Aircraft Accidents and Family

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned XLII: TAM Flight 3054

TAM A-320

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Unfortunate Responses

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned XLI: Atlantic Southeast Flight 529

Atlantic Southeast Airlines Embraer EMB-120RT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Chaos

Bugs Bunny and the Gremlin from “Falling Hare

In the original Twilight Zone series’ Third Season, Episode Three: The Shelter, a group of friends learn a lesson about themselves when a 1960’s nuclear attack warning was announced in error. What resulted was chaos; neighbor turned against neighbor in a bid to survive until the erroneous warning was retracted. By then the neighbors wanted to go back to the way it was, but that … was impossible.

The United States’ condition is approaching a point of no return. Since mid-March, we, as a society, have been guided into lanes with no egress, beginning with the COVID-19 scare. Do I doubt COVID-19? No, I personally know of too many cases. But, I do not see the death and/or exposure data exceeding that of an annual flu season. In fact, there is no consistent information at all, no reliable data provided by trusted sources. One ‘authority’ says we will have a recurrence, while another says the virus is over … period. Who to trust? What to believe? No one, so far. How did we get here? Here is the edited version:

This Spring began with medical confusion: the ‘Wuhan Virus’. It was supposed to be a short shutdown to allow us to get control of the virus’s spread. What we ended up with was a gaggle of ‘experts’, medical ‘authorities.’ First, the medical authority (MA) said, we did not need masks … before we needed masks; the MAs then said we should be out in crowds before we had to isolate ourselves. Each day we hung on what the MAs would say next, like a Magic 8-Ball. By the end of April, we were mired in silliness.

Was the COVID virus as lethal as the MAs said? No one knows; the MAs don’t know; there was no data to compare it to, or so they said. The 2020 flu season got lost in the shuffle. But what about the data from all previous flu seasons? We were expected to believe career politicians and the mainstream media (MSM); as a whole, we gave up our careers, livelihoods and families, all to prevent … what? Has the true death count gone up or down? Factually, are there really new cases popping up or are there more cases because we have more testing? How many deaths are due to just COVID-19? Not one person can say definitively. How do COVID-19 cases differ from the flu we experience every year?

Like inebriated gremlins from a Bugs Bunny cartoon, our career politicians assaulted the framework of a booming economy, suffocated all ideas deemed Common Sense. Arguing with the diplomatic finesse of Moe Howard, the career politicians improvised plans to “save us all”, where they methodically exacted great harm upon the American Society’s unity – for political purposes. Irreparable damage was inflicted upon all industries – including the aviation industry. Then, an incident in Minneapolis gave career politicians the distraction they needed: create racial division and develop provocative slogans while slandering the heroes who keep us safe – the Police. One would wonder if targeting the Military is next.

And America got even crazier. Career politicians continued to divide. Suddenly rightful assembly was forbidden to prevent ‘selfishness’ from killing our neighbors. Church members were greeted with threats of legal action, while rioters, under the guise of ‘peaceful’ protesters, were free to amass in large groups. With silent political apathy, terrorists and anarchists roamed our large cities, unopposed; given freedom to destroy businesses. Innocent citizens of all ages, genders, races and creeds experienced character assassination, assault, looting, property destruction and murder, all in broad daylight, while career politicians attacked Law Enforcement, further alienating our heroes from those they served faithfully. All the while, a sycophantic MSM unashamedly lectured us about privilege; reporters, e.g. Ali Velshi reported about ‘mostly peaceful protests’, while a Minneapolis neighborhood burned behind him. How long will it be before all those who question are labeled ‘Subversive’?

And still the COVID scare rolled on. An uneducated public still confused COVID exposure numbers with fatality rates. The Health Director for California’s Health and Human Services Agency resigned. Why? Because their COVID-19 tracking, “… system was not built for this volume of data.” It is indicative of how reliable COVID tracking data is; of how fifty States don’t know what is going on. Are spontaneous COVID cases real or are they distractions?

To summarize: We have surrendered our liberties in thunderous reticence. We have conceded access to our families, homes and jobs to oblivious MAs with no practical experience. We have yielded our rights to religious expression and Police protection to career politicians who care nothing for public safety. Our Fears have hobbled Education; students and teachers have lost time under misguided State Education Administrators and corrupt Teachers Unions. Submissively, we relinquished control of our thoughts and opinions to a woke MSM intent on mocking and gagging us. Our rights to free speech and assembly have been capitulated to Children, who won’t even go back to college because, they do not feel safe. Meanwhile these children spread more fear and harm on the elderly than COVID-19 ever could. In other words, ladies and gentlemen, we have officially become the cast of The Simpsons.

However, the Coronavirus Chaos has brought about one positive result: Americans begin to clearly see these career politicians’ true colors. Career politicians overplay their hands, calling for mandatory masks wearing for … the next three months? Until November? Are they even trying to hide their disdain for us? Americans no longer question – they finally understand – that to career politicians, it is not about every American’s welfare, but of control, of power. Level-headed Americans are no longer taken in by a kowtowing MSM, who have aided career politicians in confusing and demeaning an American populace put off balance by irrelevant arguments, pitted American against American. In short, career politicians have dismissed what they were elected to do: Public Service. And cooler heads are seeing it.

Our nation is trying to rebuild, attempting an economic restart that has begun well, but will require all industries’ participation to succeed. I spoke of service; most aviation certificate holders are in the service business. Aviation is an indispensable industry, one that will lead the way, to get back in the game, full time. It very well may be the aviation industry that will get this economy, indeed the American Society itself, back in high gear.

The aviation industry has rarely been given a chance to utilize time to improve safety. The increased availability of resources and equipment down time; reduced flight schedules and more ground time has presented us with opportunities to improve. With aircraft used more economically, mechanics have more opportunities to put aircraft in prime mechanical shape; pilots can manage time to take advantage of more training. Train, repair and audit; Aviation cannot afford time to waste.

The Federal Aviation Administration (FAA) has this chance to see and be seen. Inspectors should be on ramps; walking through repair stations; looking at technical schools; investigating safety concerns on-site; revising manuals. There is much to do. If you are over sixty, wear a mask; stand a few feet back. But get out there. The FAA should be diligent, maintain a presence, supported by FAA management because safety does not take a day off.

