry up. Repair Station contract opportunities will suffer … again. A traveling public that originally enjoyed vacations, will no longer travel because their industries, such as food service, medical, manufacturing and others, are being crippled. Why? Because stimulus checks paid people NOT to work. When the stimulus checks stop – as they will – the jobs that dried up, will no longer be hiring. Why? Because they will no longer exist. Customers will not ship air freight; buying online will be gone, all due to the Count Dookus who are misdirecting us.

Take the Tourism industry: Does anyone believe that those who run, e.g., Disney, are worried about the threats to tourism? Their money is in Media and Communications; the parks are money makers, but not where they are making their Big Cash. The Park employees are expendable. Do airline bigwigs still take stimulus money? Do airline employees see the stimulus money or are they dependent on the success of the airline, their futures riding on the sustainability of a hurting economy?

Take the Aircraft Manufacturing industry: Do we understand what the ramifications of deserting military equipment in the Kabul evacuation means? Aviation technologies, born in the US, will be China’s. All US advances in aviation, e.g., composites, will be lost to an uncivilized Taliban. Military weapons will be dissected and studied by our enemies. Our manufacturing breakthroughs, originally considered top secret to give our military a leg up, which were so irresponsibly abandoned by military leadership, will be used against our sons and daughters. How many of these Count Dookus will be held responsible for the damage this has done to the aviation industry and national security?

Take the Defense industry: the refugees that arrived from Afghanistan are welcome, indeed many deserve to be here for the help they provided to US servicemen and women. But were all of those that came over the refugees who helped us? Was there a reason some made their way unmolested to the planes while others were barred, physically, from getting out? Are refugees being kept on the military bases or are they allowed to wander into surrounding neighborhoods without limits? Have they been treated for CVD-19?

Take the Medical industry: Nurses are being fired because they refuse to be vaccinated. How will the drop in available medical practitioners affect the costs of health care? How will the quality of health care be affected? How is it that medical practitioners we hailed as heroes a year ago are now dismissed, so easily terminated because, as medically qualified they recognize the dangers of an unproven vaccine? But some may say, “The Food and Drug Administration (FDA) approved the Pfizer vaccine.” Did they? Has anyone read the FDA’s letter of ‘approval’? The Pfizer letter did not approve the Pfizer vaccine; it continued the emergency authorization issued per Section 564 of the Federal Food, Drug and Cosmetic (FD&C) Act. Per the Association of State and Territorial Health Officials (ASTHO), “An Emergency Use Authorization (EUA) under Section 564 of the FD&C Act allows for the special use of drugs and other medical products under certain types of emergencies.” What this means, per ASTHO, “An EUA permits the use of unapproved medical products … in unapproved ways to diagnose, treat or prevent serious diseases …” Furthermore, “An EUA authorization under FD&C Act § 564 does not contain or confer any tort liability protections by itself …” This means that if the vaccine causes other health problems, including death, a patient is not necessarily covered by insurance. In other words, if you die from vaccine-induced complications, your family still may not receive the insurance benefits. Not … one … cent.

One third of the US population is not vaccinated; some races far outnumber other races in defying the vaccine mandates; NOTE: it is not the white race. The Bottom Line is Nobody trusts bureaucrats to tell them to get a vaccine; that belief spans all races and both genders. Would that be considered racism to force any race to vaccinate against their will? The forced vaccine mandates and vaccine passports will paralyze the aviation industry; people will refuse to fly before taking the vaccine. The departure of medical industry professionals and any industry persons involved in supplying US citizens with medical treatment will cripple health care. How many Count Dookus will be held accountable for this?

But let us return to the point about firing medical professionals for refusing the vaccine. In the last few years, the Military has been slandered; this discrediting was increased by the recent rushed exit from Afghanistan ordered by inept military leaders. The law enforcement community has been demonized, officers killed, some local governments smearing them, since the summer of 2019. Firefighters are presently being pressured to vaccinate in cities like Los Angeles; those refusing to vaccinate are threatened with losing their jobs and their pensions. Now medical personnel, such as nurses, who worked tirelessly during the real CVD crisis, are being terminated from their jobs for not taking the vaccine. How quick we are to destroy the lives of those who disagree with us, who helped us when we needed them; those with a far more experienced grasp on what this vaccine represents. Think about it: those who have dealt with CVD patients daily, say, “Do not take the vaccine,” while politicians and bureaucrats with no understanding of this virus, crush our defenders without a trace of compassion.

One might ask, if the vaccine is so imperative, why not give the approved drug Hydroxychloroquine? It remains unclear why Hydroxychloroquine was denied to so many who could have been saved. Did that make sense? Meanwhile, what are the fatality numbers? According to the latest Johns Hopkins University numbers, the CVD fatalities recorded in cities like Birmingham, Alabama: 1 in 394 (0.25%); Spokane, Washington: 1 in 683 (0.14%); Madison, Wisconsin: 1 in 1,571 (0.06%). We are hiding from a virus with a 99.7% survival rate and that is including those with pre-existing conditions. What these numbers do not record are the ages of the deceased, their pre-existing health conditions or if their death was agitated by an event, such as a car accident or house fire. What these numbers say is that the fatality rate is almost imperceptible. In the meantime, the Red Cross will take whole blood, stem cells and blood plasma from the unvaccinated; no hesitation, no requirements, no limits, no problems. How hypocritical.

Pick an industry; find a group that will not be debilitated by rising fuel costs, rising health care costs, rising food costs, rising electricity costs. The independent trucking industry; food service industry; hospitals and emergency services industries; retail industries. All industries, sabotaged by imaginary health scares and unnecessary rising costs. Our international strategies and trust devastated by the US’s ignorant withdrawal strategy from Afghanistan. Look for gas lines that go on for miles, just like in the 1970s. Supply lines devastated more than they are now. More people entering unemployment.

