Aircraft Accidents, Rip van Winkle and Longevity

Rip van Winkle, the idle protagonist of Washington Irving’s short story of the same name, went to sleep against a tree and woke up some twenty years later. He was rewarded from his extended slumber with two realities: he missed twenty years of progress (he slept through the Revolutionary War) and his lack of awareness was viewed as senility when he claimed loyalty to King George III. What a conundrum.

Have you ever heard on the news about ‘length of government service’ of any individual, say, of Congress or Presidential candidates? Perhaps one government employee had thirty years of continuous government service in the Senate while another one had forty-five years. How does that work? Does political office make one wise? Do they become closer to their constituents without having to rub elbows with them? Or do they just adopt a ‘know-better’ attitude and plod on, ignorant of the world around them?

Government service can be a respectable career. Take the brave servicemen and women who protect our nation, their diligence and dedication are of the highest degree. They devote their careers to us; they constantly revise their skills, learning to counter the latest national threats, adapting to remain proactive. They are constantly challenging themselves to be prepared for what comes next, physically, emotionally and/or technically. They are a branch of government that serves as a lesson in progress and awareness. On the local level, firefighters, emergency responders and police do the same to remain consistent and up to date, to protect themselves and others under their watch.

However, not all public servants are such as these. As one enters political government service, one is often removed from their constituents, just as Rip’s nap separated him from his community. Public servants become ignorant during their time in office. To be effective, a public servant must revisit the culture that led to their office term, they must re-identify with the constituency. If not, they take the chance of becoming obsolete, pariahs. Thirty-five years of driving a computer – don’t forget, that would include several years of driving a typewriter – does not an expert make. However, in truth, the level of obsolescence would depend on the government job and the qualifications for that job.

How would a thirty-five-year veteran of the aviation safety agencies, fare?

The Federal Aviation Administration (FAA) is the governmental agency dedicated to aviation, period. The National Transportation Safety Board (NTSB) is the governmental agency dedicated to improving transportation safety by investigating transportation incidents and accidents. The thirty-five-year (1985) veteran of the FAA or NTSB may be administrative. As Napoleon Bonaparte – or was it Frederick the Great(?) – once stated, “An army marches on its stomach,” which spoke to the soldiers’ need for provisions. It could be restated that the FAA, “marches on its records.” Therefore, the oversight agency relies heavily upon the office staff – not aviation-experienced inspectors – but those who work in the background and have organizational skills. These people, who are too often overlooked, are the lifeline of the FAA. Thirty-five years of administrative duties is an honorable occupation, a worthy goal.

However, the mission of the FAA is not restricted to the office; their responsibilities extend to the field, a field that separates experience from ‘checking a box’. The FAA aviation safety inspector (ASI) must have experience from the industry to understand the industry. The ASI must know what he or she is saying and what he or she is looking for to be effective.

What if the FAA hired ASIs with no field experience, like Operations ASIs with nothing more than a private pilot’s license? What if FAA Airworthiness ASIs were newly graduated from an airframe and powerplant school, never having ‘turned a wrench’ or changed a tire? A thirty-five-year career with no previous experience would be pointless. Would a B777 captain benefit from an Operations ASI with no experience? What about the Airworthiness ASI who is a mechanic-in-certificate only? What if either one of these ASIs were responsible for developing training, making policy or writing regulations? What would these ASIs draw from to oversee the industry? Would they make aviation safer? Think of the retirement speech, “Thirty-five years of … YOU, not knowing what you were talking about! Yay!”

Fortunately, the FAA only hires industry-experienced ASIs to conduct oversight; these ASIs have a stake in the game they are involved in – aviation safety. Working closely with industry, the FAA ASI’s thirty-five years of experience would have evolved with the industry. Operations ASIs would have regularly interacted with pilots of all kinds; been familiar with a certificate holder’s equipment and were involved in their training, first-hand. Airworthiness and Avionics ASIs worked closely with the certificate holders’ approvals, on-site inspections, learning the equipment, first-hand. Yet being a thirty-five-year FAA ASI veteran, would not guarantee success, especially if the ASI did not consistently evolve at the pace the industry did. The diversity of the industry will always surprise – with devastating results – many ASIs who underestimate an industry too headstrong to be contained. The evidence can be found in numerous accident reports – only if one has the common sense to learn the Root Causes.

Thirty-five years ago, digital aircraft had barely dawned; composites were the up-and-coming technology; the industry, today, stands close to commercial space flight as a reality. Technology, in thirty-five years has been meteoric and it will not stop. Since 1985, the thirty-five-year FAA veteran has grown with the industry, learned and been challenged by the industry. It has been thirty-five years well spent.

What about the NTSB thirty-five-year veteran?

In 1985, a digital aircraft was the exception, not the norm. Stage III Noise Standards were still ten years away; structural inspections were beginning to extend older aircraft. From 1985 to the mid-90s, an NTSB investigator would not have experienced, e.g. advanced digital instrumentation, fly-by-wire, NextGen, composites, Full Authority Digital Engine Control, aka FADEC, horizontal stabilizer fuel tanks, heavy airliner two-man cockpits, and the expansion of both International and Domestic Repair Stations. And the NTSB investigator never would. NTSB investigators never directly engage with industry.

Would the average NTSB aircraft-specific investigator (Systems, Engines, Maintenance and Structures) be familiar with the wear-and-tear of the average aircraft? That would depend: is the NTSB aircraft-specific major accident investigator an engineer or a maintenance technician? A technician would have worked the entire aircraft throughout his career; he would have worked different aircraft models and understood airline culture. An engineer would have designed one minuscule part of an aircraft.

Would engineers who designed Water/Waste systems understand Pneumatic overtemperature sensors? Can communications engineers comprehend Wing Anti-ice systems? How would an engineer who designed engine generators understand fuel-driven variable stator vanes? How many NTSB aircraft-specific major accident investigators are engineers? According to the NTSB’s Human Resources department: all aircraft-specific major accident investigators investigating any air carrier accidents are engineers. They have no career knowledge/experience about the industry or the aircraft they investigate.

The FAA has no engineer ASIs; no FAA engineers conduct industry oversight where Maintenance is a crucial issue. Why wouldn’t the NTSB have experienced maintenance technician accident investigators? Why does the NTSB rely on inexperienced engineers who have never known troubleshooting, maintenance cultures, training, or aging aircraft? NTSB engineers have been sheltered from the industry’s technological progresses for decades. Who in the NTSB was qualified with the technological knowledge to understand the B737-MAX avionics issues? National Air Cargo 102’s floor failure? Emery 17’s maintenance culture? Air Midwest 5481’s multiple procedural and regulatory errors? The numerous other accidents where maintenance and technology played a major role? With inexperienced engineers as investigatory group leads, can the NTSB successfully investigate any major accident?

Rip van Winkle was a short story with a clear message: if you separate yourself from your surroundings, you hobble your effectiveness; the world goes on without you; you become – obsolete. The good news was that Mister Winkle had experienced life with memories; he soon saw what his nap had done to him upon waking. What if good ol’ Rip had never had the experiences of a life to begin with? Then he would have been better off staying asleep on the mountain. He would have had nothing to contribute.

Aircraft Accidents and Lessons Unlearned XXXIII: Swissair Flight 111

Swissair MD-11 in reconstruction

On September 2, 1998, fifty-three minutes after departing JFK International Airport for a scheduled flight to Geneva, Switzerland, Swissair flight 111, a McDonnell-Douglas MD-11 aircraft, registration number HB-IWF suffered the first indications of an onboard fire. About twenty minutes later, while executing an emergency landing in Halifax, the airliner crashed into Peggy’s Cove, Nova Scotia, Canada. Approximately seven minutes before impact, both the flight data recorder (FDR) and the cockpit voice recorder (CVR) ceased functioning; all radio communications and secondary radar contact were lost. It would remain unknown what the last minutes in the flight compartment were.

The Transportation Safety Board (TSB) of Canada led the investigation; they followed International Civil Aviation Organization (ICAO) Standards and Practices Annex 13. The accident report, A98H0003, demonstrated a call to a higher quality accident report. It did not conclude on the ambiguous ‘probable cause’ but instead the TSB relied on root causes to dig deeper, to find the cause to the cause; the fundamental lessons to be learned. Although it referred to the need for unnecessary changes and technologies, such as cockpit video cameras and other irrelevant fixes, the report stayed the course and delivered on the root problems that made the industry aware of its technological ignorance and the need to catch up in a fast-paced rush for digital improvements that were leaving engineers behind.