If we, in the aviation industry, are proactive, we can bring back other industries, e.g. passenger travel, shipping, contractors, trucking, food services, fuel suppliers, transportation, tourism, restaurants, health services, rental services, hotel industry, retail suppliers and all other industries that are connected. Besides, Thanksgiving and Christmas are coming; we must get families back together … again. We must meet the demand, now more than ever.

Before the soapbox is relinquished … Our country is divided in ways not seen since the Civil War. Abraham Lincoln once spoke about this. “We are not enemies, but friends. We must not be enemies. Though passion may have strained, it must not break our bonds of affection.” In addition to extending olive branches, refrain from incendiary language by turning off the Social Media. Try it for a couple of days. What to do instead? Read a book (I wrote two that are good). Play Scrabble. Write a letter – in cursive. Get some sun; jump in the pool or run through the sprinkler. Call a friend or …

… better yet, invite one to your home who you are ideologically opposed to; have pillows near at hand in case a fight breaks out. Keep cynicism absent; divert from sarcastic speech. Look not for triumph in quarrels but strive instead for understanding; in other words, Bring forth the better Angels of your nature. Lincoln reasoned, “Do I not destroy my enemies when I make them friends?” Do we, indeed.

In November, we will each face a challenge, Democrat, Republican, Independent, it does not matter. We have seen how Emotions tore our nation apart; they were not concrete or shared; they produced fear which forced us into hiding. For the election, let’s look at Facts. They are tangible, mutual and though unpleasant, they do not lie. Let us vote with our heads, not our hearts. There are three questions we should each ask ourselves this November, being sure to be honest with our answers. 1 – All of those elected representatives we chose; did each one accomplish what they said they would accomplish? 2 – Is the United States better, e.g. safer, stronger, freer, for what each one did or tried to do? 3 – Did each elected representative do what was right for all Americans or did they only do what was right for themselves?

To my fellow aviation folks (and anyone else who I am honored to have visit my website), be safe, be smart, be unafraid. For the United States, think with your head, not with your heart. And know this: we are going to get through this, we are going to be fine.

Aircraft Accidents and Lessons Unlearned XL: American Airlines 587

American Airlines 587’s Vertical Stabilizer

On November 12, 2001, American Airlines flight 587 (AA587), an Airbus A300-605R, registration number N14053, crashed in Belle Harbor, New York shortly after taking off from John F. Kennedy airport. Recorded as National Transportation Safety Board (NTSB) accident number DCA02MA001, the A300 lost its rudder and vertical stabilizer during climb; the aerodynamic loads caused the loss of both engines before impact. Just two months after the September 11, 2001, terrorist attacks, the accident was thought to be terrorism, a case for the Federal Bureau of Investigation, but when it was determined to be non-terrorism in nature the NTSB shortly took over the investigation. The accident report, AAR-04/04, was adopted on October 26, 2004, almost three years later.

The NTSB determined that, “… the probable cause of this accident was the in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created by the first officer’s unnecessary and excessive rudder pedal inputs. Contributing to these rudder pedal inputs were characteristics of the Airbus A300-600 rudder system design and elements of the American Airlines Advanced Aircraft Maneuvering Program (AAMP).”

This accident demonstrated the NTSB was ill-equipped for the technical and industry knowledge challenges of this investigation. This was my first major accident as an NTSB major accident investigator; I was also the only person in the NTSB who had, not only directly worked with composite materials (and I was no expert), but had worked the A300-600 series airliner. The NTSB’s Structures investigators’ inexperience with Composites was concerning; the Structures group should have pushed management for training on composites to better understand the important safety issues they eventually missed. Furthermore, analysis of Air Transat flight 961, A310-308 investigation, made it obvious how NTSB accident report AAR-04/04 did not capture the root failures that led to the AA587 accident.

Question: Could NTSB Board members, with no airline Operational or Technical experience, base a report’s conclusions on the insufficient skills of NTSB investigators long out of the industry? The Board Members faulted American Airlines’ AAMP, then placed full responsibility for AA587 on a qualified pilot with over a decade of Part 121 flight crew experience. According to AAR-04/04, 2.4.3 Summary, “First, the first officer had a predisposition to overreact [underline added] to wake turbulence encounters.” Who at the NTSB could speak to the FO’s ‘predisposition’; that the NTSB assumed the first officer (FO) was careless and unskilled? How did NTSB Board Members and investigators, lacking a career in piloting jet airliners, reach this embellished opinion of a professional they could not understand? Answer: Another captain, whose intentions were never questioned, said so. The FO had flown with this captain … four years earlier … on a B727 …  This captain was interviewed, stated his opinion, of the FO’s “… use of the [B727] rudder pedals was ‘quite aggressive’” (AAR-04/04 page 12).

What did this misdirection of a biased interview do? For one, this biased captain’s opinion placed blame on a professional – the FO – without proof. Second, the misplaced blame distracted attention away from the true cause, which in the case of AA587, was never determined.

What did happen? In 2003, the Allied Pilots Association, parties to the investigation, submitted their report to contradict the NTSB report. It stated, “And the Board found that the composite material used in constructing the vertical stabilizer was not a factor in the accident because the tail failed well beyond its certified design limits.” Did the NTSB physically test an A300 composite vertical stabilizer and rudder? During set-up for the structural tests, a lone A300 vertical stabilizer was found to be available in Asia. However, during shipping, the stabilizer came free of securing, left its pallet and fell overboard into the ocean. The test stabilizer became too structurally damaged and compromised with sea water. Instead, the NTSB was forced to resort to Finite Element Analysis (FEA), a computerized method for predicting how a product reacts to forces; and Progressive Failure Analysis (PFA), which uses C-one shell elements based on classical lamination theory to calculate the in-plane stress. In other words, the tests were accomplished without a static computer model to test on. But were these methods accurate?

No – for three reasons. First, when an aircraft is certified, structural stress exercises are accomplished, such as when the wingtips are bent upwards to see at what deflection the wings will snap, exceeding their physical limits. The manufacturer does not use a computer model for its products’ stress tests because the computer cannot duplicate the flaws unintentionally built into a product.

