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.

Aircraft Accidents and Discipline

“When I was your age …” Every generation tells tales to make their trials more of an overwhelming challenge to the following generation. Our parents did this to us; we did it to our children. I had a particular favorite; my Uncle Frank from Miami, told my young New York cousins, who complained about taking the bus to school, that he used to walk five miles to school in Miami … uphill … in the waist-deep snow … both ways. Yeah, right. As if anybody actually walked in Miami.

These teaching moments were to prevent a worst-case scenario, to stop our children from turning into live versions of the first four kids to drop out of Willy Wonka’s Chocolate Factory tour. Parents fought bratty behavior with endless supplies of guilt, like when I gave my disruptive child the Malocchio – the Evil Eye – guaranteed to stop a child in mid-naughtiness. It was a parental tool for teaching Discipline, because guilt, in proper proportion, was an effective persuasion.

Discipline may be subject to point of view. Per dictionary.com, Discipline has twelve definitions. The first, a Noun: ‘Training to act in accordance with the rules.’ With children, this means training them to be respectful of others. In aviation, Discipline is also crucial. Respect for the Pilot in the left seat; the lead on the repair; the Flight Attendants in the cabin. In the news lately, passengers harass Flight Attendants for irresponsible reasons, e.g., not wearing masks on the flight. There are those who question if masks even work, but … that … is not the point.

To begin with, Flight Attendants warrant our respect; their training and selflessness demand it. Providing drinks and blankets? That is not their purpose. They stand between the passenger and injury or death. Second, to bully, to verbally or physically assault a flight attendant is against Federal Regulations, aka the Law. Per Title 14 of the Code of Federal Regulations (CFR) Part 121.580 – Prohibition on interference with crewmembers: “No person may assault, threaten, intimidate or interfere with a crewmember in the performance of the crewmember’s duties aboard an aircraft operated under this part.” PERIOD! End of story! FACT: Flight Attendants are crewmembers. Interference includes disobeying an order, arguing and/or bullying for any reason, especially in areas of safety. Another FACT: The Federal government can impose fines of $5000.00 or more per person per event or imprisonment; the only caveat is that the airline has to press the issue because, unless the federal agency imposing the violation is present, the airline’s flight Crewmember has to file the charge and the airline must back their Crewmember.

Whether one agrees with the masks or not, it is an airline mandate, along the lines of ‘No Shirt, No Service.’ It is the airline’s right, a business decision. Each ticket sold is a contract; ‘We, the airline, will transfer you from Point A to Point B, but our rules must be complied with.’ Flight Attendants may be enforcing airline rules – the mask rule may not be Federal Law – but Title 14 CFR Part 121.580 still applies: Flight Attendants’ directions must be obeyed. Consider this: when purchasing a ticket, mask mandate rules are made clear. No one is coerced into purchasing the ticket; it is free will. If the purchaser understood the mandate prior to purchase, then too bad, so sad – wear the mask! If I am on that flight, I will have the Flight Attendant’s back.

The eleventh definition of Discipline, a Verb, states: ‘To bring to a state of order and obedience by training and control.’ The twelfth definition, also a Verb, states, ‘To punish or penalize in order to train and control; to correct or chastise.’ Control? Punish? Penalize? Hmm, Discipline suddenly takes a dark turn, a whole new personality. Suddenly, Toto, we’re not in Kansas anymore.

There is conversation in the industry that access to flights and services will be limited if a pending passenger has not received the virus out of China (VC) Vaccine, e.g., a Vaccine Passport. Even more concerning is that members of the mainstream media, aviation circulars, social media and celebrities have taken it upon themselves to bully, to coerce others to get the Vaccine, labeling those who do not as ‘unpatriotic’, ‘selfish’ and ‘irresponsible to their neighbors’ needs’. Considering the medical acumen of these judgmental people, the proper reply would be, “Sticks and Stones …”

This name-calling falls under the eleventh and twelfth definitions of Discipline: chastising and punishing others. Federal Regulation, aka the Law, does not support this mindset; this goes well beyond anyone’s rights and powers who are not medically trained and factually driven to make such a demand.

Many of my friends have taken the Vaccine. I do not add or detract from their decision, nor judge their actions to protect themselves or their families. That is not my point. People who do not feel the Vaccine is in their best interests are being pressured and … that … I do take issue with, because it is not the aviation industry’s place to pressure these people.

There are numerous reasons for people to avoid the VC Vaccine. Facts show the virus fear is exaggerated; the death tolls do not reflect true numbers; the Vaccine is untested; religious reasons; Constitutionality issues; the Administration’s flip-flops on taking the Vaccine. Aside from the obvious, with all the media’s contradictions and the present Administration’s reversals, who would take this Vaccine? Why would the airline industry push it? Why the rush; why the urgency? What is the principled response?

This Vaccine obsession begs each of us to question: If the Vaccine is as effective as we have been told; if the Vaccine is the success the media says it is, how does one who was vaccinated contract it from the non-vaccinated? More virus cases have been discovered due to improved testing; that is good news, because assuming the reports are factual, how many have actually died from the VC and … only … the VC? How many, then, need the Vaccine? It makes no sense; it is like asking where to bury the survivors.

It is unbelievable that those of child-bearing age and younger – those unaffected by the VC and its effects – quickly roll up their sleeves; that they do not question any Facts. Instead, they gamble their futures on fear and emotion. What about those with autoimmune disorders or other patients that cannot take the Vaccine. Are they unpatriotic? Irresponsible? When is the Choice to not take the Vaccine, respected?

When the Vaccine first came out in limited supply, I asked my doctor if I should take it. He said, “No,” for two reasons. His first reason was that I (and I quote), “… was not a Vaccine candidate.” My annual physical verified I was at my optimum weight. I do not drink, smoke, take non-prescribed drugs; I exercise regularly; take zinc and assorted vitamins. At 60 years old, he took me off my prescribed blood pressure medication – I did not need it anymore. The second reason: my Doctor said the Vaccine was untested; my wife’s Doctor said the Vaccine was dangerous; our friend’s two children – both General Practitioners – said, “Avoid the Vaccine.” Who, then, should give me medical advice? Four experienced doctors or airline managers and media editors with no medical training? What is the principled response?