As this article is put to digital paper, the government is ‘forgiving’ student loans, readying more stimulus money and making it harder for small businesses, like Mom-and-Pop repair stations, to survive. When the check comes due – because it will – how many will feel that Entitlement was such a good idea? What of those whose education is lost in the pending job shortage? Will we ever feel that destroying work ethics will improve life? Whole generations will wake up one day and realize they are unable to rent, provide for their families or even buy a home. Watch as entry-level jobs evaporate due to illogical minimum wages and robotics. The food service industry is already turning to artificial intelligence and robotics will soon replace food preparers. Air cargo sort facilities will follow their courier services’ lead and go robotic for everything, from aircraft loading to full cargo sorting. This will follow into passenger service where live ramp employees will be phased out to prevent paying exorbitant minimum wages, health care costs and time off. Future generations, with no skills, will woke themselves into poverty. What Count Dooku will this impotent generation blame then?

Nothing over the last year and a half makes sense; each government demand is illogical and not based in facts. Hydroxychloroquine, an approved drug shelved while an untested and unapproved vaccine is pushed for mass distribution. A virus with an imperceptible fatality rate inspiring massive fear; bureaucrats silencing doctors; our protective agencies being demonized; our economy being sabotaged; the Middle East being destabilized; politicians so untrustworthy their incompetence would be comical if they were not so serious. And all the while, these destructive strategies are lauded for their diversity and humanity.

One more reference from SW: ROTS, where Life imitates Art. When all the galaxy began the twenty-year duration of the Galactic Empire, Senator Amidala said, “So this is how liberty dies, with thunderous applause.” We are in danger of losing all our liberties. Only those who do not understand are cheering.

Aircraft Accidents and Lessons Unlearned LIII: Northwest Airlines Flight 255

The resting place of Northwest Airlines flight 255

On August 16, 1987, at about 19:45 (7:45 PM) Eastern Standard Time, Northwest Airlines flight 255 (NWA255) crashed shortly after taking off from Runway 03 Center at Detroit Metropolitan Wayne County Airport in Romulus, Michigan (MI). The Douglas DC-9-82 aircraft, registration number N312RC, failed to climb out before striking light poles, a building’s roof, then the ground. The aircraft broke up as it slid, never veering from its takeoff heading.

The same pilots were flying this third leg of four bound for Phoenix, Arizona, that originated in Minneapolis, Minnesota. The National Transportation Safety Board (NTSB) assigned NWA255 accident number DCA87MA046; Accident report AAR-88/05, published on May 10, 1988, stated, “… that the probable cause of the accident was the flight crew’s failure to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.”

The probable cause was correct. Examination of the cockpit voice recorder (CVR) showed that during taxi out on departure, the flight crew did not run the preflight checklist and, based on the flight control positions found after the accident, did not extend flaps and slats for takeoff. Unlike the stabilizer trim being set without verbal confirmation (the sound of the stabilizer trim ‘in-motion’ horn recorded on the CVR), there was no aural indication that flight controls were extended. From here the report should have examined why the pilots did not run the preflight checklist, to get to the Root Cause of the accident, whether it was a failure on the airline’s procedures; a lack of productive check rides or even something human factors related. However, accident investigators failed to pursue Root Cause.

The report’s reference to the takeoff configuration warning system (TCWS) and its apparent electrical failure diverted attention away from the sole probable cause: pilot failure to use the checklist. As AAR-88/05 stated in the Probable Cause, “Contributing to the accident was the absence of electrical power to the airplane takeoff warning system which thus did not warn the flight crew that the airplane was not configured properly for takeoff. The reason for the absence of electrical power could not be determined.” This was a coincidence that the pilots’ break with procedure aligned with a system that did not function correctly, but should the TCWS have been a contributing factor or a Finding?

Using the accident number, DCA87MA046, the NTSB docket page was queried for Field Notes and Team Lead Factual Reports, especially the Systems Lead’s TCWS notes. The Docket Search Result, however, was “Zero Dockets” as was the docket search result for Delta Airlines flight 1411’s accident report notes, which will be discussed later.

To be clear, the TCWS is a redundant system; its purpose is to alert the pilots of the misconfiguration. TCWS is not designed to remind pilots nor is it a hazard warning in the course of normal flight, e.g., terrain or pending midair collision warnings. Although, the TCWS warns when procedures are not followed, it should never be relied upon to sound. TCWS is a last resort, designed to never be used. It was not an accident cause nor was it a contributing factor. The NWA255 pilots’ failure to run the preflight checklist was the only Probable Cause. The checklist failure, however, was not a Root Cause.

This distinction is important because responsibility – in some cases, as in NWA255, sole responsibility – needs to be defined. If we are to learn the true lessons from aircraft accidents, we must ignore unrelated distractions and narrow the initiates down to root causes, otherwise the lessons are clouded. In this case, the cause was procedural; the NTSB focused attention away from the pilots and called for technology to fix the problem, clouding the problem even further. This diminished pilot skills, their responsibility given to technology. Pilots became more obsolete.

What was the TCWS? The TCWS in the NWA255 DC-9-32 was a mechanical system that employed a series of switches and sensors that reacted to the position of, e.g., the engines’ throttle cables, landing gear sensors, cable or hydraulically driven flight control drive units. TCWS could also work during the landing cycle, assuring flight controls and landing gear were in position for approach and landing. Compared to today’s digital TCWS, the warning system was very rudimentary, but effective. If the flaps, slats, landing gear and/or spoilers were out of takeoff configuration, an alarm horn would sound. It was unlikely that the TCWS was a deferrable item; if non-functional, the plane was not airworthy until repaired.