Second, the increased use of composite structures in aircraft components, such as all flight controls, was relatively new at the time of AA587. Industry mastered composites repairs – after – the composite aircraft were already in service … not before. Detecting composite material defects was an evolving science. Third, the NTSB did not have structural engineers with composite experience. Instead, the NTSB relied too heavily on Airbus to police their own product’s integrity.

What events occurred in the accident aircraft’s history? The accident aircraft, serial number (S/N) 420, was issued its airworthiness certificate on July 13, 1988 and it had flown for thirteen years before the accident. During the initial post-accident maintenance review, records showed that S/N 420 had ‘sat’ on its tail, overstressed the empennage.  This Maintenance Chairman’s Factual Report (MX Factual) should have recorded this. Aircraft ‘sit’ when a tail-heavy weight imbalance occurs, such as fuel in the stabilizer fuel tank. The tail could have struck the ground with great force, enough to damage the vertical stabilizer mounts or rudder hinges. Fact: an aircraft is not designed to ‘sit’; undetected structural flaws could form within the composite layers of components. Did such damage occur to S/N 420, the accident aircraft?

S/N 420 also had nine vertical stabilizer and/or rudder modifications (MX Factual page 12). Could any or could all of the nine modifications have introduced damage within the composite layers? Why did the NTSB fail to give structural integrity proper attention? Did the NTSB give full attention to the composite inspection programs, not only of American Airlines, but of all A300 operators? Where the AAR-04/04 investigation failed, the Transportation Safety Board of Canada (TSBC) accident report A05F0047, Air Transat flight 961 (AT961), found answers.

On March 6, 2005, AT961, an A310-308, was at Cruise approaching 35,000 feet of altitude (by contrast, AA587 was below 2000 feet and at Climb) when AT961’s rudder separated from the vertical stabilizer. The TSBC did not waste resources creating easy solutions, such as wake turbulence or pilot error. Instead the TSBC investigated structural integrity of the vertical stabilizer, the attach points for the rudder and maintenance programs that inspected the composite components’ integrity and the effects of various harmful agents, such as water/ice, deicing practices and chemicals.

The TSBC embarked on an in-depth series of structural examinations, in some cases using sister rudders designed and built to the same specifications as the separated rudder. The TSBC went beyond tests conducted by the manufacturer at rudder certification, such as static load, fatigue, damage tolerance and flutter tests. They thoroughly examined the rudder maintenance inspection program; subjected the test rudders and original vertical stabilizer to chemical and contamination tests, elasticity laminate tests, impact damage testing and bonding tests. The TSBC understood that composites, in relation to the industry, was a young science and that there was much to be learned, much to improve upon.

Where the TSBC exceeded the NTSB in report writing can still be seen in investigations today. For instance, the investigatory methods employed in the 1960s did nothing when investigating the B737-MAX accidents; the use of unqualified/inexperienced investigators and outdated investigatory practices brought the industry no closer to safety with the B737-MAX and only allowed the unsafe practices at Lion Air and Ethiopian Air to continue unimpeded.

Meanwhile, it was hoped that Airbus, knowing that AA587 received a less-than-adequate investigation, took it upon itself to build integrity into its composite products, increased the quality of maintenance structural inspections/testing and learned what was ignored during the AA587 investigation. Despite the errors of AAR-04/04, Industry learned; operators of Airbus products (and Boeing products) learned what was missed with AA587: how to design an aircraft to operate for its lifetime with some newfound safety built-in. Hopefully, someone took the initiative to get it right.

Aircraft Accidents and Going Virtual

Aircraft Maintenance Instruction in the Future

There is an old saying in the Education field, “There is no such thing as a stupid question.” For many years that line has held true. Despite this adage, it would be argued by me that, “The only stupid question is the one never asked …until it is too late.” And that is just not right.

In the (hopefully) final days of the COVID-19 scare, ideas have been presented in the aviation industry that aviation schools should move to decrease stand-alone (instructor classroom) instruction and replace/increase virtual instruction (VI), where students attend class through personal computers and the internet. It is floated as a ‘back-up’ plan, just in case, COVID continues to hang around, like a viral version of Jar-Jar Binks. COVID is the mystical magical virus that will suddenly disappear around Thanksgiving 2020, where someone at the table is bound to say, “Hey, do you remember a couple of weeks ago when we had to wear masks and maintain social distancing? Strange, huh?” Yeah, strange.

Back-up plans never seem to go away. Not emergency plans, like how to survive a Chicxulub asteroid strike, but back-up plans. Some back-up plans are good, e.g. buying a generator because of New Hampshire ice storms, while other back-up plans are not. They evolve into the norm, what we must do if we, as a society, are expected to survive the … (insert emotionally packed, crazy reason here). And that is the shame of it, that aviation, as one of the most noble industries the past century produced, might abandon common sense Training/Instructing just because we are afraid … no, conditioned, to fear being in the same room with more than three people.

My wife teaches 7th and 8th grade students. This past March the middle and high schools shut their brick-and-mortar doors; teachers taught virtually. There was a learning curve for high school age students as VI was introduced. The big negatives for VI were not the teachers’ instruction obstacles; they were student discipline. Parents, suddenly stuck in the same house with their little angels, surrendered to every whine and temper tantrum. The Department of Education, in its questionable wisdom, decided no student could fail. 7th through 12th grade students did not test because VI teaching upset their tender sensibilities. Video game proficiency replaced class work. And they all graduated to the next grade.

Colleges did not have better luck; thousands of students were restricted to the dorms for the closing months of the semester. Summer enrollment dropped. Classroom instruction adapted to the VI concept, which lacked the quality of classroom instruction. The problem was that high school and college students lost the structure that school schedules offered. Did some of these high school and college students engage in the civil unrest that has rocked our country since May? Could be. Would major cities have burned if students were in school? It is likely that students who studied … say, American History, would not have attacked Memorials like the 54th Regiment of Massachusetts for being … racist (???).