It seems strange to have aviation executives pressuring customers through guilt to take a drug that cannot be untaken. The Vaccine cannot be removed once received; it cannot be filtered out of the blood; it is a forever vaccination. Who knows this Vaccine’s effects on Americans in the future? Its effects on pregnant women; their unborn children? How do we know? How will the aviation industry be impacted when we learn all the yet-to-be-discovered side-effects? Imagine designing an airliner with the attitude of, “We will build it, fly families in it and, only then, check to see if it is safe.”

States, like Oklahoma, require those wanting the Vaccine to sign a waiver, acknowledging the VC Vaccine is Experimental; that the government is not liable if the Vaccine causes injury or death. What is an Experimental drug? In 1987, my Mother died from Amyotrophic Lateral Sclerosis (ALS) – Lou Gehrig’s Disease, a progressive neurological disorder that traps an alert mind in a crippled body. In 1985, she volunteered for an experimental drug program to test a cure, knowing that the drug would not restore her limbs or prolong her life – she would still die. Life Insurance would not cover her death because the experimental drug could backfire, hastening the ALS. Mom took the experimental drug, anyway, hoping to save future generations. That … is what an Experimental drug is.

We have fast tracked this Vaccine, processed it, labeled it, assumed its safety, administered it, all without any United States Food and Drug Administration (FDA) approval. Does the FDA no longer play a part in our safety? The FDA website states: “The FDA must regulate and approve new prescription drugs before they can be sold to the public.” The FDA works with pharmaceutical companies to test and approve what we consume. Do we not need the FDA anymore? Imagine the Federal Aviation Administration no longer requiring tests and approvals before a new aircraft is certified.

And, what about Hydroxychloroquine, the malaria drug that was recommended – and prescribed – by doctors to combat the VC? FACT: Hydroxychloroquine is an FDA-approved drug, yet it was shelved while an unapproved VC Vaccine was distributed. Does this make sense? Is this principled?

Aviation safety demands clear thinking, logical applications and, yes, Principles. Aviation people know this, live this every day. The aviation industry’s future depends on careful analysis and, yes, unpopular ideas. Aviation Accident Investigations depend solely on Root Cause analysis to correctly determine unsafe aviation issues. Perhaps some feel that the VC Vaccine is a roll of the dice; an absence of discipline; a false hope; even a from-the-hip reaction to Probable Cause. Some view it as, “Maybe it will fix it, or maybe it will blow up in our faces. Let’s pull the pin and see!” If the Vaccine proves to be not what we were told, was our reaction undisciplined?

Aircraft Accidents and Lessons Unlearned XLIX: Three Elizabeth Accidents

Three Accidents in Elizabeth, New Jersey

Between December 16, 1951 and February 11, 1952 – a fifty-seven-day time span – Elizabeth, New Jersey became the center of unwanted attention, indeed the unwanted recipient of tragedy. The three Elizabeth accidents were unique to each other for their Root Causes. However, as dissimilar as the accidents were from each other, positive outcomes could not have come about if not for the coincidence of location and the briefness of time.

On December 16, 1951, a Miami Airlines (no recorded flight number) C-46F aircraft crashed soon after takeoff. The accident was investigated by the Civil Aeronautics Board (CAB), who could not determine causes, Probable or Root. At two and a half miles from Newark Airport (EWR), the aircraft descending to 200 feet, the wings rotated ninety degrees to the ground. With almost zero forward speed, the aircraft plunged, striking a home and a brick building before it came to rest on a bank of the Elizabeth River.

On January 22, 1952, American Airlines flight 6780, a Convair CV-240, crashed on approach into EWR; the cause was undetermined, but believed to be engine or propeller related. The weather that afternoon at the airport was: ceiling at 400 feet; visibility three-quarters of a mile; light rain and fog. The aircraft, during final approach, stayed left and high of the glide path, eventually moving right of the glide path. At five seconds after the last approach advisory, American 6780 disappeared, “…  from both the azimuth and elevation screens of the ten-mile precision scope.” American 6780 crashed in the city of Elizabeth, at the corners of Williamson and South Streets; the aircraft’s descent led to impact with buildings.

On February 11, 1952, National Airlines flight 101, a Douglas DC-6, crashed following takeoff out of EWR. The climb-out was normal until the point the aircraft passed the Newark Range Station where it was observed to, “… lose altitude suddenly and veer slightly to the right”; this was blamed on an in-flight reversal of the number three propeller at high power and the subsequent feathering of the number four propeller. These conditions, plus the low altitude at which they occurred, made recovery impossible. The Captain reported to Controllers that the aircraft lost an engine and was returning to the field. The aircraft struck an apartment house near the intersection of Scotland Road and Westminster Avenue in Elizabeth.

With three separate operator accidents occurring within ten miles of each other and in such a short period of time, the focus naturally turned towards the common factor: air traffic control (ATC). However, all three CAB accident reports eliminated ATC as a suspected cause early in the investigations. ATC’s procedures were normal, they did not deviate from routine operations. Neither aircraft was misdirected; ATC did not err, blindly routing an aircraft into an inescapable trap. Finally, moments before each crash, conversations were routine; the language and directions showed no elevation in urgency; ATC maintained communications until the aircraft discontinued transmissions.

Today, commercial aviation accidents involving buildings are rare. Air France 4590 hit a hotel because the pilots had no directional stability to veer; American 587 fell onto a Belle Harbor, New York neighborhood; Emery 17, fighting to maintain longitudinal control, struck a wingtip on a building, short of the runway. In each instance, the aircraft struck the building(s) as a consequence of the accident’s root cause having already occurred; impacts with the buildings were unavoidable.

If the three accidents occurred in separate states or isolated cities – not localized in Elizabeth – the accidents’ consequent effects, namely the building strikes, may never have been noticed. These confined ground events came to President Truman’s attention, who asked military strategist and B-25 pilot, James Doolittle (famed orchestrator of World War II’s Doolittle Raid) to examine the Elizabeth accidents and report on the hazards of United States’ airports operating in close proximity to civilian communities. Doolittle’s report, The Airport and Its Neighbors, co-written with Charles F. Horne, Administrator of Civil Aeronautics and Jerome C. Hunsaker, Department Head of Aeronautical Engineering for the Massachusetts Institute of Technology, was submitted on May 16, 1952. It was a study to, “… recommend action to alleviate certain immediate problems inherent in the present location and use of airports …” Their aim: “…  to propose policies and procedures designed to insure sound and orderly development of a national system of airports, to safeguard the welfare of the communities and to meet the needs of air commerce and the national defense.”