However, if the TCWS were recognized as a cause, NTSB investigators made a significant omission by not interviewing the Minneapolis maintenance crew and another error by ignoring the maintenance history. It was a critical mistake that Maintenance information and research was absent. Had the throttle cables recently been replaced; the flaps rigged; the landing gear time-changed? Had the mechanic in Minneapolis moved the throttles forward to see if the horn would sound? Was there a preflight inspection conducted by Maintenance and, if not, why not? This could have led to proactive recommendations.

Which is why the NTSB’s fixation with an alleged TCWS electrical system power loss was odd. The docket was empty of any enlightening data related to what the NTSB Systems engineer proved or if he/she was looking in the right place. During the aircraft breakup, sensors were jolted out of place; cables became excessively stretched or broken. It also, unless circuit breakers were physically open, raised the question: How did the Systems engineer determine that power was not available to the TCWS? More importantly, why was the supposed electrical power loss considered a contributing factor?

This is why going off on tangents was wrong. It was dangerous to divert resources and attention away from the investigation path. Additionally, the Probable Cause was for serious information. Investigations that branch off into unrelated departures, leaves the correct causes to be diminished, to get lost in the minutiae of other theories. Speculation should be raised in the investigation’s Analysis phase; if it cannot be proven it should not make the accident report and should be edited out with other theories. If the Systems investigator gave credence to phantom electrical problems, why not question a TCWS sensor design; a switch location; a throttle rigging procedure? All of these components could have just as easily affected the TCWS warning horn. Where would speculation end?

The investigator spent four pages of the report talking about an electrical problem that could neither be found nor proven even existed. In those four pages the investigator did not move the investigation forward, nothing productive was learned. Was the investigator-in-charge unable to bring the conversation back to facts?

It was unclear from the accident report, whether TCWS function was confirmed by the flight crew since the CVR transcript began after the pilots conducted their pre-flight. Any aural warning checks performed by the flight crew during their pre-flight were omitted from the CVR transcript. Even if the CVR transcript recorded the pilots’ pre-flight check, the TCWS could have malfunctioned during pushback or taxi-out. During a review of the transcript, there were five unidentified identical noises titled: “((sound of click))” that occurred between 20:43:11 and 20:44:39 as the aircraft was powering up for takeoff and running down Runway 3-Center. Was this the TCWS aural warning trying to function? The investigator never identified this clicking sound.

It was unfortunate that time was wasted on tangents. Proactive measures could have been worked out with the Federal Aviation Administration (FAA) to identify the Root Causes of the pilots’ failure to follow procedures. On August 31, 1988, 381 days after the NWA255 accident (113 days after AAR-88/05 was adopted), Delta Airlines flight 1141 (DAL1411) crashed during takeoff at Dallas-Fort Worth International Airport. The DAL1411 accident report, AAR-89/04, stated as the Probable Cause, “(1) the Captain and First Officer’s inadequate cockpit discipline which resulted in the flight crew’s attempt to take off without the wing flaps and slats properly configured.”

Following AAR-88/05’s adoption, the FAA issued Air Carrier Operations Bulletin #8-88-4 in June 1988; the Delta Certificate Management Office received Bulletin 8-88-4 on August 30, 1988, and Delta received the bulletin on September 5, 1988, five days after the DAL1411 accident. Bulletin 8-88-4 directed an airline’s FAA Principal Operations Inspector to review, “… overall takeoff warning system performanceand ensure that the checklists appropriately support required crew actions …” Checklist non-compliance was the fundamental cause of NWA255 and, unfortunately, DAL1411. With NWA255 having occurred over a year prior, its investigators might have prevented DAL1411, whose pilots did not run the preflight checklist, just like NWA255’s pilots.

AAR-88/05’s recommendations were toothless, as if the NTSB called them in. Expedite the issuance of guidance materials? What does that mean to the industry? Have Principal Operations Inspectors emphasize the importance ‘disciplined application of standard operating procedures’; ensure training includes cockpit resource management? These were not recommendations; they were the restating of the obvious. If Northwest Airlines messed up their required training, then say so; state it clearly.

Finally, two points about why analysis of 34-year-old accidents is important, especially when digital aircraft monopolize our skies. First, the NTSB has not changed its approach to accident investigation procedures; they still employ decades-old practices, e.g., using engineers with zero industry experience, who do not understand airline culture. That is why all Maintenance issues were missed. Second, the NTSB did not get NWA255 right. What improvements, then, have been implemented into the aviation industry today? If the fixes were wrong in 1988, are we any safer in the 21st century?

Aircraft Accidents and Fabricating

Battle of Monmouth during the War for Independence

Of all the young of the animal kingdom, the most helpless at birth is the human. Whether due to overprotective human emotions through evolution or natural instinct, the human infant is heavily reliant on its parents for everything. Often, the only way a human child can communicate its distress is through crying, loud and long, until it is satisfied. Amazing how adults today, especially politicians, continue to cry, loud and long, about manufactured issues. One could make a killing in the adult pacifier business. Professionals, concerned with aviation safety, are being drawn into a political battle of social justice.

In 2001, after the 9/11 attacks, it took several days before civilian flights were back in the air. However, per the Bureau of Transportation Statistics, it took three years for the industry to recover to pre-9/11 levels. Last year’s strains dwarf the aviation impacts of 9/11 where Aviation’s losses took place over months, not days. Recovery will take a lot longer. Pilot training issues; Federal Aviation Administration (FAA) oversight backlogs; internal audits of operators and repair stations all demand attention. In the meantime, Politicians focus on Aviation, hobbling our industry with fears of new COVID strains, while fabricating new divisive agendas, the latest: Diversity and Inclusion.