College age youth, fresh from high school, attend Trade Schools, e.g. aircraft maintenance (A&P) schools. Per Title 14 Code of Federal Regulations (CFR), Part 147.21 General Curriculum Requirements states that to acquire an Airframe (A) certificate requires 750 hours of Airframe-specific classroom instruction; a Powerplant (P) certificate requires 750 hours of Powerplant-specific classroom instruction. Both or either require 400 hours of General classroom instruction. Each A&P technician today had received 1900 hours of certification classroom instruction. Would A&P schools lobby the Federal Aviation Administration (FAA) to ease up on the required face-to-face classroom attendance hours in favor of VI, to prevent exposure to COVID-20, -21, -22 …?

For the time being, tech schools are not – cannot – eliminate the brick and mortar school. Why? Because there are still required hands-on labs. But, how far off are virtual labs? The technology exists to sit on a Florida beach while living in the Arctic, how long before we substitute real engine rebuilding with virtual versions in the lab. What would be the benefit of that?

In truth, brick and mortar buildings are disappearing. Companies like Circuit City have surrendered their classic building showroom for the cost-savings, e.g. rent, employee benefits, warehousing space, etc. for the dot-com. No doubt brick-and-mortar represents a heavy cost for the retail industry, but aviation is not a retail format. No links to click or search engines to use. One must turn a wrench or fly by instruments. Why? Because learning comes from INTERACTION; there is no substitute for it. One must get their hands dirty in order to learn. Virtual is too easy and it is not right.

Back in the early 1990s, my airline invested heavily in initial computer-based training (CBT) – an early version of VI – for its hundreds of pilots and mechanics. The airline converted a large room; one side of the room had dozens of computer monitors for pilots to train, the other side had dozens of monitors for mechanics and a small hall separated both kingdoms. If a monitor was inactive for fifteen minutes, a company logo screen saver bounced across the monitor. Many nights after work, I stood in the hallway, glancing left and right, seeing dozens of sleeping employees, as the company logo lazily bounced across the monitors. Despite happening decades ago, strict CBT was ineffective; it lacked INTERACTION.

The classroom instructions I took since the Eighties as an aircraft mechanic, as a National Transportation Safety Board investigator, as an FAA inspector, they were effective, not only because of the Instructors’ experiences, but because of the discussions that took place between students about the lesson material. Even as an A&P instructor, as an instructor at the FAA Academy or the NTSB Academy, learning was enhanced because students and instructors learned by speaking about their experiences, by interacting, by exchanging ideas and solutions.

Question: How would it be decided we should get back to pre-COVID stand-alone school instruction? Who decides? Would the trade schools push to go back? The problem is that once a regulation exemption is granted, how do we put the toothpaste back in the tube? Look what fun we are having with state Governors refusing to return to any semblance of pre-COVID-19 economies. Or maybe we would trust the hundreds of conflicting health experts who cannot remember what they said from Monday to Wednesday.

I have taught stand-alone classes; I have seen the conversion from stand-alone to VI. My opinion is it would not work, especially with high school graduates; they lack the discipline to learn in a VI trade school environment. Furthermore, they would not know how to transfer from a VI environment to the workforce; their work ethic would be irreparable. Students would be confined in four wall sterile environments, scattered across many miles, distracted by their cellphones and social media. Instructors would answer questions via texts with no controls, no discipline. Any Interaction would become non-existent.

Could regulation exemptions be abused? Sure, non-exempted regulations are abused all the time. The FAA exists to oversee certificate holders, e.g. technical schools, to assure regulations – the laws – are followed. Over a decade ago an A&P school was shut down, its owners imprisoned. Why? Because they were graduating unqualified technicians with A&P certificates. Aside from other issues, many of the new A&Ps could not speak, read or write English. Title 14 CFR 65.71(a)(2), Eligibility Requirements: General, has stated (since 1962), “To be eligible for a mechanic certificate [A and/or P] and associated ratings, a person must — be able to read, write, speak and understand the English language, or in the case of an applicant … certificate endorsed ‘Valid only outside the United States.’” This is the law. English is our primary language. By abusing the regulation, the guilty school made our industry unsafe.

Unfortunately, for a certificate holder to save money, the temptation to break the law can be a driving force. How much easier would it be to work around the system if the FAA approves VI on a permanent basis? Who would be flying our airliners? Who would be maintaining them? Would the flying public trust aviation again?

VI would be the easy thing to do. But would it be the right thing to do? We would end up with a generation of pilots and mechanics socially incapable of working with others, making undisciplined decisions without making the required effort. We would have a workforce with a high school mentality; we would have nothing. And that is just not right.

Nothing is easy. But who wants nothing?” President Donald Trump

Aircraft Accidents and Lessons Unlearned XXXIX: United Airlines Flight 266

B727 Engineer’s Panel

On January 18, 1969, United Airlines flight 266 (UA266), a Boeing B727-22C, registration number N734U, crashed into Santa Monica Bay. The airliner took off from Los Angeles International Airport (LAX) four minutes earlier; they were attempting to return, following a number one engine fire warning, when the accident occurred (accident report number AAR-70/6). After impact, the sections of UA266 sank to a depth of 950 feet in the Pacific Ocean. The cockpit gauges were destroyed. All three engines were recovered on February 11th, the flight data recorder (FDR) and cockpit voice recorder (CVR) between February 21st through March 4th.

The National Transportation Safety Board (NTSB) determined that the Probable Cause, “… of this accident was loss of attitude orientation during a night, instrument departure in which all attitude instruments were disabled by loss of electrical power.” The NTSB’s probable cause went on to say, “The Board has been unable to determine (a) why all generator power was lost or (b) why the standby electrical power system either was not activated or failed to function.” But is that what happened or was it a simple case of confusion brought about by technical inexperience?

In 1972, almost four years later, Eastern flight 401’s pilots fixated on an indication light bulb inflight. Unknowingly, with attention diverted, they casually flew the L1011 airliner into the Florida Everglades. What if UA266’s “loss of attitude orientation” was not the result of a power loss, but was because the crew simply lost focus on the job at hand: flying the aircraft – like Eastern 401?

The B727 aircraft entered service in 1963. There were three flight crew members: Captain (CP), first officer (FO) and second officer (SO). The CP and the FO flew the aircraft; the SO monitored the various systems’ panels. The B727 had three generators, one on each engine. After engine start, each generator was synchronized, then manually tied to their bus; the SO had to purposely engage the generator. One engine generator could power the airplane and would have to be manually tied.