The MD-11 was one of the first airliners to mainly employ digital technology. These ‘fly-by-wire’ systems were/are just that: wires replaced the heavy cable systems for flight controls, shrank the size of actuators, employed lighter composite materials and reduced the gauge (wire diameter) of wires that handled lower current wires than their predecessors. This reduced the airliner’s weight and increased efficiency. However, there are always trade-offs; ‘fly-by-wire’ also established a new learning curve for pilots, mechanics and engineers, a curve that did not follow the rules of earlier ‘analog’ aircraft.

Both the FDR and CVR ceased to function well before the crash occurred; each circuit breaker (CB) was close in proximity to the fire, which was a main contributor. The loss of both recorders presented the TSB with a unique problem: how to determine what the flight crew spoke of in the cockpit and what the various control inputs were during the last minutes of flight. The recorders are considered by all accident investigators to be a most important tool.

However, CVRs can become a crutch; a double-edged sword that works against common sense, as seen in the National Air Cargo 102 accident report, AAR-15/01. The correct analysis of the CVR depends heavily upon those who interpret the recorder. In emergency events, words are garbled, distorted inside the oxygen mask; pilots talk over each other or alarms drown out important conversation. FDR information can also be confused when determining what control inputs were the pilots’ and what was caused by the aircraft’s confused signals. The effectiveness of both recorders is also dependent upon power being supplied, constantly. In Swissair 111, it appeared that both recorders suffered failures due to power cut-outs to the recorders themselves.

A primary cause of the in-flight fire that doomed Swissair 111 was determined to be a recently installed In-Flight Entertainment Network (IFEN) into the cabin electrical bus; the IFEN was added post-manufacturer as part of a supplemental type certificate (STC), an engineering design that allows modifications and improvements to an aircraft. While one of the major contributors was location, the most influential cause was the flight crew’s inability to disable the IFEN system, indeed their being unaware the IFEN was not disabled when they deactivated the cabin electrical bus. All systems are designed, per regulation, to be disabled by the flight crew in flight. The IFEN system defied this design.

A second cause was the use of metallized polyethylene terephthalate (MPET) type-acoustical blankets, used to ‘quiet’ airstream noises. The MPET blanket and other materials behind the CB panels were flammable and in close proximity to the CB wiring. These materials did not meet the fire-preventive requirements for the aircraft and contributed to the fire propagation. The CBs used in the STC installation were not capable of protecting against wire arcing events, which contributed to the start of the fire. These hazards also led to a loss of digital instruments vital to aircraft control.

The IFEN, “design, certification, installation, testing and operation presumed that the ‘non-essential, non-required’ designation [of the STC] confirmed that whether failing or operating normally, the IFEN installation would have no adverse effect on aircraft cockpit operations.” This meant that the STC planned for the IFEN system to not become a hazard to the electrical system. However, the STC did not account for the IFEN remaining powered when selecting the CABIN BUS switch to off [powering OFF the cabin electrical bus]. This was a result of poor engineering; the IFEN system remained powered.

The circuit protection for the IFEN was located in the Upper and Lower Avionics (UAL) CB panel, to the right and aft of the First Officer’s seat. The CBs for many flight control, flight attitude, communications and other critical systems, including the FDR were routed to the UAL panel. In addition, wire bundles coming off the UAL panel and other nearby electrical controls were routed behind or in close proximity to the UAL panel.

Wire bundles are comprised of dozens of angel hair sized insulated wires bound together so as to be routed through the structures behind the panels. Individually or as a group, these wires have a low resistance to the effects of heat, which affect their resistance. Overheated, the wire can allow too much current to the circuit, where the CB breaks the circuit shutting off power to the system it protects. Heat can also damage the integrity of the wire permanently.

The TSB found in their report under 4.3.3.2 Limitations of FAR 25.1353 Electrical Equipment and Installations, that separation of the wire bundles behind the CB panel were, per their analysis, inadequate; heat generated behind the CB panel was not evacuated properly. The Flight Crew Reading (Map) Light also was given considerable attention as during other MD-11 inspections, there were problems discovered with the light and the insulation blanket installed behind. Although this was a good find, the map light did not contribute to the fire. Instead, the attention dedicated to the map light occupied three pages of the report and, with other unassociated topics, acted as a distraction to the report’s findings. It would have been better addressed at the report’s conclusion.

What led to this accident were two simple mistakes. The first was an STC was generated and its contents were used to install an IFEN system in the airliner, in fact several sister ships, that did not deenergize a system when selected OFF. Its root cause was the inexperience of the engineer(s) writing the STC with the peculiarities of digital aircraft as opposed to analog. This problem was not limited to digital technologies introduced with airliners like the MD-11; it was also a major upset with composites, lighter metals and the tasks once handled by the second officer. The learning curve was extensive, not only in Operations and Maintenance learning the new aircraft, but it also took years to get airliners like the MD-11’s reliability to where it should be, what the manufacturer advertised it as.

The second root cause was McDonnell-Douglas’s use of MPET insulation blankets and ventilation of heat behind the CB panels. These errors allowed arcing and prevented heat removal that acted together to create a safety hazard.

While the second root cause was more easily rectified with a change in parts; the first was not. For years design flaws were built into aircraft by airliner manufacturers, e.g. Turkish Airlines 981, and/or the modifications found in STCs and other devices of change, as found in the LAS DC-9 accident in Mitu, Colombia in 2003. These are two examples that, without proper research, led to catastrophic events. It is (and was) the responsibility of the Federal Aviation Administration (FAA) to keep a tight grip on engineering. The Swissair 111 tragedy was due to misses on the FAA’s watch. The misses continue because inadequate attention was given in this and other reports to the research needed in correctly writing STCs. However, the new territory of digital was also found to be entered into too quickly.

Swissair 111’s report, bought at a heavy cost, should have been an example of investigatory superiority. Its attention to detail and search for root cause should have been representative of where accident investigation needed to be.

Aircraft Accidents and Ginger Rogers

Ginger Rogers was an agile, talented dancer with incredible timing and footwork; her career on Broadway, in Vaudeville and the cinema cemented her in the hearts of Americans. She could make waltzing beside the ever-graceful Fred Astaire look as normal as a walk across the park, to music of course; her elegant dancing outshining Astaire, because Ginger Rogers, “… did everything he [Astaire] did – backwards … and in high-heels”. One thing that cannot be said of Ms. Rogers was that she was not a 200,000-pound aircraft. So why do so many unappreciated semi-professional rug cutters want to treat a B737 or A320 as if Ginger is pushing back to the taxiway?

There appears to be a new trend making its way in the news these days: dancing wing-walkers. No, not the type of wing-walker who rode on the top of a biplane in the 1930s; the only person’s safety they risked was their own. These are airport personnel who guide the aircraft back, relaying warnings to the pushback tug driver or alerting the pilots to dangers at their wingtips. It is specifically NOT to trivialize these safety people but to explain why they are vital that this article is based.

Look, everybody likes to have fun at work and, according to the job, fun can be had to differing degrees. However, there are times when fun must be put aside, and care must be taken. Firemen don’t spray each other with the fire hose; truck drivers don’t swerve through lanes to the beat of their favorite song. The airline passenger filming the unchoreographed escapades of the breakdancing ramp employee sees only a six by twelve snapshot of the ramp activity. It is far different from the view the pilots see or the person pushing the aircraft back observes, the one who has, for the duration of the pushback, full responsibility of the airplane, flight crew, passengers and every single person on that immediate ramp area.

The person sitting in the pushback tug only sees – an airplane, which takes up 80% of his view, just radome, nose gear and aircraft belly. Off to the side are the ramp employees, aka wing walkers, who can see what is behind the aircraft, to the side of the aircraft and anything along the extensive wingspan that the aircraft occupies in its reverse-bound odyssey. As the aircraft is pushed backwards, the pilots are fully dependent on the ramp crew to maintain a safe distance from anything that can jeopardize the aircraft’s safety, which includes: ramp equipment, personnel, taxiing aircraft and aircraft being pushed back from adjacent gates. There are also aircraft starting engines, whose jet blast can affect safety.

Ramp employees have been known to fall under the wheels of wide body aircraft under the best of conditions; their legs crushed or worse. Ramp employees wear hearing protection that does its job well, blocking any noise from reaching the employee, including aircraft engine noise. Wings have been known to be breached by ramp equipment that was haphazardly parked to the side, their safety gates or loader decks infringing on the aircraft silhouette, the no-go area that an airplane occupies in the gate. Plastic bags have escaped baggage carts, only to be ingested into an aircraft engine, which cancels the flight. The ramp is a dangerous place, whether in a hub airport or a small station. There are hazards galore that threaten safety, life and aircraft.