The report was broken into six sections: Part I, The Airport and Its Neighbors; Part II, Aviation – a National Asset; Part III, The Airport as a Local Problem; Part IV, The Airport as a National Problem; Part V, The Airport in the Community Plan and Part VI, A Survey of National Airport Policy. It was published when Hawaii and Alaska were not yet States; the Chicago Convention convened only six years prior and jet airliners began replacing piston aircraft, needing longer, more sturdy runways. It was essential to lay out the changing situation.

The first four Parts introduced aviation as a necessity of commerce. In the 1950s (up to the early 1970s) airlines were regulated; ticket prices made flying a luxury and aviation safety was a work in progress. Aviation was fueling business and providing jobs. The authors confirmed that aviation was a permanent fixture; as the new kid in town, commercial aviation would establish itself, much like air cargo in the 1970s and unmanned aerial vehicles today. Aviation was dependent on airports; very few airlines, e.g., Pan Am, landed at marine terminals, like LaGuardia’s. Airport proximities to housing and manufacturing were a growing concern that, like Elizabeth, demonstrated the need for solutions.

Parts Five and Six spelled out a need to plan for development; not to leave airport futures to chance but to practicality – and safety. Research for Planning, Airport Responsibilities, Zoning and other strategies were necessary to reconcile airport expansion with civilian population growth. In the 1950s, suburbia was still a young concept; the report was concerned more about the demands of the times: cities.

In the report, the point of community encroachment was made, “Many communities are approaching an impasse arising from limitations to safe operation on existing airports combined with a physical inability to improve or extend them because homes or factories have been built close to the runway ends;” even sixty years ago real estate was getting tight. During the War, airfields sprouted up amidst communities. As the report stated, airports of every size and purpose created closer ranks between airports and nearby communities. Military facilities and ground obstructions were not the only congestion; aircraft approach and takeoff lanes got closer as well.

The commission made two suggestions for zoning: “(1) That certain extensions or over-run areas be incorporated in the airport itself, and (2) that larger areas beyond such extensions be zoned for proper authority, not only to prevent the erection of obstructions that might be harmful to aircraft, but also to control the erection of public and residential buildings as a protection from nuisance and hazard to people on the ground.”

These last five Parts of the report were the justification, the arguments. The tactic of the report was generated in the second section of Part I: The Recommendations. Doolittle, Horne and Hunsaker wrote twenty-five Recommendations for the President to act on in his Federal capacity and to sell to the forty-eight states and assorted territories. These recommendations established the direction both airports and neighboring communities would take, including the control of airspace over these areas. Airports would now be certified; air traffic control would be improved.

The first recommendations spoke to the funding of airports, government responsibilities; took more practical approaches to planning and what airports needed to operate safely near communities. The second group of recommendations focused attention on airport zoning, namely what could be built, how high and how close to airports, with special emphasis on runway approach/departure paths. The third set of recommendations addressed what affected safe flight, such as: crosswind equipment, runway lengths, air navigation aid installations, raised circling and maneuvering minimums. The fourth recommendations set concentrated on airports’ effects on neighboring communities, e.g., minimizing test flights; limiting commercial and military training over congested areas; focusing on noise reductions and training pilots to decrease nuisance factors. Recommendation 25 attended to the transition of helicopters in civil use.

The report brought airport concepts decades forward; even though airports would evolve over the next sixty years, the foundations of airport safety were outlined in The Airport and Its Neighbors. Today, there are several airport categories: Commercial Service (Non-Primary and Primary Service), Cargo Service, Reliever and General Aviation (National, Regional, Local, Basic and Unclassified); some are controlled, some are not. They progress, changing with the times and technology. But they owe their valuable role to tragedy. A reminder that when we learn what needs … what must … what demands to be learned, we make effective changes that improve safety for years to come.

Aircraft Accidents and a Dangerous Precedent

Bele and Lokai of the planet Cheron in Start Trek TOS, Season 3, Episode 15: Let This Be Your Last Battlefield

In the late 1960s, the television show Star Trek (aka, The Original Series) showed us our future; the diversity of the human race in a professional environment: The (White) Captain; First Officer/Science Officer (Alien); Pilot (Asian); Navigator (Russian); Communications Officer (Black Woman); Engineer (European) and Physician (Southern Doctor). These characters interacted every week; they displayed how these different folks could work together towards common goals. Even the villains and antagonists were interracial men and women, so no group escaped praise or being booed or hissed at. What made the show so appealing was that race and gender played no part in any character’s qualifications or the storylines; each character was qualified to do their job. As Star Trek played out for the next half century in spinoffs and movies, the diversity factor never quit; Captains, Bridge staff, Chief Engineers, Medical and Security personnel were all represented by each race and gender, again, because these characters were qualified to hold their positions in the show. Even aliens were both racial and gender blind.

According to an April 13, 2021, Washington Post article, “… [Unnamed] Airlines said last week that it had set a goal to train 5,000 new pilots, at least half of them women or people of color, at its new flight school over the next decade.” The article goes on saying that this will improve safety.

How disingenuous for an airline that is now focused less on safety and more on theater. The article revealed a ‘woke’ airline management’s trivial agenda. More importantly, the airline set a dangerous precedent. Question: How does one reconcile hiring practices based on skin color and gender – to aviation safety?

The aviation industry is diverse; the Facts, e.g., applications, seniority lists, training records, can prove that out. For those who understand this, Facts are not necessary. A few less informed (inexperienced?) individuals commented on the airline’s announcement, praising the airline’s ‘brave move’, by comparing non-safety sensitive occupations, like tech company managers, to pilots; they likened someone who sits at a desk in a large office to a pilot who flies multimillion-dollar aircraft … full of people. The airline’s ‘woke’ practice was lost on many aviation enthusiasts; these individuals put political correctness first, the flying public’s welfare, second. For these people, no Facts will ever be enough.

And then there were the head-scratching comments, such as the pilot of many decades and (allegedly) former air operator manager who commented that in his X number of years in the cockpit, he saw many pilots with ‘borderline’ quality – and that no one spoke up. He continued by saying that “… as more women and people of color occupy the cockpit, the safety profile will improve”.

And there lies the rub. The first problem with this gentleman’s statement was that he saw many pilots with questionable skills in the cockpit and … that no one spoke up??? Did he speak up? As a member of management, was the welfare of the flying public not his responsibility too? Those ‘borderline’ pilots lacking in flying skills, whether white, black, green or purple, should have been trained harder or given a non-safety position in the company. That is Airline Management and Safety 101.