AAR-70/06’s probable cause consisted of opinion, not fact; for this, it was confusing. “… all attitude instruments were disabled by loss of electrical power.” Little evidence suggested a loss of electrical power; that was pure theory. Instead, the report demonstrated a mismanagement of the aircraft electrical system and a group of investigators who were unfamiliar with the B727.

AAR-70/06 also showed why maintenance-experienced investigators would not only have understood what happened with the electrical power, they would have realized what the SO was doing … or more importantly, not doing. Why? Because United SOs were pilots but their function on the 727 was as an onboard technician. Pilot or engineer investigators would not understand the technical issues with aircraft electrical systems. The accident SO logged only 40 hours on the 727 (Appendix B); his job was to run the systems panel, troubleshoot systems’ problems in flight. He received basic technical training. At 40 hours (maybe 12 to 20 flights), it was unlikely he ever worked many deferred systems, calculated a fuel load, swapped generators or manually adjusted cabin pressure. Certainly, never in a high stress situation.

Consider the SO’s last words: “I don’t know what’s going on.” Classic straightforward confusion. The CP and FO were flying in low visibility, high-stress conditions, possibly disoriented. A #1 engine fire; sporadic contact with LAX; a SO with systems panel problems. Both pilots would have divided attention from flying to help the SO – seated behind them – figure out the panel. They could have missed any directions by the air traffic (ATC) Departure Controller (DC). Did the pilots even realize ATC was calling? If power was out, Standby could have been selected, the battery used to transmit on the #2 radio.

The report AAR-70/06, stated in Finding 14: “The No. 2 and No. 3 engines were developing power at impact.” The post-accident engine tear downs showed number (#) 2 and #3 engines were producing thrust at impact; therefore, the #2 generator was providing electric power the whole time. Did the SO mistakenly disconnect the bus tie? Did the SO not close the bus tie? Did he fail to select ‘GEN 2’ on the Essential Power selector switch? Did he accidentally disconnect busses that powered the CVR and FDR?

The CVR transcript showed unorganized engine shutdown procedures between the fire warning bell (1818:30) and CVR cut-out (1819:13.5). In that 43.5 seconds, did the FO return controls to the CP? Who was flying the aircraft at takeoff? Why did the FO have to ask the CP if he should retard the #1 throttle? Were the #1 engine extinguisher agents used? At 1818:45, an out-of-configuration or takeoff warning horn sounded when the #1 throttle was retarded. The horn was the only indication the crew attempted to shut down the #1 engine and there was no evidence that #2 Generator was selected.

More importantly, was the question of ‘indeterminate later time’, when the CVR and FDR were offline. Was it momentary? 30 seconds? One minute? At 1819:13.5, the CVR, the FDR and the transponder target cut out. The DC stated that UA266 did not respond to course directions. The ATC timer showed UA266 disappeared (impact) from the scope within two [radar] sweeps – four seconds each (Page 3, Note 4) at 1820:30. The CVR recorded nine seconds before impact, which was one second plus the two sweeps. The CVR had stopped for one minute and twenty-five seconds. The DC said he directed a right turn, but UA266 turned left and increased speed. Was UA266’s ‘increased speed’ the steep angled descent UA266 was found to hit the water at? Did UA266 even know they were descending?

At 0.5 seconds after CVR resumption, someone said, “… fields out.” Investigators believed the SO commented on the #2 generator’s electrical field, but if electrical power had been restored, why would the generator field be ‘out’? Besides, the “fields out,” speaker was unidentified. ‘Field’ could have been the airport or ‘field’. Investigators did not know. The “… field’s out” could have meant they had just discovered the communication problems with LAX. Was there stress in the crews’ speech? From the transcript, the SO never said that power had been restored. Did anyone notice the power returned or that power was even missed? The crew may not have known the radios, CVR, FDR or power were lost, because the FO or CP never commented about instrument recovery.

1.5 seconds after CVR returned, the SO stated, “We’re gonna get screwed up.” Two seconds later, the SO said, “I don’t know (what’s going on).” Question: If the SO failed to select Generator 2 on the Essential Power, would the instruments remain powered? Would the FDR and CVR have dropped offline? In his confusion with #2 generator, did he accidentally cut power to the busses powering the recorders?

In the last five seconds, the FO stated, “Keep it going up Arn [CP], you’re a thousand feet.” Two seconds later, the FO said, “Pull it up.” One second later: IMPACT. In those last five seconds, did the CP and FO return full attention to flying, like Eastern 401? The angle the aircraft hit the water suggested they were not aware of their attitude; the sudden call, “Pull it up,” suggested that neither pilot was focused on their rate of descent or pitch angle. The crew shut down the #1 engine without any procedures, no checklist. Could the crew have inadvertently put the aircraft out of configuration without realizing it? To answer the Standby system question, “(b) why the standby electrical power system either was not activated or failed to function”, if the crew did not know there was a power problem, they would not have select Essential Power to Standby. It was likely that the CP and FO focused attention on the young SO’s panel, then became disoriented when they looked back, just like Eastern 401.

Hindsight is 20/20; this is distinctly understood. However, accidents such as these should be reexamined and taught by/to investigatory agencies for the lessons unlearned, particularly mistakes made that could have prevented later accidents. UA266 represented lessons unlearned for investigatory agencies:

  1. Probable cause was useless in 1969 and is useless today. Root cause analysis should always have been pursued as the goal.
  2. Accident investigation reports have spiraled into opinions pieces, not factual analysis. Guessing may have saved time but what amateur opinions cost the aviation industry cannot be measured.
  3. The CVR and FDR data, analyzed while investigating accidents, must receive expert analysis by experienced aviation investigators.

UA266 represented lessons unlearned for the industry:

  1. An opportunity to improve cockpit resource management (CRM), a concept raised in the 1950s. The UA266 crew’s response to the #1 engine fire was disjointed, uncoordinated. CRM should have been a major focus.
  2. Better checklists and pilot-to-pilot challenges for flight crews to handle important events, such as terminating an engine fire or radio communication breakdowns.
  3. Enhanced ATC procedure reviews for communication losses with any aircraft in any stage of flight, whether takeoff, cruise and landing.
  4. Improved technical training for all pilots, specifically for the SO, whose real-life experience was as a pilot, not a technician.

