Aircraft Accidents and Sense

Amtrak’s Empire Builder de-railed

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Southwest Airlines flight 812, aircraft N632SW

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and the Imitation of Art

Count Dooku’s Realization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned LIII: Northwest Airlines Flight 255

The resting place of Northwest Airlines flight 255

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Fabricating

Battle of Monmouth during the War for Independence

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned LII: Eastern Airlines Flight 980

Mount Illimani with La Paz in the foreground Picture by Donald

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and the Other Shoe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned LI: Arrow Air Flight MF1285R

Arrow Air Douglas DC-8-63

On December 11, 1985, Arrow Air flight MF1285R, a Douglas DC-8-63, registration number N950JW, crashed on departure out of Gander International Airport, Gander, Newfoundland. The aircraft had been taking off from runway 22; it did not achieve altitude before, according to witnesses, it banked right and pitched up, all while descending down the embankment at the end of the runway.

The Multinational Force and Observers chartered the flight to bring service men and women of Fort Campbell’s 101st Airborne Division back to the United States from Cairo. The aircraft had a scheduled stop in Gander as part of its flight plan, taking on fuel and catering services.

The Canadian Aviation Safety Board (CASB) conducted the investigation, the subsequent hearing and wrote the accident report. The report stated that wing icing was the accident’s major contributor. Not mentioned were other major contributors, e.g., poor judgment and a lack of conditional awareness; the flight crew did not correctly analyze the danger imposed by ice accretion on the flight surfaces.

A look into fatigue and its effects on the crew was made by examining the research of Doctor Stanley Mohler, Director of Aerospace Medicine at the Wright State University of Medicine. Doctor Mohler applied his fatigue-rating index to the flight crew’s schedule and found that the crew’s conditions, at the time of the accident, fell into the “category of ‘may dangerously deplete physiological reserves’.” Doctor Mohler determined that the accident crew was fatigued despite their taking the flight over from the arrival crew in Gander.

An examination of the aircraft and engines determined that the number four engine was not operating as efficiently as the other three engines. However, tests and flight simulations eliminated the aircraft and engines as contributors to the accident.

The accident flight’s weight and balance records were examined and found to be safely within the mean aerodynamic chord envelope; the center of gravity (CG) was well within limits. The cargo weights were identical to those of the previous leg and the passengers did not change seating. An argument could be made comparing actual weights versus average weights, but the CG would still have been safe. The CASB had calculated the weights and found a discrepancy, but the previous leg’s CG was not retrimmed in flight, therefore the accident aircraft’s CG was not in conflict.

The CASB gave credence, in the absence of other information, to witness statements about flight controls, hydraulics, the number four engine and thrust reversers, all of which could not be substantiated. Another, a yellow/orange glow under the aircraft belly was entertained, but could not be validated as anything more than, e.g., a red anti-collision beacon reflecting off the open landing gear slave doors.

It was unfortunate that CASB Board Hearing time was wasted on issues that had little to do with the accident; not to say examining all possible scenarios was wrong, just pursuing information irrelevant to the accident. For instance, the Director of Maintenance (DOM) was asked about an uncontained engine failure that had occurred four years earlier in Casablanca and the repairs to wings and flight controls as a result. A DOM does not concern himself/herself with non-emergency items or repairs, no matter the detail; the DOM would instead be a good source for company policy and fleet problems, not individual aircraft. Missing cargo panels and Engine Hi-temp gauges received unnecessary attention; they were not found to be contributors to the accident and diverted interest away from the causes.

It was determined that icing was the likely culprit of this accident. Ice would have answered questions relating to increased stall speeds, the roll to the right, inadequate lift, even a heavier than recorded aircraft weight. The ice could have been distributed unevenly across the wings upsetting lift on one side more than the other. The aircraft, having recently arrived from the previous leg, could have had supercooled wings, which, after being newly fueled, would have added to the icing problem. Little was added by some witnesses interviewed: ramp handlers, fuelers and servicers who did nothing to answer aircraft icing questions. Oddly, the report made no mention of the flight engineer’s preflight external inspection, for he could have seen wing ice and snow accumulation from behind the wings.