But then he said that “… as more women and people of color occupy the cockpit, the safety profile will improve.”  How does one square that circle? How does an airline’s safety profile improve when the racial or gender numbers change? How does one equate Aviation Safety to the quantity of melanin in one’s skin and/or how many X chromosomes one has? Does that even make sense?

This speaks volumes to how meaningless the airline’s announcement was. It obviously appealed to some shortsighted political correctness warriors. Perhaps they feel the Federal Aviation Administration (FAA) should require operators to focus on diversity instead of safety. Maybe the National Transportation Safety Board (NTSB) should revamp its critical mission; spearhead industry studies that direct more women away from running tech companies to running air cargo. Perchance the Departments of Transportation, Interior, Commerce, Defense, etc. will refocus on diversification instead of wasting time on safety, security and wellbeing.

Over these last few years as each new politically correct concept took center stage, companies fell over themselves to be seen as in line with each new concept, as if the topic du jour was foremost on every American’s mind. The problem is that with each politically correct concept – aka Distraction – someone else becomes the new target: the police, the military, political parties, religious groups, age groups and, of course, people of certain race or gender. We become numb; it becomes easier to ignore the static, to allow the bullhorns to blare and the sarcasm to fly. Question: Is airline management that bored that they now waste our time with self-served posturing? Weren’t their post-COVID Stimulus payouts large enough?

To serious aviation folks: Is there a gender or racial problem to begin with? One could ask the airlines, since they suggested that diversity numbers were a problem, what are the actual ratios? Maybe, the numbers are not as bleak as the progressive airline makes them out to be. The FAA, as an unbiased source, could get those numbers. That way, America can go back to the important issues.

My perspective: For almost four decades I rode the cockpit jumpseat of various airlines, whether I was flying to fix one of my airline’s broken jets in the field or as an FAA inspector conducting enroute inspections. Throughout those four decades, I have flown with pilots of both genders; sat and talked shop with flight crews – both in the cockpit and in the cabin – of every known race. As an FAA and NTSB instructor, I taught pilots who were sister and brother; husband and wife; parent and child. The pilots I have known flew everything, from a Cessna Citation to a Bombardier Dash 8 to a DC10 wide body, both Parts 121 and 135. Lots of pilots; lots of diversity. So, is diversity even a problem these days?

On social media in March, how many all-female flight crews were celebrated; all black female flight crews; all Asian flight crews; mother and daughter flight crews. I am confused by these postings. Why? Because I see them all the time … every single day. No one cares anymore who has three-striped epaulets and who has four. These sights are the norm, not the exception. The airline industry is diverse – and safe – because it uses qualified individuals. The FAA and the NTSB are diverse, only because they hire professionals for their skills. Diversity results from these hiring practices; it does not cause them.

Diversity is subjective, it is open to interpretation. Safety is specific; something is either safe or it is not. What would be considered a diverse pilot group? When I was a hiring supervisor, we were tasked to hire as diverse a workforce as possible. The problem was the job drew mostly white guys in the airport I worked at. How do you hire to diversity when diverse populations do not apply? Should we alter the interview process; should we interview for diversity or for skill and experience?

When I went to airframe and powerplant school in New York City, the breakout of students in my class were: two women, one Asian guy, two Black guys and the rest were White guys. I attended on loans, State and Federal assistance because I was broke. Public transportation and major highways were very close. Everybody tested to be enrolled. How would diversity be forced into such a situation?

The question still remains: What does Diversity have to do with Safety? How does requiring an equal racial ratio or gender ratio make an airline safe to fly? How does racial equality across the mechanic workforce guarantee safe aircraft? Air Traffic Control? When a pilot, mechanic or controller works on their training and developing their skills, it is not to check a political box. It is to assure the persons in those positions are qualified. Would any airline suggest that, to keep the racial and gender numbers even, they would drag everyone across the finish line, equally? Compromise the qualifications? What about the people who cannot make the grade, pass the flight school; would the airlines fail them? Would their pilot financial investments result in failing those unqualified or pass everybody with a wink-and-a-nudge?

What effect would Diversity have on safety? Hiring for Diversity would negatively affect safety … period!

Ralph Waldo Emerson once said, “Fiction reveals truth that reality obscures.” The picture above is from a 1969 Star Trek episode called ‘Let This Be Your Last Battlefield’. Frank Gorshin and Lou Antonio played Bele and Lokai, respectively, two citizens of the planet, Cheron who were prejudiced against each other. In one memorable scene, Captain Kirk and Mister Spock tried to comprehend why the two Cherons hated each other. The Cherons said that, though both were half black/half white, the black and white sides were reversed on Bele and Lokai. Kirk and Spock still did not grasp the hate. The Cherons thought Kirk and Spock were fools for not seeing the racial disparity that they saw. But it was the prejudiced Cherons who were the ones obsessed with pushing racial divides. Sound familiar?

Americans have come through decades of faults and, along the way, each generation has corrected for the faults of the former. Women hold many influential jobs and powerful positions. Both genders of all races are prominent in every industry; it is hard to remember when it was otherwise. Yet some people agitate; they must stir up old bigotries; pick at the scabs; insist on seeing bias where bias does not exist. Their Emotions blind them to Facts. But, maybe the agitators are the bigots, finding racism in the aviation industry where it does not exist; placing Diversity over Safety. In aviation, Diversity is not the problem. Instead, making diversity a problem … IS the problem. And doing that to aviation safety sets up a dangerous precedent.

Aircraft Accidents and Lessons Unlearned XLVIII: TWA Flight 841

On April 4, 1979, Trans World Airways (TWA) flight 841, a Boeing B727-31, registration number N840TW, suffered an uncontrolled maneuver, beginning at 39,000 feet; the aircraft rapidly descended for seventy-one seconds before it stabilized at 5,000 feet near Saginaw, Michigan. The number 7 leading edge slat departed the aircraft, the tracks and actuator for the number 7 slat were substantially damaged.

The flight left JFK Airport for Minneapolis roughly fifty-five minutes before the event began.  This meant the aircraft had been at cruise for close to an hour, meaning no secondary flight controls, e.g., four sets of flaps, eight slats, six Krueger flaps or ground spoilers would have been extended. The first indication of a problem, per the pilot interviews, was that the Captain’s altitude director indicator – ADI – showed a right bank of twenty to thirty degrees. From this indication to the recovery at 5,000 feet, the flight crew were in reaction mode.