Is Diversity really a problem in Aviation? Impossible to prove either way with no existing resources for Facts, data or evidence. For unskilled labor, evidence depends on many factors, e.g., location, cost-of-living, etc. Among skilled labor? Not likely. Forty years ago, I was unskilled labor in Kennedy and LaGuardia, where there was a healthy mix of all races and both genders. Later, as an FAA-certificated airframe and powerplant (A&P) technician, race or gender were irrelevant; the job depended on skill, certification and experience. When in management in Newark, I could not hire diversely for skilled positions because a diverse candidate pool did not exist. That is the reality, whether one chooses to believe it or not. If tangible data exists that the Aviation industry is racially corrupt, it must be presented. Allegations, based solely on feelings, are destructive.

Many high-paying positions in Aviation require skilled individuals. There are entry-level positions, but the more challenging require FAA-certification. Even so, not every FAA-certificated pilot can fly an airliner nor FAA-certificated technician troubleshoot a digital navigation system. Among numerous factors that affect an aviation candidate’s hiring are passing a check ride or furlough recalls. A job candidate is not defined by race or gender; skill has nothing to do with Deoxyribonucleic Acid – DNA.

Recently, the Media, some airlines and aeronautical school leadership, would have us believe that the greatest threats to aviation safety today are racism, gender-bias and inclusion. To the thousands of dedicated men and women I have worked with of all races, who have been improving aviation safety for generations, this news must have been a surprise, to learn that Safety can be improved by a concept such as Diversity. The answers, as suggested, are in people’s hearts, not in Root Causes or Facts.

This is a divisive phenomenon that has been escalating for several months. How many friendships, marriages and families were destroyed for having the ‘wrong’ view on any topic that may be hindered by bothersome Facts of any kind. For example, with the unending ‘threat’ of COVID, why not close the border, or at least control access since many confirmed cases are crossing in? Is that racist or common sense? Some people, who do not know me, would call my way of thinking ‘racist’.

There are two problems with this emotional name-calling. First, COVID and ‘racism’ are fundamentally dissimilar; they have nothing to do with each other. Second, calling someone ‘racist’ dodges the question; it is a social justice tactic to distract from the discussion and, thus, a solution. But maybe distraction is the idea. Responses like ‘Nazi’, ‘Hitler’, ‘Racist’ are distractions. They serve no logical purpose, solve no problem. Challenge climate change? You’re a ‘climate denier’. Question COVID vaccine safety? You’re an ‘anti-vaxxer’. Question Diversity as a job qualifier in a safety-sensitive position? You’re a ‘racist’, ‘homophobe’ or ‘misogynist’.

How do we know racism and gender-bias dangers exist? For one, government is telling us so. The FAA will spend millions to crush alleged gender-bias into dust; a typical government response to a crisis that does not exist, a dilemma in search of a Fact. On June 25th, the United Kingdom’s The Daily Mail reported, “Woke FAA Advisory committee recommends using gender-neutral terms like ‘aviator’ and ‘flight deck’ to avoid offending ‘femme’ workers;” The Washington Post (WAPO), Fox News, etc. also reported this story. A WAPO article by Lori Aratani suggested that the term ‘cockpit’ was not gender-neutral, stating, “… male crew members have sometimes ‘wielded the term [cockpit] to undermine femme workers’”. WHAT? Male crew members “wielded a term”? How does One ‘wield a term’? This makes no sense because Ms. Aratani Fabricated a problem. That is what Media does.

If I ask why terms, like ‘cockpit’, are not gender-neutral, the reply will be, “You’re a misogynist.” Ms. Aratani showed how the Media will not even invest the time to get the story right. They do not respect their aviation audience. Is the WAPO correct? Are professional women victims of pilots who “wield the term ‘cockpit’”? Are female Captains really ‘maidens in distress’ on their own flight deck? Or, perhaps instead, the Media is poo-pooing professional women, painting female Captains as helpless and in need of men to protect them from male chauvinist aviators. It also suggests that reporters, like Ms. Aratani, are not assigned stories despite their ignorance of the subject, but because of their ignorance. A reporter’s lack of topic knowledge generates emotional responses, like name-calling, and cannot be taken seriously.

There is little doubt that the Media has become unreliable; politicians are as well. No sane person trusts the Media (or politicians) and they have no one to blame but themselves. They have regressed into diluted sources of opinion; Facts no longer matter. The Media is hijacking the narrative of our industry and it is not productive. Therefore, are their calls for Diversity and Inclusion justice sober demands?

Inside aviation, there are other serious safety issues, such as political ignorance bleeding into our industry. This obliviousness comes from outside the aviation industry, arguing artificial issues that have nothing to do with how the aviation industry functions. Are these outsiders hijacking legitimate and trusted aviation resources? Last month, Embry-Riddle Aeronautical University (ERAU) called for papers: “Attention writers: The Journal of Aviation/Aerospace Education and Research (JAAER) is proud to announce a call for papers related to diversity, equity, and inclusion in the aviation industry. This special issue will aim to publish thought-provoking scholarly and research articles related (but not limited) to race, age, gender, sexual orientation, religion, and other nascent and incipient forms of inequalities in the context of the organization and work within the aviation and aerospace industry.”

Note how ERAU applied the words ‘scholarly’ and ‘research’ with ‘diversity’ and ‘inclusion’; they have nothing to do with each other. ‘Scholarly’ and ‘Research’ were being used to make ‘diversity’ a valid path to aviation safety. This JAAEC paper mirrored the FAA’s Diversity and Inclusion plan (DIP). The FAA stated on its website, “Diversity is integral to achieving FAA’s mission of ensuring safe and efficient travel across our nation and beyond.” How does Diversity and Inclusion ensure Safety and Efficiency? How strangely unrealistic of the FAA. Has the FAA become UN-diversified since Jane Garvey and Marion Blakey ran it? Look at the FAA’s mission statement: “Our continuing mission is to provide the safest, most efficient aerospace system in the world.” One could conclude that, by promoting DIP as a hiring measure, the FAA has already forfeited their own mission statement. Diversity and Inclusion equaling Skill and Experience as hiring qualifiers? Is this for real?