Let’s expand the view the young passenger/video-taker is missing. As the video-taker is safely sitting inside the aircraft, the mechanics or ramp personnel are pushing the aircraft backwards into an active area. As the pushback continues, the aircraft is turned (backwards) to go left or right to the taxi line. Obstacles that were not originally in the aircraft’s path, now move into view and, thus, into a menacing position. For instance, a fuel truck, heading towards gate 8, may stop to allow the pushback to continue, its tank now in the wing’s path. At night, the dangers are less visible.

This is why wing walkers are not just a safety measure but a critical necessity to the passengers reaching their destinations. However, these airport personnel, whose job it is to keep passengers and aircraft safe, are being distracted from their very important safety work. Suddenly, wing walkers need to ‘get-their-groove-on’ for the occasional airline passenger who, despite ignoring the very important safety brief taking place and having their cell phones off, choose instead to be an audience to these ‘Tony Maneros’. Videos keep popping up in the digital media showing ramp personnel, who are supposed to be watching the clearance of the aircraft wing or tail, now hamming it up for the aircraft passengers. Hoping to be discovered, these guys (and gals) just break out the moves, lighted wands playing light-sabre visual effects across their path, as some passenger eagerly videos the performance.

My take on these antics is simply this: Stop it! Cease! Desist! Please, in the name of God, knock it off!

As the performing ramp employee, aka ‘Tony Manero’, is focused on putting on the best performance of his recent career, the consequences of ignoring the dangers may seem trivial to the average passenger. But are they? Ramp equipment parking areas are prime real estate, although a loader or ground power unit may occupy a footprint off to the side of the aircraft’s silhouette lines (parking area) a safety rail may intrude into the silhouette area, in the turning arc of a wing’s winglet, e.g. maybe someone left a belt loader’s ramp in the raised position. An airplane isn’t pushed back in a straight line; the reason for wing walkers is to prevent damage from unexpected sources.

What can happen if an aircraft’s wing strikes an unyielding metal loader gate? A wing’s winglet could be ripped from the wing tip; this would ground the airplane. Perhaps the gate could rend open the bottom of the wing’s fuel tank, spilling hundreds of gallons of jet fuel over the ramp; this would cause a fire hazard, cancelled flights (other nearby airliners where the fuel migrates to) and missed connections.

Well, what about the performing ramp employee’s safety? Does he see the baggage cart tongue in his path? Does he see the set of equipment chocks laying on the floor where they are not supposed to be? The resulting consequences of the dancing ramp employee tripping over a baggage cart tongue or chocks are a snapped ankle, a spiral fracture or the need to count missing teeth after head-butting a heavy steel cart.

Now there are deice personnel who are joining in the fun; they twitch their hips in the confines of their deice bucket, rolling their hands while doing everything they can to be entertaining, perhaps be the subject of a video that goes viral. Left unchecked, however, these people will be the subject of something, though they will not be happy about it. Their job is to properly deice the airplane, so the aircraft does not crash at the end of the runway. Their job is more important than a viral moment on the net.

To any ramp manager whose employees desire the Broadway lights and attention, please find them somewhere else to work, such as loading aircraft or, better yet, put them somewhere they can’t be tempted by the performing bug. Please! They are dangerous.

Wing-walking may be a tedious job; it is understood. Many of us who have worked for an airline have been wing-walkers at one time or another. Mechanics wing-walk for their entire careers, especially those who work in the hangar or tight ramps when moving aircraft for maintenance. Like everything in aviation, wing-walkers serve a very important purpose: Safety. They provide safety for the airplane, every person on the ramp and every soul on the aircraft.

Oh, and the deice guys who think it is their time to shine with the busted moves? Pay attention to what you are doing. If deicing was that irrelevant, you would be handed a broom and told to sweep the wing or something ineffective as that. This is not a joke; people’s lives literally depend on your work quality.

Please leave the dancing to Ginger Rogers; she was a professional. Her moves were choreographed, practiced and streamlined. Wing walkers and deicers, your job should occupy all your attention – stick to it. Passengers, please don’t encourage the wing walkers to perform; look straight ahead at the flight attendant and, even if you have heard it a dozen times, follow what he or she is saying. And please, everyone traveling, Happy Chanukah, have a Safe Holiday and Merry Christmas. And God Bless our Military and keep them safe all year and especially during the Holiday Season.

Aircraft Accidents and Lessons Unlearned XXXII: Northwest Airlink Flight 5719

Picture by Douglas Bader

On December 1, 1993, on approach into Chisolm-Hibbing airport in Minnesota, an Express II Airlines, Inc. Jetstream BA-1300, doing business as (dba) Northwest Airlink, tail registration number N334PX, impacted terrain. The accident number, DCA94MA022, was researched for information through the National Transportation Safety Board (NTSB) archives, but no archived reports were found, except for those that were comprised in the final accident report AAR-94/05.

The problem with a report like AAR-94/05, is that it is based on an emotional argument, not factual. It preceded other emotionally based reports, like ValuJet 592 and Colgan 3407. The facts of the investigation, often straightforward, get lost in the tragedy’s victim numbers or circumstances. An investigator’s job is not to get distracted but to remain focused on the accident’s facts.

The Probable Causes of the accident were as follows [numbering added for clarity]: “The National Transportation Safety Board determines that the probable causes of this accident were [1] the captain’s actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrumental meteorological conditions. Contributing to the accident were: [2] The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain; [3] the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures; and [4] the Federal Aviation Administration’s inadequate surveillance and oversight of the air carrier.”

What is gained by looking at an accident that occurred twenty-six years prior? What is to be learned from a small commuter accident? That is precisely the point, that each accident, from a passenger-packed jumbo jet to a single-engine private plane, is important because each accident, if incorrectly investigated, leads to another. Each has a lesson – or lessons – to teach us and, as in this case, lessons to be unlearned that were taught wrong to begin with.

Express Airlines II, dba Northwest Airlink, flight 5719 was a Title 14 Code of Federal Regulations Part 135, ten or more passenger air commuter, contracted to Northwest Airlines as a regional server. The investigation was a major accident investigation – accident number DCA94MA022 – because it involved certification requirements for its operations and maintenance, exceeding those of a general aviation aircraft and other smaller certificates. The timeframe, from accident (December 1, 1993) to final report (May 24, 1994) – no hearing – was just under six months; there were nine investigatory groups formed that contributed to the accident investigation. However, six months is extremely quick and did not lend itself to much time for testing, detail or completeness.

The root or actual causes of the accident were not run to ground; instead the investigators settled on probable cause. Beginning with the fourth probable cause: “… the Federal Aviation Administration’s inadequate surveillance and oversight of the air carrier;” was ambiguous. Imagine a picture of a square mile of the mid-Pacific Ocean; an arrow is placed on a wave, stating: ‘You Are Here’. The probable cause had no point of reference, no usable information. What did the NTSB, with its limited certificate holder experience, find that the Federal Aviation Administration was inadequate in? A finding about Air Carrier Operations Bulletins failed to clarify the collapse of trust or what constituted a failure of surveillance and oversight. No lesson was learned; indeed, no lesson was generated at all.

Probable cause number one: “… the captain’s actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrumental meteorological conditions.” The first ten report pages, ironically titled: 1. FACTUAL INFORMATION, described a captain who was hard to work with, following him from the previous day to the day of the accident. His every growl and ill-tempered action from 24 hours before the accident flight was analyzed and commented on by gate agents and cleaners. Were these persons experts in human behavior? Did they even know the captain? This was hearsay. From the cockpit transcript, crew conversation leading up to the accident was casual dialog; no disagreements. There was no arguing or interrupting associated with poor communications. Where was the breakdown in crew coordination?

The captain was criticized by a cleaner (no one else was onboard) for dressing down the first officer for an improper preflight because the first officer missed the broken landing lights. It was the captain’s job to require the first officer to do his job. Crew coordination takes two; each pilot is responsible for his/her breakdown of the communication. However, from the transcript, there were no miscommunications or problems. The captain was tough, but for an investigator to base a report’s probable cause on the word of people the captain rarely had interactions with, let alone conversations with, was unprofessional. The NTSB Board Members should have pushed back on the hearsay; instead, they were disengaged.