The National Transportation Safety Board (NTSB), in report AAR-81/08, determined that the Probable Cause of the inflight upset was, “… the isolation of the number 7 leading edge slat in the fully or partially extended position after an extension of the numbers 2, 3, 6 and 7 leading edge slats and the subsequent retraction of the numbers 2, 3 and 6 slats, and the captain’s untimely flight control inputs to counter the roll resulting from the slat asymmetry. After eliminating all probable individual or combined mechanical failures or malfunctions which could lead to slat extension, the Safety Board determined that the extension of the slats was the result of the flight crew’s manipulation of the flap/slat controls.” Report AAR-81/08 went on to say, “Contributing to the captain’s untimely use of the flight controls was distraction due probably to his efforts to rectify the source of the control problem.”

The NTSB investigators’ statements bordered on accusatory – without evidence – that the flight crew introduced the slat extension by their, “… manipulation of the flap/slat controls.” Unless the flight crew stated that they extended these secondary flight controls, no one should have assumed that any slats were extended at cruise. However, NTSB investigators held that the flight crew either deliberately or unintentionally extended flight controls due to the erasure of all but nine minutes of the cockpit voice recorder (CVR) recording. Report AAR-81/08 called this action ‘a distraction’; he said, “… the Captain’s untimely use of the flight controls was a distraction due probably to his efforts …” Use of the word ‘probably’ was not in relation to probable cause; it was used in lieu of fact. The ‘probably’ was not a definitive statement; it was not analysis. It demonstrated that NSTB report AAR-81/08, while supposedly based on Factual information, had been founded on an allegation.

On the B727, the CVR erase button is on the second officer (SO) station’s side panel. The allegation meant that, not only were the Captain’s actions suspect, but that the two copilots: the first officer (FO) and the SO, would have been complicit in the ‘distraction’, otherwise the Captain would have had to set the brakes, get out of his seat and hit the ERASE button, if the SO refused. The allegation would have also assumed that CVR transcripts were indisputable, which gets to the heart of many accident report confusions, that CVRs were 100% reliable for determining accident cause. The CVR is, and was, never 100% reliable. CVR recording quality has always been compromised by any and all cockpit noises, e.g., aural alerts, wind noise, conversation overlaps, etc. If, in this case, the pilots did erase the CVR, was this an acceptable action? Questionable. However, after reading the NTSB’s reaction in AAR-81/08, it would have been understandable why any pilot would remove ambiguous CVR information. In AAR-81/08, the NTSB investigator assumed – without fact – misconduct on the Captain’s part. Furthermore, NTSB Board Member Francis H. McAdams agreed with this line of thought. He wrote a dissent that disagreed with the Board’s findings and questioned how they interviewed the Captain. It was important to note the four other Board Members did not question the Findings. What did this say about how the other four political appointees grasped the nature of the allegation?

AAR-81/08 was, as are all accident reports, vital to industry’s understanding of what happened, to prevent reoccurrence. AAR-81/08’s Probable Cause never addressed the Root Cause. The pilot’s actions, during the event were responsive to the probable cause: the uncontrolled maneuver. However, the Root Cause should have answered the question: Why did the number 7 slat come out of the stowed position in cruise?

On page 18 of the report, titled: History of B-727 Leading Edge Slat Problems, the report stated, “According to FAA service difficulty reports (SDRs), from the beginning of 1970 through the end of 1973, seven cases of a single leading edge slat extension and separation on B-727’s during flight were reported without mention of whether the extensions were scheduled or unscheduled.” Pause here to direct attention to the use of the words ‘scheduled and unscheduled’. Fifty-seven minutes into cruise, the wings were ‘clean’; lift-augmenting flight controls, i.e., the slats, had been stowed for nearly an hour; there would be no reason to extend them until Approach. It would be dangerous and counter to design.

The Probable Cause stated, in part, “… after an extension of the numbers 2, 3, 6 and 7 leading edge slats and the subsequent retraction of the numbers 2, 3 and 6 slats …” Aside from the unusual insinuation of extending slats in cruise, the report suggested that the crew isolated one lone slat – number 7. This suggestion demonstrated that investigators had a fundamental misunderstanding of the B727 slats’ operation. No slat on the B727 operated independently, therefore, there could be no ‘scheduled’ extension of the number 7 slat – the flight crew could NOT do that. Slats 2, 3, 6 and 7 are deployed together when the flap handle is placed in the Flaps – Two Degrees detent. Slats 1, 4, 5, and 8 plus all six Krueger leading edge flaps all deploy when the flap handle is placed in the Flaps – Five Degrees detent and beyond to forty degrees. The problem with AAR-81/08 was that investigators kept referring back to a single slat deployment, which the pilots … could … not … do; even activating the flaps manually using the electrical system, the crew could not – could not – deploy a single slat, by itself. The number 7 slat deployment was unintentional and unexpected. The report went on to say, “… we recognize that if the No. 7 slat did not extend as the consequence of some series of failures and malfunctions in the slat system, then it must have been extended as a result of flightcrew action.”

Did NTSB investigators ask if a slat deployment would have triggered a warning? Actuation of any slat would have resulted in an illumination of the leading-edge device (LED) deploy/unsafe light indicator on the pilots’ instrument panel. Each of the B727’s eight slat LED switches is internal, meaning the switch is inside the actuator. The LED indicator light is Extinguished when the slat is stowed; Yellow when the slat is in transit and Green when the slat is deployed. This fact should have led investigators to ask the pilots: “Did you see an LED indication prior to the event?”

Consider that with all the LEDs retracted in cruise, for the captain to extend slats, he would have had to reach over the throttle quadrant and pulled the flap handle out of its ZERO detent – or – actuated the manual electric controls over his head. An out-of-configuration alarm, e.g., a takeoff aural warning would have sounded. The FO and/or SO would have questioned the action. Even if the Captain recklessly did all this, the FO and/or SO would have reported the incident to the Chief Pilot, who, with the Federal Aviation Administration Principal Operations Inspector, would have acted.

Did the NTSB investigators conduct a thorough maintenance investigation? The number 7 slat was missing, its slat tracks and actuator were severely damaged. The right wing displayed impact scratches and the righthand outboard aileron had been hit by the departing slat. The NTSB performed some basic inquiries into N840TW’s maintenance history and the slat system’s inspection and maintenance, but it was not deep or broad enough; the past maintenance examination was cursory. As the probable cause stated, “… if the No. 7 slat did not extend as the consequence of some series of failures and malfunctions in the slat system, then it must have been extended as a result of flightcrew action.” This meant that the investigators made ineffective explorations into why the number 7 slat was out of configuration.