Diversity is subjective; Aviation Safety is objective. In aviation, the path to Safety is specific, e.g., following a maintenance manual’s instructions, pilot training, deicing an aircraft, etc. In aviation, how does One promise Diversity? The answer is, One cannot. If two men, one Asian without an A&P FAA certificate and one Hispanic with an A&P FAA certificate, apply for the same A&P job, the Hispanic man will get the job because he is FAA-certificated. It has nothing to do with Diversity. This is true with many aviation positions: pilots, avionics technicians, air traffic control, management, airports, inspectors, investigators, auditors. The DIP is disingenuous.

ERAU’s JAAER paper request is just as suspect. ERAU began in 1925. Were they not Diverse in the 96 years before 2021? What took so long to be diverse? This insincerity is troubling. One, some ERAU instructors are not required to be FAA-certificated or experienced, e.g., English and Math teachers. ERAU can hire a diverse staff and should have done so before today. Two, ERAU is also a Trade School with experienced FAA-certificated instructors. The JAAER papers will delegitimize the Trade School qualifications, tying skilled and experienced Trade School Instructors with unskilled Academicians. Many university professors entire careers are behind a podium, never working with data; coining confusing phrases, like ‘ecological feminism’ or ‘nowtopia’, strung together with ambiguous blather. Is JAAER’s integrity being exploited to give credibility to Opinions and Hearsay?

United Airlines announced new Diversity goals that at least half the pilots hired will be people of color and women. How odd. United Airlines has been around for almost a century. Were they not Diverse before this? Why not also be diverse in hiring equipment mechanics, flight attendants, planners, hangar technicians, ramp crews, upper management, flight scheduling, meteorologists, avionics, ramp controllers, gate agents, etc.? Aren’t these positions worthy of notice; don’t their lives matter?

To suggest the USA is a racist and gender-biased nation is ridiculous. Reality crushes opinion because Diversity is all around and in the most obvious places. In Politics: Hillary Clinton, Nancy Pelosi, Alveda King, Barack Obama, Michelle Obama, Ben Carson, Tim Scott, Kristi Noem, Nikki Haley, all political bigwigs. Entertainment: Jennifer Aniston, Morgan Freeman, Angela Bassett, Denzel Washington, etc. all entertainment powerhouses. Media: Don Lemon, Laura Ingraham, Rachel Maddow, Barbara Walters, etc. These people represent both genders and different races; all exemplify the USA’s Diversity and Inclusion. In the Tokyo Olympics, Tamyra Mensah-Stock, an American black woman who won Olympic Gold in Wrestling, said, “I love representing the US. I freaking love living there.” Does that sound like someone who is discriminated against?

Why commit to a course of action that already exists? The FAA committed to Diversity in 2014. It is unclear why the FAA would commit to something it was already doing. Equally puzzling was if ERAU and United Airlines were already diverse, why publicly promise to be what they already claimed to be? Why, indeed. Perhaps they never placed Diversity over Safety. Or, perhaps, some are placating to select groups. Diversity may not be about Safety; it may be about pandering.

Per the New York Post, Fleishers, a New York City major beef supplier was forced to close after employees walked off the job. Why? These employees hung unauthorized signs for an admitted Marxist group in the company’s street-side windows; the Chief Executive Officer removed the signs because they were not approved. The entitled employees ‘felt threatened’ and walked off. How easy it was to cripple a business with politics. A company destroyed by a few signs and the selfishness of entitlement.

What does this have to do with aviation? Many know the grey area where political, religious or social ideology holds businesses captive, corrupting a business’s integrity, forcing it to take political sides. These Marxists hobble businesses like mobsters break kneecaps. Aviation is being targeted in this way by using our own people against us. The punchline is that Marxists will never respect those who surrender.

Many people view collaborating with and adopting Marxist ideologies, e.g., defunding law enforcement; attacking emergency services; the dissolving of Immigration and Customs Enforcement (ICE) and dismantling of the military, as un-American, as a very real threat to our society. Many leaders of different races say that Diversity is not an American problem; professional women are distancing themselves from those who would undermine commerce and society. Are ‘woke’ businesses really standing up for Diversity … or are they kneeling to anti-Americans? What is the endgame here? Do any that deflect adverse attention towards the Military, Law Enforcement and ICE, do they deserve the support of the American people? Should alumni support schools that stir unnecessary division? Should goods and services providers who promote anti-America propaganda deserve to be patronized? If they would stand by and not support our protective services, should they be supported?

Aviation is not given to selfish agendas, petty politics or fabricated emergencies. Aviation is given to professionalism born of experience, of skill. It is dependent on entrepreneurism, competition, safety and growth. Government’s only place in aviation is to provide oversight and assure safety, not dictate how imaginary social justice should be meted out or how the aviation community conducts business. There is something inherently wrong when those we trust to improve aviation, purposely confuse issues and compromise our integrity, all the while treating us as fools. Aviation is all about people, regardless of race, gender or status, doing their best for all people. We must not allow our attention or dedication be divided by those whose political agendas undermine us.

Aircraft Accidents and Lessons Unlearned LII: Eastern Airlines Flight 980

Mount Illimani with La Paz in the foreground Picture by Donald

On January 1, 1985, Eastern Airlines flight 980 (EA980), registration number N819FE, a Boeing 727-225A crashed at 2040 (8:20 PM) local time while descending towards a landing at La Paz airport in Bolivia. The aircraft impacted Mount Illimani at the 19,700-foot height mark; the aircraft was destroyed by impact forces.