In 1982, an Air Florida B737, flight 90, crashed taking off out of National Airport. Cause: Icing. At the time of Arrow Air MF1285R, the airlines were required to have deicing plans approved by the Federal Aviation Administration (FAA) in their Operations Specifications. Deicing was not a new concept; at the time of this accident, airlines were already using anti-icing fluids with deicing fluids. So, why, after the disastrous Air Florida flight 90 accident, where the root cause was negligence on part of the flight crew, did this flight crew choose to fly the airplane, untreated by deicing, under a similar precipitation event?

It was interesting that the CASB did not raise a more obvious question: Was this accident due to simple negligence, military charter concerns or both? Military charters are frequent business ventures between the military and commercial aviation; my son returned from the Iraq conflict on a Continental B767 thirteen years ago. In addition, the military assures civilian lift support by engaging with air carriers in the Civil Reserve Air Fleet (CRAF), where the military supplements the air carrier to have access to their aircraft in time of need.

But CRAF does not work like a charter. In a charter, the airline does not work with the military, the military is the customer. And while the military and the commercial airlines are dedicated to safety, their paths to safety are far different because their missions are different. It is this disparity in safe practices that results in urgency miscommunications between the air carrier provider and the military customer.

Therefore, what is it about military charters that makes the most qualified airline personnel lose their capacity for common sense?

A load master for a B757 charter company wrote (what he considered to be) an amusing an article about how humorous a B757 captain was who, while flying a military charter, scoffed at a deicing delay and instead swept ice and snow from his wings with a broom instead of “having to wait” for the deice crew to show up in the morning. Aside from not being funny, the operational and maintenance violations were numerous beyond the captain ignoring the airline’s deicing program.

In April 2013, National Air Cargo flight 102, a B747 cargo jet crashed while taking off out of Bagram Airfield in Afghanistan. The accident was due to unrestrained cargo, which moved aft on rotation. This same freight exceeded the cargo floor’s structural weight limits, destroying the floor’s integrity when the B747 landed in Bagram. The floor’s failure left the floor cargo locks and netting restraints useless – the cargo moved because there was nothing to hold it in place. The accident B747’s cargo bay was marked with cargo weight limits per station that normally would have prevented the accident by drawing attention to the overweight loads, but National 102’s load crews and pilots ignored these warnings.

The planes, National Air Cargo 102 and Arrow Air MF1285R crashed, but not because safety protocols were not in place. As a rule, the Department of Defense (DOD) conducts regular audits on those the DOD contracts with and the air carriers with CRAF agreements. Similar to FAA audits, the DOD audits employ Operations and Airworthiness representatives who dig into the air carrier’s policies from a safety standpoint; in fact, DOD audit findings require the FAA air carrier certificate office respond to discovered safety items of concern with how the safety issue would be corrected and how quickly. If not corrected, the contract is canceled.

However, an air carrier audit did not cause the Arrow Air MF1285R crash. Arrow Air’s deice program existed; the flight crew was familiar with the meteorological conditions and fueling issues with which icing would become a problem. Did the second officer conduct a preflight walkaround? Did the flight crew opt out of deicing in favor of an on-time departure? An airline is run on a schedule; as part of the airline culture, there is an urgency to ‘fly the airplane’, to meet the schedule and the next one.

Did time constraints for departure eclipse common sense and experience? The aviation industry will never know because the right questions were not asked. However, when entering into a lease agreement, the most important factor to be considered is safety, even when it is inconvenient.

Aircraft Accidents and Recognition

NTSB Chairman Robert Sumwalt

Before there were a bevy of health gurus, there was Jack LaLanne. Jack, who died in 2011 at the age of 93, spent his lifetime spreading the values of exercise and good nutrition for thirty-four years on his show, The Jack LaLanne Show, where he not only helped those of all walks of life to better, healthier living, he was a living example of what he professed – the man had even skipped dessert since 1929. He performed 1,033 pushups in 23 minutes in 1950; on his seventieth birthday, while shackled and handcuffed, he pulled 70 rowboats, with a man in each, across Long Beach Harbor, CA. In short, he ‘walked the walk and talked the talk’. He was the health expert for many decades and never equaled.

This kind of dedication is what is known as being “qualified for the job”. Jack did not get elected health expert, he lived it; he showed by example that his insight worked; acknowledged by the international community as the model. And for his lifetime achievements he received recognition.