The second probable cause: “The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain.” Was this probable cause correctly focused? The captain’s training history demonstrated several problems, including several failed proficiency checks, yet the captain maintained his rating after retraining. The investigators did not succeed in their pursuit of training information. Serious training issues should have raised alarms with the Operations investigators. Why did the investigators not question the instructors’ training techniques, pursued the instructors and their quality? The instructor information was scarce.

The third probable cause: “… the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures.” What ‘widespread, unapproved practice’ did the company fail to identify? The report did not say. The investigators had access to the trainers who gave instruction to the pilots. Were they teaching unapproved practices and what were those practices? The problem with interviewing persons who have much to lose (the instructors) is that they will shine attention on the deceased crew, the ones who cannot argue in their own defense. The investigators should have had better interviews with other Express II pilots to see if they were receiving different training.

The Findings in this report did not represent factual information; the use of terms, such as ‘suggested’ or ‘should have’, diverted from the facts of the investigation, allowing speculation to be reported as fact. The nonexistent amount of time dedicated to testing, the lack of a hearing and the unnecessary analysis in factual matters, signified that the investigators’ efforts were inadequate. The report never made clear why the captain’s actions were unsafe, or why the first officer’s responses were in question.

The investigators dropped the ball and focused attention in the wrong direction. What, then, could have been the cause of the accident? Two questions: What about icing and was the aircraft deiced in Minneapolis airport before it departed? The investigators spent a lot of the report questioning the pilots’ integrity; what efforts were given to prove mechanical integrity? Too little was done to show if icing or frozen water was a contributor.

Deice fluid is made of 50% deice fluid and 50% water. During deicing, water has been known to get trapped in fairings surrounding the elevator pushrods. At altitude, the deice water freezes at below freezing temperatures. At cruise, small inputs are the norm, while at approach speeds the larger inputs are critical. What if they were hampered by ice? If the aircraft was deiced in Minneapolis, trapped ice could have made elevator movements sluggish or non-existent. The aircraft would have been more difficult to control at slow speeds or to recover from a steeper descent. Speculation? Perhaps, but the investigation failed to explore other effects upon the aircraft’s flight control integrity. This accident investigation showed no lesson learned; nothing of value came out of the report. The investigators’ rush to close the accident report found nothing that would increase safety and ignored the obvious. This questionable investigation itself should be a lesson unlearned.

Aircraft Accidents and UAS Data, Part IX

Beginning in November 2016, with Aircraft Accidents and UAS Data, Parts One and Two; then in October 2018 with Parts Three and Four; March 2019 was Parts Five and Six. In May 2019, Part Seven was written; Part Eight in October. The unmanned aerial system (UAS) and the national airspace system (NAS) continues to need dedicated professionals who both understand the UAS industry and comprehend the need for rules. The fifth Article (study) has been written by principal authors: Ryan Wallace of Embry-Riddle University (ERAU); Jon Loffi, Samuel Vance, Jamey Jacob and Jared Dunlap of Oklahoma State University (OSU). Their study titled: Cleared to Land: Pilot Visual Detection of Small Unmanned Aircraft During Final Approach is a qualified sequel to the four previous studies. This article was printed in the ERAU Scholarly Commons, Volume 6, Issue 5, Article 12.

As with the previous studies, the author team makes use of real-time situations and equipment to simulate as closely as possible the concerns. In the accomplishment of the previous studies, the teams have employed manufacturer-specific equipment to track certain sUASs; they have observed airspace violations around major airports, e.g. Daytona Beach IA, and commercial air routes, e.g. banner-towing. They have made use of the services of volunteer project pilots, with qualifying FAA-certifications.

More importantly, the teams have contributed to the future of unmanned flight safety. All the studies conducted had a unique theme; when taken together, the themes demonstrate a step-by-step story about how the UAS industry should prepare their operators for inclusion in the NAS. The writer for this website has written about these studies, to point out the futility many persons have of trusting to government to solve all the problems with UAS safety.

The article’s Problem statement is: “The threat of a midair collision between a sUAS [small UAS] and manned aircraft is heightened during the final approach phase of flight, as aircraft transition from higher-altitude airspace into the low altitude arena now populated by small unmanned aircraft. Absent benchmarks for electronic detection and sense and avoid systems, pilots rely primarily on visual senses and proper visual scanning techniques to ensure a positive separation and collision avoidance from sUAS platforms during this segment of flight.”

This problem statement demonstrated the correct concern for sUAS that threaten aviation safety; the concern has grown exponentially over the years: “The number of pilot-reported encounters with unmanned aircraft has been on the rise, since 2014 …” The article further stated, “… more concerning is the number of unreported UAS encounters during the final approach phase of flight.”

A Notice of Proposed Rule Making (NPRM) called Safe and Secure Operations of Small Unmanned Aircraft Systems, was introduced in 2019, to combat the intrusion of sUAS vehicles. It gave aviation professionals an opportunity to vent their concerns. However, an NPRM is a feeble argument; it holds no consequences and cannot be acted upon in a timely manner; it is a band-aid.

The article raised three questions:

  • What is the visual detection rate for a small unmanned aircraft system by an aware pilot when transitioning from an instrument approach to visual landing?
  • What is the mean distance at which a small unmanned aircraft system can be detected by an aware pilot when transitioning from an instrument approach to visual landing?
  • What factors affect visual detection of small unmanned aircraft systems by pilots?

The study was conducted under controlled conditions, a safe distance from regular commercial traffic. The place: a modest landing strip in rural Oklahoma. The approach was at 60 to 70 knots. The weather conditions: visual flight rules. Pilots: two per single-engine aircraft. The sUAS: a DJI Phantom (white quadrotor) against a green and brown terrain. Even with the pilots knowing the sUAS was either to port or starboard, the visual detection rate was “… 12 out of 40 possible events, resulting in an overall detection rate of 30.0%”. Moving sUAS were detected during 9 out of 18 possible events, resulting in a detection rate of 50.0%. Static sUAS were detected during only 3 out of possible 22 possible events, yielding a detection rate of 13.6%.”

Question: Given the study pilots’ awareness of an sUAS in his approach vicinity, how much harder would it be to see an sUAS against a background of dense visual ‘noise’? The study employed pilots watching for known targets against contrasting farmland, which easily betrayed the white sUAS in flight. But what about an approach into La Guardia airport at 140 to 150 knots? Would a B737 pilot easily distinguish an sUAS on approach over the mosaic that is Jackson Heights to runway 4 in midday?

The authors were very familiar with the effects of sUAS interference on populated airports. ERAU is near Daytona Beach International Airport (IA) and close to Orlando IA. OSU is near Tinker Air Force Base and Will Rogers World Airport. They understood that reaction times for pilots, whether a Cessna 150 or a B737, were extremely limited. From the study, they learned the fact that visually detecting an sUAS was almost impossible when the pilot did not know the sUAS was there and not camouflaged against a multicolor background or below line-of-sight over the nose of the aircraft.

What is required is perspective. This writer is not a pilot; never, outside of a simulator, landed an aircraft. What would happen to a car’s windshield or frame if someone hit a solid object (not a bird) at the approach speed of a Cessna single-engine aircraft: 60 to 70 knots (70 to 80 miles per hour)? The solid object would penetrate the windshield, kill the driver; the object would make the car undriveable and unsafe. The car, driving on a two-dimensional plane (X and Y-axis), could result in the death of the vehicle’s occupants and, perhaps, wiping out anyone else within crashing distance.

What about a car driving at the speed of a B737 on approach, at 140 to 150 knots (161 to 172 miles per hour); what would the effect be on that car if it operated in a three-dimensional plane (X, Y and Z-axis)? All passengers would be at risk; everyone below the approach would be at risk (think American 587); the engine could be destroyed at a critical point of approach (think US Airways 1549); if the driver survived a windscreen impact, he would be trying to safely land the vehicle … somewhere; an impossibility over a major city.

There remains through all these studies one simple question no one has asked: Why would anyone need to violate NAS airspace and endanger lives? This website addressed this concern in last week’s archived article: https://danieltenace.com/2019/11/08/aircraft-accidents-uavs-and-finding-nero/

An analogy for this activity is: the equivalent of randomly dropping a brick off a highway overpass or shining a laser at an approaching airliner. Are these thoughts speculation? Perhaps, but speculation based on fact is theory and theories are proven by using facts. Unless we continue to shut our eyes to the danger, a midair sUAS impact will prove these theories to catastrophic effect.