A file (the only one found) of the Bolivian accident report, ‘Eastern%20980%20and%20Letter.pdf’ included Appendix A: a November 5, 1985, Letter to the NTSB Chairman; Appendix B: the Republic of Bolivia Ministry of Aeronautics report and Appendix C: the safety recommendations of Captain Don McClure. The Bolivian report in Appendix B stated, “… since the cockpit voice recorder [CVR] and flight data recorder [FDR] could not be recovered because of bad weather conditions and the inaccessibility of the terrain, the conclusion of this report has not been fully confirmed.” This statement was important as, among other reasons, the National Transportation Safety Board (NTSB) planned to get the FDR and CVR recorders at a later date.

The accident investigation and its subsequent report were accomplished and prepared by the Comision Investigadora de Accidentes e Incidentes de Aviacion (Board of Inquiry on Aviation Accidents and Incidents) of the Direccion General de Aeronautica Civil (Civil Aeronautics Bureau). The EA980 accident was assigned NTSB Accident Identification number DCA85RA007. Per the NTSB website, the foreign authority – Bolivia – was the source of accident report information. There was no NTSB docket information.

Working from air traffic control recordings of communications between EA980 to both Santa Cruz and La Paz control, the events that led to the accident were adequately pieced together. EA980’s last transmission: “La Paz, EA980 leaving flight level 250 [25,000] for 18,000 at this time,” was normal, relaying no sense of urgency or confusion from the flight crew. There was no reason to question that EA980 impacted Mount Illimani without an emergency taking place; EA980’s course, as discovered by post-accident analysis, had deviated twenty-six degrees from the assigned approach, which would account for the aircraft wandering into a course that would align with the mountain’s location.

In absence of any conflicting information, the aircraft hit terrain; given the time of night and the lack of identifiable landmarks, it is clear the flight crew became either disoriented or they intentionally veered away from the assigned flight path. No emergency calls or desperate transmissions, the aircraft, which was mechanically sound, had likely flew a controlled flight into terrain. This was a practical answer; the loss of recorders and survivors would not contradict this possibility.

Yet, Mount Illimani is a sizable land mass; would the flight crew have not seen it? Eastern 980 may have had a similar disadvantage as the Titanic, in that meteorological and astronomical conditions may have assisted in dooming the flight. With the Titanic, the calm sea and the dark of night hid the iceberg from view until the last moment. Could something similar have happened to Eastern 980?

Through the report, there is no reference to Lunar illumination, such as if the Moon was ‘out’, what time the Moon was seen and at what phase it was in. On January 1, 1985, the Moon was in Waxing Gibbous; this phase of the Moon appears from daytime to early evening and its brightness is from 59% to 99%, depending on what point of the Waxing Gibbous phase it was in. If the Moon was overhead, it might have provided an adequate illumination on the terrain below. However, the Moon would have been close to or below the horizon during EA980’s last minutes.

Were there adequate ground lighted references, e.g., cities, towns or highways for the crew to get a visual reference. It is unclear, but unlikely that in this part of Bolivia, these types of illuminations would have been enough to aid the flight crew in their situational awareness. Would Mount Illimani have suddenly ‘appeared’ as Eastern 980’s lights painted it? Were the B727 aircraft’s Krueger flaps even extended past five degrees, allowing the wing lights to point forward or were the wing root lights illuminated? Not likely as EA980 had not reached the point in its approach to run the landing checklist. The B727’s landing lights were most likely off.

What was the weather like? Did meteorological conditions hamper EA980’s flight crew by blotting out any celestial illumination from the sky, perhaps a starfield behind Mount Illimani or even the descending Moon? The accident report stated that, per La Paz control on January 1, 1985, the following weather was at the La Paz field: “La Paz 080/12 unlimited, 3SC500 iCB750-3AS2400-07/04 QNH millibars 1034 inches 30/53. Cumulonimbus SE of airfield.” Several pilots familiar with reporting international aviation weather were consulted, but the language of this transmission has changed since 1985; it was unclear what conditions were above 12,000 feet. However, EA980’s last weather report reflected the weather on the La Paz airfield, not where EA980 was flying near Mount Illimani. In addition, investigators believed EA980 drifted off course to avoid flying through inclement weather.

Finally, had the flight crew turned on the interior lights, thus eliminating their night vision? Was the pilots’ night vision compromised by the instrument lights enough to nullify any possibility of discerning shapes outside the windscreen? If they looked out, could they have separated Mount Illimani’s silhouette from the inky blackness of dark? It is reasonable to conclude that EA980 flew a controlled flight into Mount Illimani; that is a practical conclusion, almost impossible to disprove. Any responsible organization would have accepted the logic of that probable cause.

In Appendix C, Captain McClure retraced each leg of EA980’s accident flight plan and provided several observations and recommendations, based on his flying experiences and familiarity with La Paz. He gave insight into cultural and procedural problems that he felt contributed to unsafe practices that led to the flight 980 confusion as well as concerned him regarding ground crew practices. It was unclear whether any of Captain McClure’s recommendations were acted upon, indeed even added to the accident record.

It was the Appendix A letter that was most confusing. Among the items found in the Google search was a letter allegedly written nine months after the accident, outlining an attempt by inexperienced climbers to find the CVR and FDR recorders. To be clear, for professional climbers to ascend Mount Illimani to rescue survivors would have been a noble effort. However, EA980’s impact was too catastrophic; there never were any survivors to save; this fact was known within hours of the accident. To recover the deceased and/or their effects, an effort, though well-intentioned, would have been fool-hardy, even for the most experienced climbers; it would have had to be weighed against the risk – by professional climbers. Would the ends have justified the means? The odds for costly loss of further lives might have outweighed the benefits. There were no survivors, no effort would have changed that.