Imagine what later accidents could have been avoided had some actual lessons been implemented in the UA266 accident report. As mentioned in Aircraft Accidents and Kobe Bryant, CVRs and FDRs are tools; if they are not used correctly, they are nothing more than paperweights. The post-tragedy of UA266 was that the data was not analyzed correctly by those who understood airline culture and training.

Aircraft Accidents and Kobe Bryant

A Flight Data Recorder

“Emotions are the enemy of Truth.” You might expect that to be a Star Trek quote, a Vulcan adage to explain away a vengeful alien’s demise, but it is not. Emotions are the antithesis of what all accident investigatory groups, e.g. the National Transportation Safety Board (NTSB), are supposed to be about. Mister Spock’s lack of emotions shows how investigators should view all accident investigations – dispassionately. Body counts – though tragic – have nothing to do with WHY an aircraft crashes. They never have.

On January 26, 2020, Kobe Bryant was killed when the helicopter he was in crashed, accident number DCA20MA059. The helicopter, a Sikorsky S-76B, was owned and operated by Island Express Helicopters, a Code of Federal Regulations, Part 135 operator. The helicopter impacted terrain. The accident investigation continues; the root cause is still undetermined.

All the accident’s victims should be mourned. The loss of life is always tragic and should be recognized. However, Mister Bryant’s name should be separated from accident investigation DCA20MA059. His involvement is the only reason the NTSB dedicated vast resources to the investigation. But investigatory agencies tend to become mired in the emotional issues. DCA20MA059 is an investigation. The NTSB should concentrate on the accident’s causes, not the tragic loss of life. To do otherwise could be perceived as exploiting Kobe Bryant’s celebrity – and tragedy – to push an agenda.

In a Saturday, June 6, 2020, article titled: “NTSB Urges Helicopter Makers to Install Black Boxes Months After Kobe Bryant Accident”, Fox News’s Vandana Rambaran said, “In an unprecedented move Tuesday, the National Transportation Safety Board directly urged six of the largest helicopter manufacturers to install black boxes that provide information in a crash, like the one that killed NBA star Kobe Bryant.” First, this is not unprecedented; investigative agencies have been circumventing oversight agencies, like the Federal Aviation Administration (FAA), for years. The NTSB has used different venues to avoid regulatory challenges, e.g. accident hearings, sunshine meetings, the media and, of course, Congressional Hearings. These attempts are silly. Why? Because the NTSB lacks the aviation experience to second guess the FAA’s authority in regulatory, engineering and technical knowledge.

The flight data recorder (FDR) is viable equipment on any aircraft, assuming, that is, if it is correctly interrogated. On December 18, 2003, a Líneas Aéreas de Suramericanas (LAS) DC-9 crashed in Mitu, Colombia. This DC-9 had an early generation FDR system, the most basic FDR with minimal sensors. The Colombian government asked the NTSB to read the FDR data, which the NTSB analyzed, along with the Cockpit Voice Recorder (CVR). The NTSB interrogator ‘discovered’ that the stabilizer trim cables jammed and caused the accident. But this was inaccurate. What really happened was the cargo floor failed; the broken floor pinned both the engines’ and ALL the flight control cables, not just the stabilizer trim. The NTSB did not discover the accident’s true root cause before meeting with the Colombian officials because the inexperienced NTSB interrogator misread the rudimentary FDR’s data.

How did the NTSB misread the LAS FDR data? Because the NTSB hired only one experienced investigator who worked commercial airliners, e.g. the DC-9. That person, who was at the meeting with the Colombian officials, pointed out the interrogation error, thus embarrassing the NTSB’s Director of Aviation Safety. The NTSB interrogator did not ask anyone to assist him in reading the FDR data. This is an important point; a common, rudimentary FDR system, used by airlines, could not be interrogated by the NTSB, because there was no one there who understood the DC-9’s sensors or cable system.

What does this have to do with helicopter accident, DCA20MA059? A fixed wing aircraft has sensors for its FDR located all throughout the airframe, from the nose gear to the upper rudder; from one wing tip to the other wing tip. A fixed wing aircraft uses air speed to generate lift over its wings, aka Airfoils.

However, a helicopter creates its own lift with rotation of the main rotor; the main rotor blades are the airfoils. There are no flight controls on the blades because the lift is manipulated by the changing angle of each blade. Since there are no flight control panels, there are no spoiler, aileron, flap, rudder, elevator, tab or ground spoiler sensors. Data on a helicopter is simplified, localized; all data-producing components are located near the pilot; important sensors’ data can be downloaded from the pilots’ gauge programs, e.g. oil pressure, attitude, bank angle, fuel quantity, transmission rotations, from sensors in the engine(s), the controls for the main rotor and the tail rotor.

And this is where the point of the LAS accident comes into play. The NTSB’s Director of Aviation Safety recently stated, “The more information we have, the better we can understand not only the circumstances of a crash, but what can be done to prevent future accidents.” Precisely! This is a true statement. It also underlines what the NTSB doesn’t do, namely hire investigators with specific talents. If the NTSB is truly concerned with accurately determining Root Causes of helicopter accidents, as they should; if the NTSB wants to become skilled in investigating helicopter accidents, as they must; they only need to follow one simple solution: HIRE … MORE … HELICOPTER … EXPERIENCED … INVESTIGATORS. That is all. Problem solved.

When I worked at the NTSB, there was only one investigator – since retired – who had helicopter experience. Since then, it appears the NTSB has hired only ONE investigator with helicopter expertise – just ONE. What does this mean? The NTSB has only one person qualified to investigate helicopter accidents. Only one person who can help interrogate a helicopter FDR.

The ‘lone helicopter investigator’ raises another issue. How has the NTSB been investigating helicopter accidents when they never hired helicopter-experienced people to interpret the data? How did these people (accustomed to investigating fixed wing accidents) determine if Ground Resonance or Retreating Blade Stall occurred? Were these accidents investigated correctly?