For instance, in April 2018, Southwest Airlines flight 1380, validated the dangers of an engine when its blades separate at operating speeds; this would be the scenario should an engine fan, turning at over 1800 rotations per minute, hit a solid object, e.g. sUAS. A windscreen, designed to absorb the impact of semi-solid objects, such as a bird, will not be able to sustain the damage made by an sUAS and will result in the pilot(s) being killed. That is a fact; the windscreen will not survive an impact with a solid object. It was never designed to. This is the fifth installment in the authors’ attempts to educate the aviation community, as a whole, about real dangers. Their intention is to make known possible threats to all aviation-minded people and to provide the facts for the industries to base productive conversations on, work proactively towards safety as opposed to reactively, to challenge the industries to prevent accidents before they happen.

Aircraft Accidents, UAVs and Finding Nero

There is very little proof that Emperor Nero fiddled while Rome burned, especially since the fiddle did not exist at Nero’s time. It’s the expression that matters; it is meant to allow us to envision one who just wants to see the world burn, for selfish reasons. The unmanned aerial system (UAS) industry knows about their Neros and they are hiding in plain sight.

Before this author analyzes the latest unmanned aerial vehicle (UAV) study by Doctors Wallace, Vance, Loffi, Jacob and Dunlap: Cleared to Land: Pilot Visual Detection of Small Unmanned Aircraft During Final Approach, next week, it is probably best to explain why the Neros of the UAS industry are going to destroy any progress the UAS industry has made.

UAVs continue to threaten air commerce, whether airliners, corporate operators, banner towers, crop dusters or aerial fire-fighters; irresponsible children with UAVs are endangering lives and property, both in the air and on the ground. Why would they do this? Why would someone shine a laser at an inbound airliner when they know the light blinds the pilots? The child wants to see the world burn. View a video, FAA investigates drone flying near news choppers: https://www.youtube.com/watch?v=NGbiWSLMvdk

If we wait for an accident, that would require a year-long National Transportation Safety Board (NTSB) investigation; it would also be futile. Waiting for an accident is reactive and deadly. In addition, the NTSB’s track record is in question. They will punt by blaming the Federal Aviation Administration (FAA) for everything, which does not address the safety issues or fix the problems. Besides, the NTSB fundamentally does not even understand the FAA.

Since it was determined that the FAA will have sole jurisdiction over the oversight of the UAS industry, no one has taken time to establish just what that means or how successful that mission will be. There are many consequences to not exploring this assignment proactively, to conveying responsibilities based on the sole logic that the FAA has the word ‘Aviation’ in its title.

To be fair, let us discuss the facts of the situation; let us look at the FAA’s Operations side of UAS oversight, since it is the Operations aviation safety inspector (ASI) who works with UAS operations. Airworthiness handles the maintenance side, but it would be the Operations side that would oversee all UAS pilots and operators, such as pilot certification, testing, enforcement and giving the UAS operator his/her operator certification. They would also be responsible for safety violations with UAVs that fly too low, too high, within restricted airspace, etc. To be clear, these ASIs occupy one third of a flight standards district office (FSDO), the office that would oversee UAS issues in a specific area.

What does that mean? Let us look at an average FAA FSDO: the Portland, Maine FSDO. There are only twenty operations ASIs working 8:00 AM to 5:00 PM, Monday through Friday. They oversee three states: Vermont (17 usable airports), New Hampshire (29 usable airports) and Maine (40 usable airports), whose combined area is 54,358 square miles; that’s 2718 square miles per operations ASI. Each operations ASI normally oversees ten to twenty air operators; then there are flight schools, designated examiners, hundreds of helicopter and fixed-wing pilots. Incidentally, less than half of these ASIs have been trained on, or are familiar with, UAVs.

UAV operators can number in the thousands in those states. That means there is one ASI to oversee thousands of certificate holders each, across three states. Major airports like Manchester, Burlington and Portland are under these twenty ASIs’ jurisdiction; that does not include the 83 other airports that regularly report UAV infractions, e.g. trespassing over airport airspace, busted altitudes or flying within an airport’s approach pattern. If a UAV violates the airspace in Burlington, the FSDO is not situated nearby to respond; in fact, the operations ASI is ten hours away, depending on flight availability and/or highway traffic.

During this recent upturn in the economy, the aviation industry has experienced a rise in employment opportunities, pilot jobs particularly. It is financially beneficial for pilots to seek out jobs in the industry; those jobs pay far better than the government does. This affects the number of operations ASIs leaving government positions, as well as those who are no longer looking at government as a viable job opportunity to apply for. Then there are those operations ASIs retiring, which is on the rise. What the FAA ends up with is a shortage of qualified operations ASIs, many of whom have no UAS experience.

Many UAS social media commenters are short-sided critics; they speak from emotion, not common sense. “If anything happens, it’s the FAA’s fault. They’ve been dragging their feet.” Just like the NTSB, these critics do not understand how things work. It is far easier to blame everyone else. If you don’t believe that, turn on the news and see how much government is addressing problems in their own states. In short, government is not the answer.

What happens, then, if the UAV problem continues to get worse? For those who need a history lesson on just how businesses can be devastated by consequences, in 1978, American Flight 191 crashed in Chicago. American Airlines, it was learned, cheated on the engine installation and caused the accident. However, the DC-10 was grounded for over a month; many airlines, e.g. Laker Airways, were hit hard by American Airlines’ incompetence. There are other examples: The Boeing B737-MAX, which has been grounded for months and which the investigatory groups still have not gotten right. It does not matter if the investigatory groups got it wrong, the airlines suffer financially.

The shuttle Challenger caused a two-and-a-half-year grounding; the shuttle Columbia, two years. Each shuttle disaster resulted in millions of dollars lost by companies whose businesses depended on satellite launches; they had to wait in line for years for future shuttle opportunities or invested in more expensive launch vehicles.

At no time during these groundings did anyone from the National Aeronautics and Space Administration or the FAA get their pay interrupted. However, with American 191 many domestic airlines were hurt due to the grounding of a wide-body aircraft; many international airlines could not fly into the United States; their businesses were hit hard. Thousands of flights were cancelled, jobs were liquidated and profits from restructuring delays were lost.

How many UAS businesses are willing to lose it all because of a few irresponsible children? Whether your business is real estate, mapping or website building, if a UAV causes a major accident, the UAS industry will be hard-down grounded – not might be, will be! UAS businesses will be financially devastated by these children who continue to threaten aviation safety. And when the grounding is over, how long will the aviation industry make you suffer for what had happened? How long will they work to block UAVs from re-entering the national airspace? Their lobbyists are more vocal and well-funded.

Many may argue that the FAA authorizes some uncertificated pilots to fly ultralight aircraft, with nothing more than a driver’s license. Argue all you want; nobody cares about these arguments because these ultralight pilots only endanger themselves. They won’t get sucked into an aircraft engine or crash through a windscreen at 130 knots. If the ultralight pilot defies the regulations or laws of physics, they are the casualties – not strangers, not families killed in the crash.

Doctors Wallace and his co-authors have been putting these series of studies out for years; they are invaluable. They are trying to open the eyes of the UAS industry to police yourselves, create the tracking technologies and educate the children. Find these Neros and get in front of their irresponsible behaviors; prevent them from watching the world burn. The consequences will not just be your short-term industry plans. The consequences will be that your businesses will go up in smoke.

Aircraft Accidents and Lessons Unlearned XXXI: Lion Air 610

Unknown photographer – B737 Angle of Attack Vane

On October 29, 2018, thirteen minutes after departing Jakarta, Indonesia, Lion Air flight 610, a new Boeing B737-MAX, registration PK-LQP, suddenly plunged into the Java Sea. The Komite Nasional Keselamatan Transportasi (KNKT) final accident report, KNKT.18.10.35.04, was released on Friday, October 25, 2019. The report revealed multiple cultural issues in Lion Air’s Operations division. What the report also demonstrated was KNKT’s fundamental inexperience with aircraft maintenance (AC-MX) issues that directly contributed to the accident. However, the KNKT was not alone; the National Transportation Safety Board (NTSB), who assisted in the investigation, was just as naïve in AC-MX issues as the KNKT.

The major contributing factor centered around the left-hand angle of attack (AOA) vane on the B737-MAX. Whether it was improperly overhauled or not correctly installed, the two investigatory groups focused on the easy culprit of new technologies and downplayed a simple fact: the AOA vane caused the accident … period. The KNKT failed to distinguish the difference between probable cause and root cause. That AOA vane caused a malfunction in the B737-MAX’s system (probable cause), but why that AOA vane was on the airplane (root cause) was ignored. Probable cause tells how accidents occur; root cause tells why accidents occur. If one removes root cause, probable cause goes away.