On the topic of aviation safety, there is no lack of contributors. It has taken me time to realize that though others who promote aviation safety may be in conflict with some of my views, they have spearheaded much needed conversation to the front, conversation that benefits all in aviation. I sometimes need to be reminded that I did not get into writing about aviation safety to just promote my arguments or sell a book. I – we – do what is necessary to increase safety – period.

Aviation safety is not a popular topic; it is, though, one of the most important subjects affecting, not just our industry, but civilization. Like points on a compass, investigator theories can veer off in different directions so dissimilar, one wonders if they are speaking to the same event. I have sat in Federal Aviation Administration (FAA) and National Transportation Safety Board (NTSB) staff meetings where I had to check my notes to make sure I was in the right room, that we were discussing the same accident/incident. That is why leaders are so important to advancing safety; a person who not only grabs the microphone but can challenge the others who line up against him or her to do what is right.

When I worked on NTSB major accidents and subsequent hearings, (then) Member John Goglia’s seat was to the Chairman/Chairwoman’s immediate left. Of the five Board Members, he always appeared cool and collective; he was in his element. His aviation experience as a Board Member was unmatched. His aviation maintenance knowledge was unlimited. There are or were not many NTSB politically appointed Board Members who deserved their place at the table more than John Goglia.

The single reason I was hired into the NTSB was because former Member (FM) Goglia used his influence to guarantee an aircraft mechanic, experienced in the maintenance field as he was, be hired into the NTSB and work on the major accident Go-Team. Prior to FM Goglia’s push for the position I would soon occupy, aircraft maintenance was – and possibly is again – investigated by engineers with no industry experience. FM Goglia recognized that investigations into maintenance issues had to be done right; the investigator had to understand every aspect of aircraft maintenance for a Part 121 commercial airline, Part 135 ten-or-more perspective and have a healthy understanding of Part 145 Repair Stations. In other words, to know the conditions mechanics worked under, problems they faced and even problems they created. FM Goglia knew the best way to fix problems was to be able to identify them, address them and determine a way to make sure they did not reoccur.

It was more than the raising of the investigative bar that FM Goglia brought to the NTSB; it was his tenacity. He understood an inarguable fact: that to make effective changes – post-investigation – solutions had to be properly communicated to all those who would affect change, including how the FAA interpreted NTSB recommendations. Employing common sense, FM Goglia would speak with FAA management about how to word recommendations so that the transition from recommendations to FAA regulation, policy and guidance would be flawless.

He also was there to guide anyone who wanted to benefit from his experience. FM Goglia, knowing that I had no one who could show me the ropes in maintenance accident investigation, was always a phone call away with advice – especially when on-site – and his office door was always open. He would go off script; his methods did not always appeal to management at the Board, but then he was not there for management; he was there for the investigators, those at the site. They were the ones who needed the benefit of his experience.

Lately FM Goglia has been sharing his experience at his website: https://flightsafetydetectives.com with a look into past accidents. He continues to make the industry safer.

Former Member Goglia was one of few Board Members, present and past, that I knew of that could draw from personal experience and bring that to the table. Another is Chairman Robert Sumwalt. 

I never worked with Chairman Robert Sumwalt; I have seen him on social media updating the industry about the latest news of an investigation. I have known other Chairpersons in the past, but none stood on the front line as often as Chairman Sumwalt has. He did not stand on ceremony. In my career, indeed my lifetime, I cannot remember an NTSB Chairman – and very few Members – who has championed the NTSB or taken a more active role in spreading, not only the NTSB’s successes in all five modes, but infused his experience as a pilot into the discussion.

And that is what makes the difference: Experience. To ‘separate the chaff’, remove media sensationalism and rationalize the investigation. Chairman Sumwalt’s experience streamlined the Operations side of an investigation, a major part of any investigation that needed a practiced eye. That is what pilots need for safety to be improved, especially in the Part 121 world. Part 135 nine-or-less operations are far different than Part 121; crew scheduling, fatigue, recovery flights, flying Part 91, all the important factors taken for granted by the less experienced in a major accident investigation, play vital roles in safety; they and other factors are the difference between determining cause and best guesses.