Per the NTSB’s website, the NTSB stated, “In addition to asking manufacturers to install crash-resistant recorders on newly built helicopters, the NTSB also asked them to provide a means to retrofit their helicopters with crash-resistant systems capable of recording flight data, cockpit audio and images [Italics added] on their helicopters not already so equipped.” And there is the rub. Would helicopter safety be improved by installing cameras and voice recorders?  

As per the NTSB update for DCA20MA059, “The pilot [singular] and eight passengers were fatally injured and … forces and fire.” Let us be clear – there was only ONE pilot. In almost all emergency medical helicopters, police helicopters, news helicopters, traffic helicopters and Part 135 commuter helicopters, there is only ONE pilot. In an emergency, there would be no discussions. Single pilots do not talk to themselves. A pilot would not give a play-by-play of the emergency, stating what each gauge reads. The pilot would not announce what he is doing. There would be no intelligible words to record.

Then what would a helicopter CVR capture? Passengers screaming? Equipment being tossed around? The thumping of the main rotor or engine(s) drowning out all conversation. Let us be clear, Cockpit Voice Recorders are just that: COCKPIT voice recorders. They are designed to record voices and noises INSIDE an enclosed cockpit compartment. Helicopters do not have enclosed cockpits. A CVR is designed to capture pilot conversations. Passenger and flight attendant conversations are not meant for the CVR.

Per the Rambaran article, “The FAA has failed to act on an NTSB recommendation that turbine-powered helicopters record data, audio and images during flight, so the safety board instead reached out to Sikorsky, Airbus Helicopters, Bell, Leonardo, MD Helicopters and Robinson.” First, the FAA has not failed at anything. Second, Ms. Rambaran does not understand that CVR audio would bring ZERO results to an accident investigation. Cameras, on the other hand, make the emergency worse. How?

Imagine Ms. Rambaran – or any professional – having someone video her every … single … action while she is working, e.g. driving to a story; filming her while she ‘gets’ her story; recording every time she drove over the speed limit or rolled through a stop sign; stopping for lunch (how long did she take?); watching her chew her food; filming over her shoulder while she types her story; second-guessing her use of spell check; checking if she used opinions or facts in her news story. Every choice she makes is brutally scrutinized; every decision, interrogated. And … she knows her actions will be questioned.

Cameras add to a pilot’s stress and do not increase safety. Where would one put the camera? Facing the pilot? Above? Below? To the side? Focus on the instruments? Focus on the controls? Looking out the window? Is it focused for inside or outside of the helicopter? Do you use color film?

Ms. Rambaran continues: “The FAA has, in the past, resisted mandating crash-resistant recorder systems because it could not calculate a cost-benefit ratio.” This is true. Helicopter cameras and CVRs are a financial extravagance; that’s a fact. Besides, a change to the Federal Aviation Regulations for helicopter CVRs would take five years and cost over five million dollars for CVRs that will never increase safety.

My condolences to Kobe Bryant’s family and to the families of those who lost loved ones in that accident. The NTSB should steer away from the emotional side of accidents, focus on real problem-solving. They need to use tools that work. They must hire only qualified, experienced investigators; not waste time and money on agendas that amount to irrelevant technology that does nothing for safety.

Aircraft Accidents and Lessons Unlearned XXXVIII: The English Language

Partial Book Cover from English in Global Aviation

Two inspectors and I conducted surveillance on a Florida-based operator. My fellow inspectors had found issues with the operator’s weight and balance (W&B) forms. I later walked past the ramp manager’s office, where the two inspectors were talking with the manager (who spoke not-so-good English) about the W&B forms. The inspectors spoke s-l-o-w-l-y, VOCIFEROUSLY, as if the non-English fluent manager would better understand what they were telling him, but it did not help.

Since I began writing articles, I am one of a few authorities writing about mistakes made in aircraft accident reports, specifically aircraft maintenance mistakes. I am reading a book by the authors Eric Friginal, Elizabeth Mathews and Jennifer Roberts called, English in Global Aviation (Bloomsbury Academic, 2020). It is a brilliant book focusing on misuses of the English language – the language of international aviation – in aviation and how these misuses affected aviation safety.

The book is encouraging for its honesty. The authors know their topic; their expertise speaks to safety issues never raised before in accident investigations. The book is timely; it analyzes how accident investigations have been affected (negatively?) by, e.g. conversations between English-speaking pilots and foreign air traffic control (ATC); foreign pilots, whose native language is not English, with United States’ ATC; foreign pilots slipping between English and their native language in the cockpit.

Listening to the cockpit voice recorder (CVR) of an accident flight is difficult for many reasons. CVR transcripts can be frustrated by sounds that are hard to hear around, such as rushing air, audible alerts, pilots speaking over each other or pilots alternating between English and their native language. It is discouraging that an accident investigation agency (AIA) like the National Transportation Safety Board (NTSB), continues to misinterpret CVR data of an accident flight’s last minutes.

The authors first example is to discuss American Airlines flight 965 (AA965); the Boeing 757-223 struck the summit of El Deluvio mountain on December 20, 1995, near Cali, Colombia. The authors discovered important language errors in phraseology in the radiotelephony communications between Colombia’s ATC and the AA965 pilots. These misunderstandings eventually led to the airliner impacting terrain.

It was unfortunate that the Colombian AIA, Aeronautica Civil of the Republic of Colombia (ACRC), led the investigation. I was a liaison to the ACRC in 2003 for a DC-9 accident in Mitu, eight years after AA965. The ACRC missed basic air cargo modification issues while the NTSB bungled the flight data recorder readings. As with the Mitu accident, the ACRC’s inexperience on the AA965 investigation meant that important issues had been missed.

The authors spell out how, in AA965, radiotelephony communications, phraseology and plain English mistakes, led to the accident because of simple misunderstandings. The book lays out a more informative sequence of events, but the Root Cause was that the Colombian controller’s grasp of English phraseology caused confusion between the controller and the AA965 pilots.