Out of 89 findings in the KNKT report, only ten findings were dedicated to AC-MX and even those were thinned by other problems. The report had scores of recommendations which never addressed the AC-MX issues that contributed directly to the accident. Instead they focused on the minutiae, such as pilot actions in the emergency or second-guessing decisions. These were safety issues for training or design flaws to be fixed, but they did not cause the series of events that led Lion Air 610 to crash.

Per the KNKT report, on page 131, “The investigation received AFML [aircraft flight maintenance log] record on October 2018 of PK-LQP.” The report then stated, “The investigation found 31 pages not included in the package.” Were the missing pages ever found? How did the KNKT investigate an accident for one year and never find any or all of the 31 missing pages? What did those missing pages say about Lion Air’s AC-MX culture? Did they agree with digital AFML copies? Why did AC-MX keep resetting circuit breakers on the accident aircraft during the last weeks?

The left-hand AOA vane was replaced with a defective part. This happens; a defective part is called ‘bad-from-stock’. It just should not be left on the plane. In the KNKT report, page 36, the left AOA vane was operationally tested using an alternative – yet approved – method, which required deflecting the AOA vane to different positions and then verifying each AOA position on the stall management yaw damper (SMYD) computer. However, “The [mechanic] did not record the indication on the SMYD computer during the installation test.” Why? Why were operational check parameters not recorded as directed? Why did no one question the unusual maintenance steps taken to clear computer faults?

Shouldn’t the NTSB have caught these issues? The NTSB’s September 19, 2019, report failed to direct attention to AC-MX. No finding or recommendation about the missing paperwork or the questionable testing performed on the accident aircraft prior to the accident. Did the NTSB understand the culture of Lion Air’s AC-MX division and/or its repair station personnel? Did the NTSB have AC-MX investigators with AC-MX experience? Has the NTSB started hiring seasoned AC-MX investigators or are they still using inexperienced engineers?

The NTSB and KNKT’s lack of AC-MX experience was shared by the Joint Authorities Technical Review (JATR), led by former NTSB Member, Christopher Hart. The JATR team of technical representatives was chartered by the Federal Aviation Administration (FAA) to review the FAA’s certification process. On October 11, 2019, the JATR report to the FAA was published. On page XII, paragraph 11, Impact of Product Design Changes on Maintenance Training, the JATR team stated, “The JATR team was tasked to consider maintenance suitability of the design. Due to lack of maintenance expertise on the JATR, the team was unable to make a determination of such adequacy.”

Amazing! Did the FAA cancel the JATR’s check? How can a team of technical representatives, employed by the FAA to provide unbiased, rounded views into the FAA’s certification process, fail to have AC-MX expertise? Certification relies heavily on AC-MX and inspection personnel to follow the procedures and instructions for continued airworthiness (ICA) for maintaining the aircraft. The ICAs, which appear to not have been followed, directly contributed to the Lion Air 610 accident. The JATR should have employed somebody … ANYBODY … who could address AC-MX issues. This was unacceptable.

The JATR was hired to help the FAA find problems.  Instead, the JATR ignored the basic needs of the AC-MX workforce using the ICAs. How could the NTSB expect the B737-MAX to be safe if they ignore fundamental problems that led to the accident? How did the KNKT expect Lion Air to learn from a catastrophic mistake if the KNKT cannot even understand why, e.g. missing AFML log pages and unknown test procedures were important? Did the KNKT, NTSB or JATR take AC-MX or Systems training on the B737-MAX? Did they take Lion Air’s approved B737-MAX Systems training to check for quality? Anybody?

The FAA and all oversight agencies across the world divide certificate holder oversight responsibilities into two groups: Operations and Airworthiness. Operations oversees the operator’s pilots, ramps, flight attendants, training and operations control; just because engineers designed the aircraft does not mean engineers can tell pilots how to fly it. Airworthiness oversees the operator’s maintenance, inspection, training, engineering and contract outsource maintenance; just because an engineer designed a single aircraft’s system does not mean that engineer understands all the systems and how to repair them.

The FAA has used these methods to capture all manufacturers, contractors, air carriers and outsourced maintenance for decades. The FAA, unlike the NTSB and the KNKT, does not hire engineers for investigations, performing surveillance or oversight. Why? Because engineers are not certificated; engineers do not receive systems training; engineers don’t understand how an operator works; they lack experience and basic troubleshooting skills to recognize problems, just like in Lion Air 610.

Lion Air 610 is the latest example of the NTSB’s failure to determine root cause. In this accident, the KNKT and the NTSB, by trivializing Lion Air’s AC-MX, ignored a major contributor to the future of Lion Air’s safety, not just of the B737-MAX, but its entire fleet. The evidence pointed to an inherent problem at Lion Air and/or its AC-MX provider that the KNKT and NTSB missed. Did Lion Air call Boeing technical support to ask about the AOA problems between October 9 and October 29, 2018? If not, why not? Did the KNKT interview the accident aircraft’s mechanics? The KNKT report does not say. AC-MX professionals would know that the manufacturer’s technical support always answers the phone.

Could the KNKT and NTSB’s AC-MX lapses have prevented Ethiopian Airlines 302’s crash five months later? That falls within the area of speculation. However, the omission of AC-MX issues in both the KNKT and NTSB reports demonstrated that they focused on what resulted from the series of events that led to the accident and ignored what caused the series of events that led to the accident. They obsessed on certification failures on a grounded aircraft – old news, all too easy. They failed to solve the root cause of the accident.

What does it mean that the root cause was never discovered by three respected organizations: the KNKT, the NTSB and the JATR? It means that the root cause still exists, that the ignored problems with Lion Air’s maintenance program have not been identified and fixed. It means, once again, that airplanes will continue to be unsafe from a root cause of ignorance.

Aircraft Accidents and UAS Data, Part Eight

Tracking equipment picture credited to flymotionus.com

Beginning in November 2016, with Aircraft Accidents and UAS Data, Parts One and Two; then in October 2018 with Parts Three and Four; March 2019 was Parts Five and Six. In May 2019, I wrote Part Seven, but consequently I became preoccupied with a new position and a writing project, so I never returned to Part Eight. It is time I remedied that oversight.

The unmanned aerial system (UAS) and the national airspace system (NAS) conversation has been in need of dedicated professionals who understand the industry, who also comprehend the need for rules. The fourth Article (study) had been written by Ryan Wallace, Kristy Kiernan, John Robbins, all of Embry-Riddle University; Tom Haritos of Kansas State University and Jon Loffi of Oklahoma State University, titled: Evaluating Small UAS Operations and National Airspace System Interference Using AeroScope. The Article was printed in the Journal of Aviation Technology and Engineering (JATE) 8:2 (2019) 24-39. In the four studies the Authors build up to an uncomfortable reality of rules gone missing.

The first sentence in the report states, “A recent rash of near mid-air collisions coupled with the widespread proliferation of small unmanned aircraft systems (sUAS) raise concerns that integration is posing additional risk to the NAS”. What were the authors referring to when they stated, “… integration is posing additional risk to the NAS”? The sale and use of sUAS vehicles, the unmanned aerial vehicle (UAV), has grown. Consequently, as per Rupprecht Law website, before 2005, the Federal Aviation Administration (FAA) had little to do with UAVs. Aside from publishing Advisory Circular (AC) 91-57 in 1981. This AC provided guidance for those who operate UAVs as hobbies or recreationally. There are two takeaways from this AC: for one it was not regulatory, ACs never were.

For two it was 1981; many UAVs were tethered in those days or had extremely limited radio-control range. Looking in the rearview mirror, was the FAA wrong to lose sight of the UAS industry? Perhaps. If you listen to the National Transportation Safety Board (NTSB), the FAA was to blame for everything from world hunger to Who shot JR, also from the 80s. However, much of the UAS advancements came under military testing that was then later adopted into private industry. The military was out of the FAA’s purview. Blame or no blame, the UAS industry boom caught everyone, including those who employed the NAS, off guard.

In 2007, the FAA put out a statement, “The FAA recognizes that people and companies other than modelers might be flying UAS with the mistaken understanding that they are legally operating under the authority AC 91-57.” During the original struggle to get NextGen and other much needed programs off the ground, the FAA tried to stem the confusion that the UAS industry presented. Soon after, Title 14 Code of Federal Regulations (CFR) Part 107 was begun. But the federal regulations cannot be adopted overnight; they must succumb to the regulation writing process, which takes, on average, five to seven years and costs in excess of five million dollars to write – per section; Part 107 presently consists of twenty-eight sections. Who is part of this process? Everyone, from the pilots’ unions to airlines to government to lawyers. In June 2016, Title 14 CFR Part 107: Small Unmanned Aircraft Systems debuted.