In addition, the NTSB depended too heavily on Boeing to analyze their own aircraft. This raises the question: Should any manufacturer be expected to fairly review its products, especially when the determination could devastate said manufacturer? This cast doubt, not just upon the NTSB’s AAR-81/08 report’s quality, but also upon Boeing’s ability to be forthcoming about their airplane’s safety. It would have also allowed Boeing to fix any problems without any consequences.

One last item suggests the investigators’ unfamiliarity with the B727 slat system. On page 25, where the investigators justified faulting the Captain, the report stated, “… the air loads on the slat would have subjected the slat actuator rod to a compressive load of about 700 pounds and about 9 percent less if the outboard aileron was floating.” It was unclear what the investigators meant by ‘floating’, but the problem with this scenario is that the outboard ailerons are locked out at cruise – they do not move; they do not unlock until five degrees of flaps are selected – the numbers 2, 3, 6 and 7 slats extend at two degrees of flaps. In addition, the slats do not unlock the outboard ailerons, the flaps do; the mechanical device that unlocks the outboard aileron comes off the flap transmission, not the slat actuators. Therefore, the investigators should have tested, not only all eight slats but the four flap systems as well. If the slats were extended intentionally, the flaps would have moved as well.

The aviation community needs to trust the investigatory process, be convinced it is legitimate. The NTSB must not just expect quality and impartiality from the five transportation mode agencies it investigates, it must rise to the same standards itself. We will never know the Root Cause for what happened to TWA flight 841 on April 4, 1979; it is small consolation that the B727 has limited presence today in the United States, if at all. But the B727 still flies; other Boeing products have similar, if not identical, slat systems to the B727. If only the Root Cause had been found.

Aircraft Accidents and A Lotta Red

A Storm to Starboard

About fifteen years ago I took part in an audit of a Federal Aviation Administration (FAA) office in Memphis; I was required to enroute, that is conduct surveillance of the flight crew in the cockpit. That particular flight, the pilots’ weather radar digital display revealed a storm hundreds of miles across and thousands of feet high – directly in our path; the radar sweep was candy apple red; an intimidating wall of energy. The flight through the storm was … memorable; I, being Airworthiness (not a pilot), observed as the pilots made their maneuvers look easy. Upon arrival in Memphis, I caught up with my audit lead – a former 737 driver – in the hotel shuttle; he had just flown through the same wall of energy. He stared at the floor, shaking his head and muttering, “Man, that was a lotta Red.”

Flying in the cabin is dull; we do not realize that piloting can be hours of routine sprinkled with moments of heart-pounding aerobatics. The cabin is so routine because we trust the flight crew; they do the incredible, e.g., landing on the Hudson or limping in after an engine fails dramatically, because they successfully combine experience with training – – experience and training – – without which lives would be destroyed. Think about that: both experience and training save lives.

As we find ourselves crawling out from our pre-COVID-19 bunkers, squinting in the sunlight looking for a return to normalcy, it feels like we make so little progress. The reality we are not facing is that the future has a ‘whole lotta red’ in it. Update: Texas and Mississippi lifted state-wide mask orders; their states are open for the summer tourist season. The International Air Transport Association – IATA – said the January 2021 air cargo needs have risen to pre-COVID levels. Endeavour Airlines will hire 450 pilots. Major airlines are pulling their A320 and B737 aircraft out of storage; repair stations are hiring for increased customer contracts. These recent changes show that the COVID scare may finally be in our rearview mirror. Why, then, are we being asked to keep the act up until the Fourth of July? When does it end? Where are the experienced leaders? Where are those with macroeconomics training and common sense? When is enough – enough?

How much of a toll has the Wuhan Virus, aka COVID-19 pandemic, taken had on safety in aviation? One might say, “We kept our six-foot distance; wore our masks; donned our face shields; loaded the plane, tail to nose.” Then, we sat less than two feet from each other, stuffed into a narrow metal tube pumping recycled air, all while breathing through a mask with the airborne pathogen protection integrity of a spaghetti strainer. Has anyone asked what type of mask blocks airborne viruses? I know, because we used those masks in Shanksville, PA in 2001. QUESTION: Why not ban emotional support animals? They breathe, don’t they; expel microorganisms, pass on disease, like humans do? Has anyone looked into this? Excuse the cynicism, but it seems Rover has more rights than Grandma.

But I digress; that type of aviation safety is not the point of this article. Has aviation’s quality of safety suffered since the Wuhan Virus pandemic began? Have certificate holders been paying attention? Pilots, mechanics, gate agents and air traffic controllers are mask-to-mask every day, while upper echelons have meetings that resemble some form of Orwellian Brady Bunch opening credits; everyone in their own box on the screen; ‘Jan’ is asleep; ‘Greg’ surfs the net, while ‘Bobby’ chats with ‘Cindy’ on Sametime. Result: Intracompany disconnects; important choices made from the antiseptic safety of home? When I was a National Transportation Safety Board (NTSB) investigator, an FAA inspector or auditing for my former air carrier, any given day safety came into question: missed steps in a maintenance procedure; fuel leaks from an inboard flap track; weight and balance problems. Everyday safety errors demanded on-site observation and attention. Can Zoom meetings maintain that level of safety?

What about FAA surveillance, external and internal audits, have they decreased? The FAA and its certificate holders; do they communicate? Are safety complainant interviews reduced to blind telecoms? Have FAA inspectors conducted on-site safety inspections or are they trusting the inspected? Oversight visits mean: ‘OBSERVE’ the operator at work; ‘SEE’ safety problems; ‘HEAR’ what does not sound right; ‘TALK’ to people about safety concerns. Experienced observation; using one’s Training; conduct face-to-face interviews that are spontaneous, not scripted. These are vital to safety.

Much of the country is still hiding from the Wuhan Virus a year later. We are expected to, “Put trust and faith in government.” Put ‘trust and faith’ for aviation’s future – in the hands of politicians? Have these politicians or medical experts ever provided decisive answers for Wuhan Virus problems, beyond the Blame Game? FACT: the Wuhan Virus, aka COVID-19, crisis did exist. We lost many Americans, some to the misfortunes of health, but too many to the Political Incompetence of some leaders.