The authors stated, “Accident investigation is not about blame; it is about a fearless and comprehensive uncovering of any and all information that may be applied to prevent future accidents.” In part, I disagree with the authors’ view. AIAs, e.g. the NTSB, obsess about Blame and they take it out of context. Clearly, investigation reports must determine Root Cause(s), not be used as lawsuit fodder. Responsibility should replace Blame. Responsibility for safety failures must be established and addressed. If not, Probable (aka Probably) Causes become – indeed, have been – nothing but politically-correct whitewashes; they have become absurd and useless. Nothing gets solved; safety is not improved; aircraft continue to crash.

Consider the NTSB’s AA965 recommendation: “… the Federal Aviation Administration (FAA) should develop with air traffic authorities of member states of the International Civil Aviation Organization (ICAO), a program to enhance controllers’ fluency in common English-language phrases and interaction skills sufficient to assist pilots in obtaining situational awareness about critical features of the airspace, particularly in non-radar environments.” This NTSB word salad missed the point entirely. Nothing about responsibility. No urgency. No plan. No direction. A safe recommendation that solved … nothing.

On page 23, the authors said, “Accident investigators are committed to a thorough and unbiased review of all the evidence available.” This statement is true but gives AIAs too much credit. Consider Lion Air 610 (LA610) and Ethiopian Airlines 302 (EA302) (Aviation Lessons Unlearned articles XXXI, 11/2/2019, and XXXVII, 4/30/2020), two accidents alluded to in the authors’ Preface. In both LA610 and EA302 obvious investigatory mistakes were made and there was insufficient evidence to base the Findings on (like AA965?). Government agencies investigated government airlines with extreme bias (ACRC looking into the Colombian ATC?). And why did the NTSB and ICAO assign blame to Boeing? Was it convenient? All at once, Blame became acceptable, almost a noble act. An international pile-on with little-to-no proof. Then investigatory agencies, including the NTSB, guaranteed future disasters by repeating what was easy, the mantra: “It’s Boeing’s Fault.” They did this while ignoring obvious problems with the airlines’ cultures, English translations, pilot training and understanding fundamental maintenance practices.

The authors spoke of Avianca flight 52 (AV52) in 1989 (Aviation Lessons Unlearned XXXIV). In this case roles were reversed: a Colombian flight crew with a limited grasp of the English language trying to land in Kennedy airport. The root cause: the crew failed to divert to Boston, their alternate. The authors had found that AV52’s First Officer did not have a command of the English language; the captain relied on him for communicating their desperate fuel situation and emergency. In AV52’s accident, the NTSB had investigatory authority and the best Probably Cause was … AV52’s ‘fuel management’ problems(?). AV52 preceded AA965 by six years. If someone on the NTSB’s AV52 investigation team understood basic English phraseology issues, would AA965 have been prevented? We will never know.

What of the cultural problems? Before AA965, what importance did Colombia place on quality English being spoken by their ATC controllers? Six years earlier, if the international AV52 PILOTS had poor English skills, how much less would Colombia have invested in their in-country controllers? Colombian ATC standards appeared to be much lower than US ATC standards. With AV52, ICAO overhauled language requirements for international carriers. What did ICAO do about controllers after AA965?

The authors make a critical point at the end of Part One of the book: “… language issues played a role, which accident investigators recognized at some level, but which did not rise to the level of being recognized as a causal or contributing factor …” This echoes the main point of the Lesson Unlearned articles, that important information has repeatedly been missed, information that could have directed investigators to contributing factors and then the accident’s specific root cause(s). For instance, why was the Colombian controller in AA965 interviewed twice before the ACRC learned about his phraseology doubts? How was that missed the first time? Did anyone connect AA965 to the AV52 accident? What have been the consequences of these mistakes?

In chapters 4 and 7, the authors talk specifically to Aircraft Maintenance. “Accident investigators are pilots, engineers, and other technical experts.” The authors highlighted the obvious: no mechanics – and that is the point. Have English-speaking mechanics caused accidents through communication mistakes? In the Colgan 9446 accident, during an Operational Test of the elevator trim system, the mechanic in the cockpit running the pitch trim switch thought ‘leading edge (LE) UP’ meant the Elevator Panel’s LE; the mechanic observing on the tail thought ‘LE UP’ referred to the Trim Tab panel’s LE; these panels move contrary to each other. A simple communication mistake led to a reverse trim and then the accident.

Even airframe and engine maintenance manuals are, what mechanics would consider, ambiguous, in some cases, confusing. Major airliners have manuals that are difficult to understand from a mechanic’s point of view, which is why using engineers to investigate accidents is pointless; the engineers’ contributions to maintenance manuals are from an engineer’s point of view. Employing engineer investigators continually ignores ambiguous maintenance instructions used for continued airworthiness.

It is encouraging that the authors give high importance to Maintenance as a causal factor in accidents because AIAs have ignored Maintenance for decades. In the two accidents, LA610 and EA302, involving the B737-MAX, each accident’s root cause involved either the operator’s inexperience with routine Return-to-Service procedures or the operator’s pilots did not recognize (maybe ignored?) the deteriorating maintenance situation. Language barriers played a large part in these accidents; perhaps the translation of maintenance instructions from English to the native language was not the best quality.

Mechanics, unlike pilots, have the benefit of time. If instructions are confusing, call the manufacturer; if a return-to-service test does not clear the problem, call the manufacturer. In both the LA610 and EA302 reports, calls to Boeing were not mentioned. How could investigatory agencies ignore the obvious?

On page 23, “Investigators examine the corporate culture of the company for which the pilots work.” Oh, if only. For instance, AIAs, such as the NTSB, employ pilot investigators without airline experience while qualified FAA-certificated maintenance-experienced investigators are non-existent. These investigators have no experience with culture; they cannot recognize cultural issues; they cannot understand basic operator culture. Culture, in Operations or Maintenance, has rarely been properly examined as a causal factor, indeed looked into at all. The use of these investigators, unqualified in the specialties they investigate, damages investigation quality and postpones safety improvements.

I have worked accidents where English was a point of contention, where even those who live in an English-rich environment got it wrong. I have also worked international accidents where primary languages played heavily into misunderstood instructions. English in Global Aviation demonstrates that another set of causal factors are being ignored by accident investigating authorities around the world and the consequences are being felt by the flying public.