As per his NTSB website bio, Chairman Sumwalt was a pilot for 24 years with Piedmont and US Airways. During this time, he experienced mergers, equipment changes, thousands of hours of training, long days, conflicting schedules and every hurdle a line pilot could deal with, all factors that affect the safety of the flight crew, passengers and the aircraft. At US Airways, he served on the Flight Operational Quality Assurance monitoring team, which assured procedures and policies were followed by both pilot and management. Experience – Experience – Experience!

After leaving US Airways, he ventured into management at a Fortune 500 company; chaired the Airline Pilot Association’s Human Factors and Training Group and acted as a consultant to the National Aeronautics and Space Association’s Aviation Safety Reporting System program. It was his choice to step out of the left seat and pursue other safety avenues that make him stand out as an investigator and a Board Member. Not just that he was a commercial pilot, but that he broadened his effect for all aviation.

I felt the most influence Chairman Sumwalt had was his role as Chairman for the NTSB. He used his position and social media to keep the aviation community informed about the latest news of NTSB investigations. It was this function that he served aviation most notably; he took the NTSB out of the meeting room and broadcast their investigations for all to see, not just in Aviation, but Rail, Highway, Marine and Pipeline, as well.

Somehow, it is hard to imagine that Robert Sumwalt, upon his pending retirement, will simply fade into aviation history. I do not foresee him pulling a ‘Jack LaLanne’ and strong arming a B737 across a ramp on his birthday, but like John Goglia, it is expected that Robert Sumwalt will find new ways to improve aviation safety. And that is good – that is real good – because aviation needs him, needs both of them, desperately. These two aviation professionals, from opposite sides of the aviation ‘tracks’ – Operations and Airworthiness – deserve recognition for their continuing contributions, leadership and drive.

Aircraft Accidents and Lessons Unlearned L: The Wright Flyer Model A

The Wright Flyer Model A after it crashed on September 17, 1908.

On September 17, 1908, at 5:14 PM, local time, Orville Wright was conducting a demonstration for the United States War Department; he flew with United States Army First Lieutenant Thomas E. Selfridge. Wright was conducting a proving run for the military in a modified version of the Wright Flyer, the upgraded Model A. About twenty minutes into the demonstration, after three successful laps over the Parade Grounds outside Arlington Cemetery, Wright heard a light tapping. Being wary, he began to shut down the engine and attempted to glide from a height of 150 feet. Before the engine could be shut off, per Orville’s testimony, he heard, “… two big thumps, which gave the machine a terrible shaking.” A piece departed the aircraft before the airplane swerved to the right; the aircraft would not respond to his inputs. He shut off the engine, while working to regain control.

Per the accident report, Wright said, “I continued to push the levers, when the machine suddenly turned to the left. I reversed the levers to stop the turning and to bring the wings level. Quick as a flash, the machine turned down in front and started straight for the ground.” Witnesses said that at seventy-five feet, the machine began its nose-dive into the ground.

Lieutenant (Lt.) Selfridge had the sad distinction of being the first person to die in a heavier-than-air powered aircraft, a unique fatality for, at the time, only balloon and dirigible occupants were known for being aircraft fatalities. Even so, Lt. Selfridge’s unfortunate death had nothing the do with the accident; he neither affected airworthiness nor unexpectedly contributed to the accident. Aside from mentioning his unfortunate demise, Lt. Selfridge did not have a place in the investigation. However, Lt. Frank Lahm played an important role.

At the time of the Wright Brothers first flight and subsequent work with the military, the term, ‘Powered Aircraft’ was locked up by dirigibles, balloons and other lighter-than-air machines. Per Britannica.com, Gliders – one of the first heavier-than-air attempts – were receiving initial attention when Otto Lilienthal, with his brother Gustav, of Germany, “… built his first [heavier-than-air] man-carrying craft, with which he could take off by running downhill in the wind.” The Lilienthal brothers had experimented with wing camber and Bernoulli’s Principle; they studied stabilizing tail surfaces that would evolve into horizontal and vertical stabilizers, rudders and elevators. It was not until 1903 that power and aircraft were successfully married in the Wright Flyer.

Documented information on the accident was extremely limited; the unexpected disaster was witnessed by military personnel and some media; no one expected to see anything beyond the trial runs of some of the latest aircraft. The consequences of heavier-than-air flight were unknown, perhaps as alien to the people observing as those fearing a ship going over the horizon’s edge a millennium ago. It was clear from Wright’s comments that the accident was a surprise, that the modified mounted propeller upset the flight as it had; the result was completely unanticipated.