The letter to the NTSB Chairman, written by the field NTSB investigator who made the climb to the 19,700-foot level of Mount Illimani, detailed how he led a team of other inexperienced climbers to recover the recorders. The undertaking was hampered by team members’ health issues, equipment problems, food and water problems and other necessities, such as adequate shelters not being available during the ascent. The field investigator explained how he researched his ‘training’, “… about high-altitude mountain climbing so as to be well informed on the physiological factors associated with the high altitude and lack of oxygen.” Research? Why not hire experienced climbers or take a qualified climber with the team? The climb, as executed, was accomplished with arrogant inexperience.

If a ‘lack of oxygen’ affected one’s reasoning, then oxygen deprivation was present in the meeting that led to the expedition. It would have been incumbent on NTSB management to terminate any plans by this or any NTSB investigator from attempting something so foolhardy, but even NTSB management could not be depended on to do their jobs and stop such an unsafe venture.

Then there was the recorder recovery. The field investigator made it to the accident site, only to be defeated by a basic lack of knowledge of where the recorders were in the fuselage. Recorders are found in the rear of the aircraft, but their exact location can vary from operator to operator. For instance, a cargo operator may have the recorders located in the aft airstair while a passenger operator might have located them in a belly cargo hold, overhead bin or at the aft bulkhead. It was clear from the letter that the field investigator did not know where in the airplane the recorders were.

It is discouraging to read about these exploits and to accept that personal safety was not at the forefront of NTSB investigations; I would hope that NTSB field investigators today do not follow such foolish actions but accomplish their jobs safely with common sense dictating their actions – not government bureaucrats and employers of mismanagement. Not all accident sites are accessible, whether because of a lake’s depth, a mountain’s summit or the threat of carnivorous wildlife, no recovery of evidence is worth more lives to acquire. When I investigated the LAS DC-9 accident outside Mitu, Colombia, I did not drop into the jungles occupied by the drug cartel to recover evidence; the Colombian Army did with support aircraft and trained experts. That is common sense.

The Eastern Airlines flight 980 accident was tragic. Was it preventable? Most likely. It certainly was not intentional; there was no action taken by air traffic or the flight crew to misdirect the B727 into the mountain. To be clear, ‘preventable’ is often a hindsight view; we often cannot see far enough to prevent something unless it is clear what we are doing is wrong. Past successes (prior flights into La Paz) lull us into a false sense of security where we cannot see the forest for the trees. That is why we must get it right. But it also means that we learn from the best root cause possibilities. Could we prove, beyond a shadow of a doubt, that Eastern 980 was a controlled flight into terrain? No. But the NTSB could have allowed the assumption to dictate safety procedures to prevent controlled flight into terrain, nonetheless. And perhaps, they should have given Captain McClure’s recommendations another look.

Aircraft Accidents and the Other Shoe

2018 Photo of EasyJet Captain Kate McWilliams, 26, and First Officer Luke Elsworth, 19

There is an expression, per, that goes “Waiting for the other shoe to drop”. It related to New York City tenement living, where in apartments built on top of each other, the lower neighbor could hear his above neighbor drop a shoe after removing it, then they anticipated the ‘other shoe to drop’. It was an idiom for expecting something to happen.

Last week Embry-Riddle Aeronautical University (ERAU) posted a call for writers to submit papers to the Journal of Aviation/Aerospace Education and Research (JAAER) where ERAU was, “… proud to announce a call for papers related to diversity, equity, and inclusion in the aviation industry.” The ad continued: “This special issue will aim to publish thought-provoking scholarly and research articles related (but not limited) to race, age, gender, sexual orientation, religion, and other nascent and incipient forms of inequalities in the context of the organization of work within the aviation and aerospace industry.” This sounds like S0ci@l Ju$tice (S-J); the shoe dropped with the THUD! of a lead balloon.

Opinions and Feelings never eclipse Facts; Diversity … or better yet, the appearance of diversity, does not equal Safety and never will.

Academia means well; some ERAU professors and teachers aim to take advantage of the new craze: ‘Woke’ ness; validate it with research and make it real. Instead it resembles applying a new coat of paint to a rusted DC-4 hull. Most Academia never worked in or interviewed into the industry; they lecture from textbooks written by other Academics who, again, never worked in industry. Academia thinks Diversity is the new hope, that Diversity makes us winners, like a group of Safety-keteers.

But, ERAU’s call for Diversity articles does two things: First, it uses (exploits?) JAAER’s history of aviation research to force credibility on a tired argument with no resources for factual discussion. No honorable group has researched Diversity’s effects on Safety or Experience because Diversity HAS NO effect on Safety or Experience. By posting the inciting subject matter under the JAAER umbrella, ERAU makes it ‘believable’ to those who do not know better; it allows those with a divisive agenda another avenue to freely punish other groups of people they disagree with. ERAU may as well tell their present and future students who do not fall into any of these “race, age, gender, sexual orientation, religion” groups, “We do not care about you; we will take your money, but we are devaluing your contributions to aviation because you do not fit our profile.” My opinion? Perhaps. But what is the desired outcome: Safety or Job Hand-outs?

Secondly, and sadly, this ad crushes the good reputation JAAER built, which was to present well-researched information – FACTUAL information (some that has been presented on my website); ERAU is allowing JAAER to become a propaganda machine aimed at dismissing facts for opinion.

What type of scientific method of data collection would this represent? A scientific method always begins with a question, which in the JAAER’s case would be … what? What hypothesis would be raised? How would you test the prediction? How would a conclusion be presented? What scientific data could be used? ERAU is forcing a conclusion with no provable data. How does one prove bias? Does anyone who has actually worked in aviation – not taught, but worked – these last thirty to forty years honestly believe there has been race, age, gender, sexual orientation, religion discrimination on some grand scale? If so, what have they done about it before today? Why were they silent before now?