The Fatality Rate (FR) for each year, is it accurate; exactly what are the rates? First, reported Wuhan Virus FRs are unreliable. Why? Because news sources are skewed. There is no NEWS anymore; the news is mostly opinion and little fact. How do Wuhan Virus FRs compare to past Flu and Pneumonia (F&P) FRs when new F&P strains tore through our country every year, including 2019 to 2021? The Center of Disease Control (CDC) recorded those annual fatality rates. Between 2008 to 2015, the CDC’s website said: 2008-2009: FR 130,353 – – 2009-2010: FR 133,142 – – 2010-2011: FR 138,055 – – 2011-2012: FR 126,842 – – 2012-2013: FR 142,633 – – 2013-2014: FR 130,578 – – 2014-2015: FR 139,819. In March 2021, the CDC website disclosed the total United States’ Wuhan Virus FR: 524,695 deaths.

There is a stark difference between the 2008-2015 FR average of 134,488 deaths and the 2019-2021 Wuhan Virus FR of 524,695. The American people learned that the CDC’s Wuhan Virus FR is almost FOUR TIMES higher than 2008-2015 F&P Season’s FR average. But these numbers are deceptive. Why? Let us break the numbers down:

  1. The CDC’s 2021 Wuhan Virus FR of 524,695 includes those who died from the annual strain of F&P for the 2019-2020 and 2020-2021 seasons. The FRs for the F&P seasons from 2008 to 2015 did not include victims from the Wuhan Virus.
  2. The Wuhan Virus FR still includes those who died because the Wuhan Virus worsened their pre-existing conditions. These people would have survived if not for the Wuhan Virus’s influence.
  3. The 2008 to 2015 F&P FRs occurred only between November and May of each year pair. The Wuhan Virus FR has been recording since January 2020 – that is six months more. The Wuhan Virus FR count has been for eighteen months – not seven months.
  4. Every F&P season prior to the Wuhan Virus, a Flu shot was available. This vaccination reduced the FR each year. Even with the Wuhan vaccine now being available, trust of the vaccine among physicians is not equal.

The seven F&P seasons, from 2008-2015, occurred between November and May. Per the CDC, the monthly average from all seven F&P seasons, 2008-2015, was 22,415 fatalities – per season – for each month. The Wuhan Virus crisis took place during two … separate … annual F&P seasons: November 2019 to May 2020 and November 2020 to March 2021. Therefore, two annual F&P seasons claimed 313,810 fatalities from just annual F&P seasons – NOT INCLUDING Wuhan Virus victims. If we subtract the combined 2019 through 2021 F&P FRs of 313,810 from 524,695 Wuhan Virus victims, 210,885 persons died strictly from the Wuhan Virus. The average monthly Wuhan Virus FR is 12,405, as compared to the 22,415 monthly FR for the 2008-2015 F&P seasons.

Perspective: The average monthly Flu and Pneumonia fatality rate was 10,010 deaths higher than the Wuhan Virus FR, even with the seven extra months; an average of more than two hundred people – per state – died from Flu and Pneumonia than the Wuhan Virus. How many people did not take the annual Flu shot because of the Wuhan Virus? How many people died because of this? This, in no way, trivializes the Wuhan Virus victims. Instead, it demonstrates that the Wuhan Virus FR may have been exaggerated – or – bureaucrats and medical experts did not understand the numbers. Furthermore, misrepresenting FRs has damaged the nation, irrevocably. Is it possible we were victims of a scam panic that crippled our economies, families, individual successes and the entire aviation industry? How do we recover? Will we make headway as taxes rise; fuel costs soar and employment opportunities plummet?

Imagine if we had a media that was honest; told the American people the truth; made it possible for us to succeed among the ignorance. Instead, professional medical experts were like a skip in the record; they bounced from ‘wear masks’ to ‘masks – bad’. Political professionals scared us, turned us against anyone who wanted to live normally. They sounded foolish, even as they knew they sounded foolish, even as we knew they sounded foolish. Remember: “Professionals built the Titanic; amateurs built the Ark.”

My wife and I were in a restaurant in Toledo last June. An old woman came in, remarking sarcastically, “Well, it seems people are not even considerate enough to wear a mask.” To which a much older gentleman sitting across from me replied, “You’re welcome to go home and hide in your basement with your mask on.”

How will history remember us? Will it say, “We did the right thing.” or “We were like sheep to the slaughter?” I tend to think the latter. We all know someone who died of Wuhan Virus, just like we know those who died from the Flu and Pneumonia. If I could ask any victim of the Wuhan Virus a question, it would be this: “What you were forced to give up at the end, your family, spouses, last vacations, holidays, a chance to make memories; the few days you lived without any loved ones near; if you could do it again, would you do it differently?” My guess is they would say, “Yes.” And they would see a whole lotta red.

Aircraft Accidents and Lessons Unlearned XLVII: Wingfoot Air Express

The Type FD Dirigible: Wingfoot Air Express

On July 21, 1919, an American airship, a Type FD Dirigible, owned by Goodyear Tire Company, called the Wingfoot Air Express, caught fire and crashed onto the Illinois Trust and Savings Building. The Hydrogen-filled dirigible was transporting passengers from Grant Park to the White City Amusement Park when the tragedy occurred. Did Goodyear not understand the dangers of using Hydrogen? Were there no other options?

Information about the accident – and many others – at the time, was scarce; there were mostly newspaper and radio reports. Some information was gathered by witnesses and survivors, who had parachuted from the Wingfoot Air Express’s gondola. Any one old enough to remember, let alone participate in any investigation into the Wingfoot Air Express, has since passed away. The only particulars of the event can be summarized as: over the city, the airship suffered a fire near the stern and within seconds the blimp was consumed in flames. The airship buckled at the midpoint, folded and fell from the sky. It was unclear what caused the airship to initially catch fire, but the lifting gas used: Hydrogen, was highly flammable.

Ever since Henry Giffard’s steam-powered airship took flight in 1852, man had moved forward in gaining flight capability; these lighter-than-air blimps (balloons) employed a screw or similar thrust device. The obstructions to success were the inability to steer or control altitude; there was little thought given to the lifting – or buoyant – gas used. In 1884, the La France became the first controllable airship when it returned, through flight, to its starting point. The La France employed a rudder, an elevator, a sliding weight to assist in center of gravity shifts and ballonets, ‘balloons-within-balloons’ that were filled with unbuoyant gas to displace the buoyant gas in the main balloons, envelopes or bags. The use of these devices gave the La France the distinction of being the first Dirigible, a title that comes from the French word diriger, which means “to direct or steer.” The La France also used Hydrogen as a lifting gas; the experiment worked and that was all that mattered. Safety was a blind spot and it prevented one from succeeding. Using Hydrogen suggested airship developers employed a ‘fingers-crossed’ approach.