How does one qualify for a UAS remote pilot certificate? As per Title 14 CFR Part 107.61, one must:

  1. Be at least 16 years of age;
  2. Be able to read, speak and understand the English language;
  3. Be mentally and physically able to safely operate an unmanned vehicle, and;
  4. Demonstrate aeronautical knowledge by passing a knowledge test as specified in 107.31(a) OR, in short, the person holds a pilot certificate under Part 61 and received familiarity training.

To operate a UAV or sUAS in the NAS, one must meet these requirements. And this leads back to the study in JATE previously mentioned. The report first refers to data provided by Gettinger and Michael in 2015 that showed 931 UAV-to-airliner reported incidents, some taking place by airports such as Los Angeles and Newark International airports. These were visual sightings and close to or within the airport’s approach route. That was a summary of the report’s data but gave one an idea of the irresponsible behavior of some sUAS operators playing ‘chicken’ with the safety of passenger aircraft. To clarify, a narrow-body jet approaches an airport in excess of 130 to 150 knots. At that speed, a UAV could penetrate an airplane’s cockpit by flying through the windscreen or through the radome, killing the pilots before they even realized what happened.

Four years later, in Spring 2019, the JATE study took a more involved look at how to gather data. Using manufacturer-specific tracking availability, the authors measured more accurately the altitudes being violated, the airport perimeters trespassed, the approaches endangered, and times of operation ignored. The findings were not good news for the NAS. One might argue that the study authors are a group of Killjoys with a Jiminy Cricket conscience complex, but they are not. In fact, they represent a very pro-UAS group of educators and professionals in world-renowned aviation education institutions.

And to be clear, the authors’ tracking used specific equipment sold by a manufacturer with 70% market share of unmanned vehicles sold; the equipment could only track that specific manufacturer’s vehicles. The study took place in two major airports AND could not detect 30% of the UAVs presently owned and operated. The authors recommended aligning operational rules. The study stated, “The authors assert the large numbers of potential violations assessed under 14 CFR 107 rules are indicative of growing systemic risks in the NAS posed by unmanned aircraft operations. Based on the high proportions of hobbyist registrations in the sample area, the authors suspect that the majority of detected sUAS operations represent hobbyist activity or flights not otherwise carried out under 14 CFR 107 provisions.” The authors also recommend, “… Congress consider revocation of the preamble contained in Section 336(a) of the FAA Modernization and Reform Act of 2012, which would allow the FAA to codify and impose reasonable operational limitations on hobbyist and model aircraft activity to protect the safety of the NAS.” The preamble is too lengthy for this article; it is highly recommended that the JATE studies and the Section 336(a) preamble be read in their entirety.

What are we to ascertain from the study’s findings and recommendations? This article interpreted that the study made clear that bad actors within the UAS industry still act irresponsibly and in stealth, that they represent a real threat to aviation safety and the NAS. These concerns cannot be ignored; there must be swift and clear action nationwide or we will find ourselves staring into a smoking hole.

In addition, this article finds that the FAA is not up to the task of policing the UAS alone. The authors were well equipped for this study and were looking for specific findings; the FAA is not. Just as the FAA was late to the post-AC 91-57 world, the FAA cannot expect to become properly manned, trained and equipped with the latest technology by 2007 – that’s right, twelve years ago. Already they are late to the game and Congress shows no sign of relieving or aiding them in this losing strategy.

This is serious stuff folks. No quippy conclusion; no positive spin; no hopeful advice. Soon there won’t even be a can to kick down the road.

Aircraft Accidents and Lessons Unlearned XXX: Chalk’s Ocean Airways Flight 101

On December 19, 2005, Flying Boat, Inc. dba as Chalk’s Ocean Airways, flight 101, a Grumman Turbo Mallard (G-73T) amphibious airplane, registration number N2969, crashed off Port of Miami, Florida. The Mallard, a regularly scheduled flight to Bimini, Bahamas, had taken off moments before from the Miami Seaplane Base; the right wing departed the aircraft during climb and the Mallard plunged back into the Atlantic Ocean.

The root cause of the accident was corrosion that weakened the wing structure, in this case the right wing. The flexing of the wings during flight operations; the loads placed on the wings and the weakening of the aircraft’s integrity by corrosion eventually overwhelmed the wing’s structural strength; the wing catastrophically separated from the aircraft.

The aircraft, fifty-eight-years old at the time, was operated in a most hostile of aviation environments: saltwater and considerable humidity. The airplane was not just operated near saltwater, it was operated in saltwater. Because of this metal hazardous environment, corrosion was always a threat to the structure and the engines. Any gaps in the skin or moving components, e.g. flight controls, were susceptible; the two detrimental agents: salt and water, would easily hide within the crevasses and joints of aircraft components and require regular evacuating.

The National Transportation Safety Board (NTSB) as part of the accident investigation, focused attention on the Flying Boat, Inc.’s continuous airworthiness maintenance program (CAMP) and continuing analysis and surveillance system (CASS). Per accident report AAR-07/04, “As part of its CAMP and CASS program, Chalk’s Ocean Airways was required to monitor the mechanical performance of the flying fleet by collecting and analyzing data.” The CASS program was part of the CAMP and was dependent on the quality of data provided; the CASS was useless if the data was less than adequate or corrupted.

The concept of maintenance programs as they are today was born of the maintenance steering group (MSG) program. As per skybrary.aero, “… ‘Operator/Manufacturer Scheduled Maintenance Development’ is a document … The main idea behind this concept is to recognize the inherent reliability of aircraft systems and components …” MSG-1 was organized in 1968 for the B747s; MSG-2 was developed for scheduled maintenance for 1970s vintage aircraft and MSG-3 was first published in 1980; MSG-3 focused on ‘consequences of failure’.

The exact dates of the MSG were not important except to show when the programs came about. The aircraft designed and built before MSG-1 were not required to be included in the MSG retroactively; they were required, as part of their certification, to have a maintenance program built that would capture necessary maintenance requirements.

The accident aircraft, registration number N2969, was manufactured in May 1947. As part of its certification requirements, Flying Boat Inc.’s CAMP was developed; that included the CASS. In addition, Flying Boat was required per Title 14 Code of Federal Regulations (CFR) Part 121.1105 (December 2002) to have an Aging Airplane Inspections and Records Review (AAIRR). Part121.1105 applied to “… all airplanes operated by a certificate holder under this part [121] …” Per paragraph (b)(1), the operator could not operate an airplane unless they had an aging aircraft inspection and records review for, “Airplanes exceeding 24 years … not to exceed 7 years.” Operators, such as Flying Boat, had to prove “that the maintenance of age-sensitive parts and components of the airplane has been adequate and timely enough to ensure the highest degree of safety.” The review was completed in October 2005.

Why did the review miss what led to flight 101’s accident? On July 18, 2002, a Consolidated-Vultee P4Y-2 crashed in Estes Park, Colorado (accident number DEN02GA074). The aircraft, operating as a fire fighter, suffered a left-wing separation during a ‘drop’ maneuver. The aircraft impacted terrain. The P4Y-2 was manufactured as a bomber in 1944 during World War II.

One of the findings I made investigating this accident and another involving a C130A in California two months earlier (accident number LAX02GA201) with a dual wing separation, was that the operator of both aircraft, Hawkins and Powers (H&P), had CAMP and CASS-type programs designed for their P4Y-2, C130 and other models in their fleet. In conversation with the H&P chief inspector, it was learned that the fleet did not have a corrosion prevention and control program (CPCP) as part of their maintenance program.

November 29, 1993, the Federal Aviation Administration (FAA) issued Order 8300.12, Corrosion Prevention and Control Programs. The corrosion programs were dependent on the requirements of the manufacturer’s Baseline Program. The CPCPs were aimed at commercial aircraft whose age was substantial, e.g. B727, DC-8 and BAC1-11. Using the manufacturer’s baseline, operators of older aircraft could have used the manufacturer’s program or generate one acceptable to the FAA and the manufacturer.

The CPCP program, as described in FAA Order 8300.12, was a comprehensive and effective program that could have been designed to meet the needs of any aircraft built before the required date. The Order spelled out how the program worked, was revised and the recording of data. The surveillance of the program included actions required at different corrosion levels. This would have given the FAA Principle Maintenance Inspector for Flying Boats, Inc. a blueprint to approve a successful program. Per AAR-07/04, Flying Boats, Inc. did not have a CPCP for the Mallard fleet.