In 1995, I attended classes at ERAU’s Offutt Air Force Base Education Center in Omaha; the Director was a highly qualified woman, who ran the place. In 1997, when I graduated, she accepted a promotion to the Daytona Beach Campus. Four years later, after I received my Masters, she recommended me to the ERAU PAX River Education Center administrator who was a … wait for it … qualified woman who ran that Center. Twenty-six years ago, women were running the show in a prestigious aeronautical school; the same ERAU that now questions race, age, gender, sexual orientation, religion diversity. The aeronautical school in Flushing, New York I attended for aircraft maintenance certification; that school is also run by a woman with a Doctorate. Since the mid-90s, Diversity was all over the place.

When I joined the National Transportation Safety Board (NTSB), the black gentleman who oversaw International accidents – an ERAU graduate, since retired – ran a critical NTSB department since before 2001 when I arrived. Half the Systems and Powerplants NTSB engineers who work – and have worked – major aircraft accidents, including the present Division manager for Aviation? All women. NTSB Board Members through the years have been racially and gender diverse, as well.

What about the Federal Aviation Administration (FAA)? Jane Garvey, FAA Administrator from 1997 to 2002, was replaced by Marion Blakey in 2002 … after Ms. Blakey was NTSB Chairman. More than twenty-five years of aviation industry diversity and ERAU is suggesting aviation never left Kitty Hawk.

Why do we waste scorn on our co-aviation folks? Why are we willing to start battles on hills that do not exist? Suddenly airlines ‘awaken’ to Industry’s Diversity problems. Look up pictures of these ‘woke’ airlines’ Board of Directors. See who the Chief Pilot is; who the Director of Maintenance is; the CEO. Are women and racially diverse people running major divisions within these ‘woke’ airlines’ or are these so many smoke and mirror games? Doesn’t change always start at home?

What about sexual orientation? Former Mayor Pete Buttigieg is the Secretary of Transportation. He is also a gay man. A high-profile position run by Sec Pete, yet ERAU questions Diversity. And there is the rub … perhaps ERAU should focus less on Secretary Buttigieg as a gay man and more on him being a qualified man. Does his sexual orientation matter more than his decision-making abilities; his plans for Transportation; his leadership in times of crisis? Or are we to believe that Sec Pete’s only value is his choice in partners? Seriously, who cares who he marries? I just care about the job he does. Have we become, as a nation, so shallow that we judge people’s qualifications by stereotype?

Which leads to my second point: Safety. This recent concern for making the industry diverse as possible, while pushing Safety towards the back, is insane. I just want to understand: What factual research can show that a Black man has more flying talent than an Oriental woman or that a White woman can remove an engine faster than a Hispanic man? Where are these numbers? Where is the Math?

Perhaps actions are better identifiers. I personally witnessed these safety boo-boos. Can anyone identify the violator’s stereotype? (1) A pilot who was too busy storytelling that they busted through their assigned altitude; (2) A mechanic threw a wheel chock into a windmilling fan to stop it; (3) A pilot, first ‘hovers’ over the runway, before slamming the jet down in a near three-point landing; (4) A mechanic pins the nose and two main gears of a DC-10-30 before raising the gear handle, too late to stop the center gear from going up in the well – on the flight line – with no jack stands. None of these instances was owned by one gender or race. Safety and training failures belong to all people equally.

S-J, or whatever interpretation of it, is killing industries all over, diminishing experience with, essentially, nothing of substance. The FAA will spend millions of tax dollars to remove gender-specific language from policy and regulation. Now, ERAU has sacrificed their JAAER to ‘woke’ ness, creating a crisis where no crisis exists; ERAU wants to know why, race, age, gender, sexual orientation, religion, and other nascent and incipient forms of inequalities … prevent people of certain races, (what races?) ages (what age groups?), etc. from gainful employment in the aviation industry.

Think about this: What if the reason people do not get pilot, mechanic or air traffic controller jobs is because they lack skill? Are airlines supposed to have a 100% hire rate just to satisfy a set of Diversity numbers? How about the (pick a race, gender or age) pilot who just cannot pass the check ride? Damn the safety, we have a quota to meet. What ever happened to responsibility? When did our failures become somebody else’s fault? Why is it wrong to not hire someone because that person is dangerous, that they are a lousy pilot/mechanic/air traffic controller?

The above 2018 picture is of Kate McWilliams, 26, EasyJet A320 Captain and First Officer, Luke Elsworth, 19. It is irrelevant how ‘groundbreaking’ this picture is, how these two challenged the status quo. The priority is: “Are they qualified to fly an A320 full of passengers?” Luke was too young to obtain a bus driver’s license in London but he can fly an Airbus over it. We would hope these two have the experience to handle any emergency, but do they? Could they pull a “Sully”? In this technology age, could either of them fly on manual with engine out? Have either ever faced a real emergency? Maybe, maybe not. But be honest, what Diversity peddler would trust their grandchild’s life to a 19-year-old?

Hiring for Diversity does not work; training for Diversity does not work; S-J equality is not a tangible metric. Skill and experience are not determined by strands of DNA; they cannot be found in a Holy Book. To believe otherwise is a fool’s errand. While scholars and Academia elite may teach otherwise, there can be only one Beethoven, one Jesse Owens, one Katherine Johnson, one Albert Einstein; theirs and others’ talents and skills were unique; learned, not given. To suggest that Diversity can duplicate what came naturally to them, trivializes their contributions, cheapens them.

We, in the aviation industry, are anticipating the other shoe dropping. This stunt puts us all in danger.