The Wingfoot Air Express accident’s Root Cause was the use of Hydrogen for buoyancy. Giffard’s airship employed Hydrogen, as did the La France, but neither caught fire nor crashed. The focus in the late 1800s and early 1900s was the successful ability to fly, perhaps by any means possible.

Consider also that at the time of the Wingfoot Air Express accident there were no aviation regulations or policies; the aviation ‘industry’ would soon be placed under the Department of Commerce. Common sense was not referred to because aviation was still in its infancy. Any accident event details relayed between countries that experienced airship accidents were limited by available communications at the time, distance and nations at war. Even information about these events remained elusive due to the lack of attention they received; controlled flight in the 1800s was an eccentricity.

Was it not known Hydrogen was highly combustible? After all, the three requirements for combustion are (and were) Oxygen, fuel and an ignition source. Would not common sense point out that Hydrogen was a volatile fuel, if used in close proximity to an ignition source? Yes, but the driving force at the time was being the first to master flight; the other guy’s mishap was the other guy’s fault. Competitors attempting to master flight with Hydrogen were like politicians reattempting Socialism: an idea that did not work last time because the other guy did not do it right. A bad idea is still a bad idea.

Common sense did come into play … eventually. One airship tragedy that generated common sense solutions was the Roma, an Italian-made semi-rigid airship, which crashed on February 21, 1922 in Norfolk, Virginia. The Roma was purchased by the United States (US) Army in 1921. Its accident was not the result of the Hydrogen-filled envelopes, instead the rudder system failed, crippling the airship’s maneuverability. However, before it struck the ground, the airship brushed against high voltage power lines; the sparks ignited the Hydrogen-filled envelopes. The Roma became the last US military airship ever inflated with Hydrogen; all subsequent military airships used Helium.

Yet, Hydrogen continued to play a tragic part in airship accidents. The French Navy’s Dixmude (formerly the Zeppelin LZ 114) exploded in mid-air near Sicily after a lightning strike on December 21, 1923. On October 5, 1930, the British airship R101 crashed, then burned, from what was believed to be escaped Hydrogen that ignited. The most infamous Hydrogen-caused Zeppelin accident was the LZ 129 Hindenburg, which burned near its mooring tower in Lakehurst, New Jersey, on May 6, 1937.

The use of Hydrogen as a lifting gas for airships was used predominantly from the 1800s up until the Hindenburg disaster. During World War One (WWI) (1914 – 1918), fighter pilots understood Hydrogen’s volatility. Fighter aircraft, e.g., the Nieuport 17, were equipped with outer wing strut mounted rocket tubes; the electrically triggered rockets were designed to ‘shoot down’ enemy observation balloons and airships using Hydrogen.

Per records, of the thirty-two non-military blimp disasters, eleven were attributed to Hydrogen explosions before the Wingfoot Air Express and another eleven dirigible accidents from the Wingfoot Air Express, up to, and including, the Hindenburg in 1937. By comparison, the other airship accidents were blamed on weather, fueling accidents or other reasons. Yet, Hydrogen’s use was still widespread. Why? From Giffard’s airship through the end of WWI, Hydrogen was the only buoyant gas available, even for military applications.

The only discovered substitute for Hydrogen was Helium, an inert gas that – per the dictionary – “… is not chemically reactive,” meaning it would not explode if introduced to an ignition source. Per the National Academies of Sciences, Engineering and Medicine, the presence of Helium was discovered in 1895 from uranium and thorium ores. In the early 1900s, “… helium was found to exist in rather large quantities in the natural gas wells of the midcontinental United States.” Upon entering WWI, the US opened three helium extraction plants in Texas: two in Fort Worth and one in Petrolia.

Helium was expensive to produce. In 1919, investments permitted the large-scale production of Helium; major production was limited to the US and Canada, allowing the Helium supply to become political. It was believed that countries, such as Germany, who were undergoing political upheavals with the rise of the Third Reich, were denied access to the US’s helium. If this were true, it helps explain why a country as advanced in zeppelin technologies as Germany was, still relied on Hydrogen as a buoyant gas, even in commercial usage – eighteen years after events like the Wingfoot Air Express accident.

The reasons Hydrogen was used as a buoyant gas, despite its dangers, has been discussed here: Hydrogen was the only buoyant gas known at the time; poor communications; warring nations prevented the sharing of information; the need to experiment outweighed safety and Helium had not been available. All these reasons, though factual, had nothing to do with the causes of the individual accidents.

What, then, would have been the Probable Cause of the Wingfoot Air Express accident and what would have been the Recommendations? Since Probable Cause rarely has anything to do with the Root Cause(s) behind any accident, the Probable Cause in a Wingfoot Air Express-type accident could have been an engine that was allowed to operate too hot; the Recommendation would have been to improve engine monitoring methods. A lightning strike; Recommendation: improve meteorological forecasting. Static electricity discharge: Recommendation: prevent static build-up. Cigarette smoking; Recommendation: control where people smoke, which, ironically, the Hindenburg had a smoking room just for this reason.

None of these Recommendations, however, were solutions; they would not have fixed the problem, corrected the Root Cause of the Wingfoot Air Express accident. Engines can operate safely at higher temperatures; lightning exists where rain is not present; every moving airborne object attracts static electricity; many passengers and crew members on passenger dirigibles in the early 1900s, smoked.

The Root Cause, however, would have been specific: the use of Hydrogen as a lifting gas. Contributing factors to the Root Cause could have been expanded to include conditions of combustion, e.g., poor maintenance practices that allowed a gas envelope to leak or poor venting of the envelope area. The Root Cause would have said, no matter what measures were taken to prevent ignition, Hydrogen gas was dangerous to use.

In the end, Wingfoot Air Express caught the attention of the city of Chicago, which updated its aviation safety rules to prevent dirigibles from flying over Chicago. The city’s response was to a Probable Cause mentality; the response did not make aviation safer. Only addressing Root Cause would have improved safety. Anything else was just words on paper.