Consolidated-Vultee, manufacturer of the H&P’s P4Y-2, was no longer in business. Furthermore, the P4Y-2 was not required to follow FAA Order 8300.12 due to its age. However, at the time, it was the failure of H&P to have a CPCP in place that allowed, among other things, for the aircrafts’ corrosion and structural degradations to go unnoticed. In the G-73T Mallard’s case, corrosion had infiltrated the wing structure and fuselage so severely it was difficult to determine where metal began, and sealant ended. The wings suffered from many types of corrosion effects, e.g. crevice or environmental cracking. N2969 and her sister aircraft, were flying on borrowed time.

The CPCP, AAIRR, CAMP or other acronym and alphabet programs did not fail to capture the data; the FAA did not miss the signs; the NTSB did not fail to pass on what it knew. What destroyed the Mallard and the two H&P planes was a lack of common sense; this was the root cause of all these accidents. Grumman never expected that the G-73T would have as long a life as it did, operated as a regularly scheduled airliner into the next century. Consolidated-Vultee never designed the P4Y-2 to fly through mountain passes. It was a bomber; it was not designed for the incredible stresses of a firefighter.

As early as 1988, aircraft manufacturers were handed a cold plate of reality when Aloha Airlines flight 243 nearly came apart in flight. Flight hours, how many hours an aircraft spent flying, long thought to be the standard of measure of an aircraft’s lifespan, would need to be replaced with a more telling measure: flight cycles, which measured how many times a plane took off/landed. Aloha 243 was the catalyst to limiting commercial airliner lifetimes. Common sense won out.

Flying Boats, Inc. operated outside the norm as did H&P. The industry gave little thought to flying boats; there were bigger airplanes to worry about. Manufacturers saw no money in designing amphibious 18-seated airplanes or firefighters. Common sense had no means to cultivate in an industry that took no notice. Meanwhile, Mother Nature, often thought by the arrogant to be placed under control, will always play the last card.

Aircraft Accidents and Sabotage

In the 1991 Star Trek movie, The Undiscovered Country, Lieutenant Valeris explains her plan to delay the Enterprise by giving the crew a lesson on delaying tactics. According to Valeris, wooden shoes, called Sabots, were thrown into industry machinery to disable the workings as a sign of protest, thus the term, ‘Sabotage’. However, according to Grammarphobia, the term actually comes from John Spargo’s 1913 book, Syndicalism, Industrial Unionism and Socialism, where two anarchists recommended French labor unions adopt a policy of work slowdowns previously employed by British trade unionists. The word ‘sabotage’ was taken from a Scottish colloquialism, Ca’ Canny, which meant “go slow” or “be careful not to do too much.” One of the anarchists came up with the French equivalent, sabotage, based on the verb, saboter, which meant “make loud clattering noises with wooden shoes”. Lieutenant Valeris, it turned out, was partially right; wooden shoes fit in there somehow.

These past weeks, the news has been running a story about an American Airlines’ mechanic who allegedly sabotaged the navigation system of a B737 at Miami International Airport. A disturbing report, to be sure, but I will not litigate it here; I leave speculation to the self-professed ‘experts’.

The mechanic was charged with “willfully damaging, destroying or disabling an aircraft.” These are very serious charges and could cost the mechanic twenty years in prison, if found guilty. And for what? Higher pay? More overtime? These things are not guarantees made by any airline, or company for that matter.

Decades ago, I worked in an airline out-station, a three-mechanic ramp in the Midwest. We were doing more engine maintenance, a spreading of the workload with other ramps. We had an archaic engine stand that we pushed around with a ramp tug; it was inconvenient; we wanted a lift truck. Our perception was that it was imperative we got a lift truck and listed the reasons to management. However, we did not receive one because we were one ramp among dozens who worked engines. The reasoning was, we didn’t NEED a lift truck to do our jobs, we just WANTED one.

In the end, unhappy as it made us, no one promised us a lift truck … ever. Just like no one promised us higher pay or overtime. I eventually wrangled a lift truck from an east coast ramp – legitimately and with some ingenuity – but that is another story. What we did not do was generate a job action to get our way. We did not put ourselves over other company personnel or the customer. So, what would possess someone to turn to sabotage? What does it mean to sabotage an aircraft; to be a saboteur?

The first thing to understand is that any action against a US registered aircraft (commonly known as an ‘N’ registered aircraft) is a federal crime. Why? Because, simply put, an aircraft is a federally registered vehicle. I remember thirty years ago a disgruntled ramp employee intentionally drove an airplane tug into an aircraft fuselage-mounted staircase. The young vandal expected the local police to come to his house, some of whom he knew. He was surprised to find federal officers had arrived to take him to a federal lock-up hundreds of miles away. That was the first day of his eternity.

As per Cornell Law School’s Legal Information Institute, a saboteur or the like, is defined under Title 18 United States (US) Code 32 Destruction of Aircraft or Aircraft Facilities (a) (1). “Whoever willfully sets fire to, damages, destroys, disables or wrecks any aircraft in the special aircraft jurisdiction of the United States or any civil aircraft used, operated, or employed in interstate, overseas, or foreign air commerce.” This definition efficiently captures every action that could be done to delay or disrupt a flight by actions against the aircraft itself.

Once someone goes down that path, he will find that the Law is unsympathetic to higher pay, overtime and lift trucks. Even if the saboteur just wanted to make a statement or scare the company, the Law has the gravitational effect of a ton of bricks; it is that simple. Dike a wire, block a pitot tube, deflate a nose strut, they are all equal in the eyes of the Law. No matter the severity of the action, it is still considered sabotage.

What, then, if the saboteur wanted to act like a Gremlin and disrupt service, slow down an airline’s schedule without doing any physical damage traceable back to the saboteur? What if the saboteur wanted to do the aviation equivalent of crying, “Wolf!”? Title 18 US Code 32 Destruction of Aircraft or Aircraft Facilities (a) (5) and (7) addressed that question: (5) “Whoever willfully interferes with or disables, with intent to endanger the safety of any person or with reckless disregard for the safety of human life, anyone engaged in the authorized operation of such aircraft or any air navigation facility aiding in the navigation of any such aircraft.” And (7) “Whoever willfully communicates information, knowing the ‘information to be false’ [quotation marks added intentionally] and under circumstances in which such information may reasonably be believed, thereby endangering the safety of any such aircraft in flight.

How would this be relevant? What does the word ‘flight’ even mean? As per Title 14 Code of Federal Regulations Part 1.1 Definitions: Flight time for pilots, for instance, means, “Pilot time that commences when an aircraft moves under its own power for the purpose of flight and ends when the aircraft comes to rest after landing.” ‘Swell’, thinks the Gremlin, twirling his mustache, ‘I will delay the flight with a false alert during pushback. No harm done.’ The Gremlin would argue that any forced delay before the aircraft moved under its own power would not be considered ‘flight’.

However, there are many applicable definitions of the term ‘flight’. One has a ‘flight’ begin when the first person has boarded an aircraft for the intention of flight, such as a pilot or flight attendant performing preflight checks. An airline may define ‘flight’ as when the brakes are released for pushback to when the brakes are set at the destination. Then there are flight cycles, flight hours, etc. A flight attendant can get injured if the plane stops suddenly on the runway during her preflight briefing due to some false information relayed to the pilots. Also, a drone pilot playing chicken with an active flight on approach may inadvertently cause injury or damage to the aircraft.

“I didn’t mean to,” is not an alibi. “They did not pay me enough,” is not an excuse. Sabotage may not be the intent, but the Law will not see it that way. Endangerment is endangerment, it is that clear.

I’m not a lawyer; I have limited access to lawbooks; there are many other laws that better clarify the words ‘sabotage’ and ‘flight’. The point is, taking job actions against an airline or any company is so very wrong and, furthermore, it does not work. Logistically speaking, cameras populate aircraft ramp areas. Ramp personnel, in post-9/11, are trained to spot abnormal activity. Drone tracking is improving as are the technologies in aircraft for sensing system anomalies. The dumbest idea anyone can come up with is to think they are smarter than everyone else.

Why would one think that a job action in the form of sabotage is a good idea? The days of the sabot are long past as are the entitled attitudes toward what everyone is ‘owed’. We have three options when we are unhappy with our jobs. Quit, get a new job or deal with the misery. We have all had lousy jobs and these three options may not sound like good options, but sabotage is certainly not the fourth option.