Per the airspacemag.com website, First Lt. Frank Lahm, after freeing Orville Wright and Lt. Selfridge from the accident aircraft, immediately began investigating the wreck. He would submit his report to the War Department five months later. Lahm had flown with Orville Wright a few days earlier and was familiar with the Model A; he had witnessed the accident and helped rescue the occupants. Lt. Lahm had access to all witnesses and the wreckage was available to analyze.

Before his demonstration for the War Department, Orville Wright had replaced the original 104-inch propellers on the Flyer with 108-inch propellers to increase aircraft speed. During the demonstration, the aircraft had reached a top speed of forty miles-per-hour and an altitude of 100 to 150 feet above ground.

When Wright heard the tapping sound, he was confused; his subsequent actions were not fast enough to prevent tragedy. The aircraft nosed over and lost 125 feet of altitude before Wright recovered, but he did not have enough room in the final 25 feet to pull adequately out of the dive; the skids – landing gear – dug into the earth and the aircraft crashed with what one reporter described as “frightful force”. Wright later commented, “A few feet more [of altitude], and we would have landed safely.”

During interviews, several witnesses had confirmed what Lahm had seen: a piece of one of the Flyer’s propeller blades had separated from the end of the propeller, causing a propeller imbalance. Lahm’s report stated, “… excessive vibration, this guy wire [securing the front rudder] and the right-hand propeller to come into contact. The clicking which Mr. Wright referred to being due to the propeller blade striking the wire lightly several times, when, the vibrations increasing, it struck it hard enough to pull it out of its socket and at the same time to break the propeller.” The term ‘guy wire’ may have been used in error; a guy wire is used to stabilize, brace or stiffen. The rudder was a moving flight control. However, the function of the wire was irrelevant, as was the title assigned to it; that it was in a position to be struck by the propeller was critical. It was not clear if Wright’s control movements moved the rudder wire into the propeller’s path or whether the amount of wire tension allowed it to swing into the propeller.

Was this accident preventable? Not likely; there were no previously similar situations for Wright to have learned from. The Model A did not have gauges to monitor the propeller or the rudder movements; all sensing of flight controls and engine monitoring were rudimentary, limited to sight, sound and feel. Even if Wright had identified the problem with the propeller, it would have been unlikely he could have shut the engine down in time to prevent the accident.  

In today’s aviation, what would have been the norm for Wright’s propeller modification. First, as the Model A was a redesign … of an aircraft without a type certification, the Model A would have been classified as an ‘Experimental’ category; it would have been operated under a special airworthiness certificate (SAC) and it would have been subject to the limitations according to its category. Per the Federal Aviation Administration (FAA) website, experimental category aircraft SACs are issued today to aircraft used in Research and Development – for which the Wright Flyer Model A qualified. Other limitations of Experimental aircraft include: Showing compliance with regulations; Crew training; Exhibition; Air racing and Market surveys.

The 108-inch propeller Wright changed to would have required testing as a either a modification or a complete redesign. The change in manufacturer design would have required checking to assure a clear path for the blades – no airframe in the blades’ paths. The blade materials would be tested for structural integrity. The propeller would be rated for safe operation with the Model A’s engine and that there was engineering paperwork to assure the propeller was a safe addition to the powerplant. Assuming the propeller was constructed of wood, the blade angles, symmetrical uniformity, the bonding of propeller to hub, balance and effects of air on the propeller’s structure would have had to be engineered as well.

Even in 1908, there were lessons to learn – and some to unlearn – from early heavier-than-air powered-aircraft of the day. Even politics played a part in the demonstration of the Model A; Wright had reason to believe that Selfridge was friends with and would show favoritism towards, Doctor Alexander Graham Bell, an aircraft builder and rival for the War Department’s aircraft contract. However, on that fateful flight, there was nothing dubious about Orville Wright’s intentions, which was to make an aircraft to the War Department’s specifications.

Perhaps the only lesson to be learned that day was to maintain aviation safety, no matter what; to think outside the box and to anticipate … anything. A lesson not to be unlearned over a century later.