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.

Aircraft Accidents and the Minimum Wage

A Realistic View of Raising the Minimum Wage to $15.00 per Hour.

In March of 2018, actress Jane Fonda, other celebrities and local politicians wrote to New York (NY) Governor Cuomo, demanding that the minimum wage for NY’s waiters and waitresses be raised so that the food servers would not have to rely on tips for pay. The progressive celebrities wrote, “Women deserve to earn a fair base wage so that the tips they still collect don’t come at a personal cost.” They felt that the food serving industry was unfair, discriminated against waitresses. In response, per the metro.us website: “‘Leave our tips alone!’ Waitresses reject Hollywood actresses’ plea to end tip credits”.

In May 2019, NY Representative (Rep), Alexandria Ocasio-Cortez proposed a minimum wage regulation forcing employers to ‘make up’ the difference of tips earned by – Servers and Bartenders. According to the NY Post, Rep. Ocasio-Cortez’s proposal met strong opposition from … Servers and Bartenders.

Why did these celebrities and politicians intervene in matters they did not understand? Were they being condescending or were they just uninformed? Ms. Fonda’s politics have been questionable since Hanoi, while Rep Ocasio-Cortez has a history of misreading her constituents’ needs, e.g., the Amazon debacle. How demonstrative that celebrities and politicians know so little about average Americans, that their causes du jour are so … wrong! Do entitled celebrities and politicians even know what minimum wage law (MWL) is or how it came about? Have these pampered folks ever earned a minimum wage?

According to Cornell Law’s website, “The national minimum wage was created by Congress under the Fair Labor Standards Act (FLSA) in 1938”. Eighty-three years ago, minimum wage began at $0.25 per hour; eighty-three years ago, America was coming out of the Depression. Was the minimum wage intended as a stepping-stone, a first rung on the ladder to earning better living wages, as some suggest? No, there is nothing to suggest that; the minimum wage may unintentionally promote good work ethics in people, but it was not designed that way. Others say that a fair minimum wage is a Constitutional right, that it will raise the lower class. No, the minimum wage is a law – not a right; there is a vast difference. And there is no proof the lower class will be ‘raised’ or ‘razed’.

What does Cornell Law say about the MWL’s origins? “The purpose of the minimum wage was to stabilize the post-depression economy and protect the workers in the labor force. The minimum wage was designed to create a minimum standard of living to protect the health and well-being of employees.” The point: eighty-three years ago, the minimum wage was never meant to become the norm; it was to serve during a crisis, a roadmap for successfully exiting the Depression. Do workers still need this outdated law? Who knows? No one will talk about it. What does this have to do with aviation? Everything.

In fast food restaurants, counterpersons rarely take orders; food requests are typed, then paid for on a touchscreen. Aviation, itself, has reduced manpower through the years, subtle processes that took decades to introduce. In 2001, some major airlines still did their own maintenance. Today, maintenance is farmed out to domestic contractors and/or repair stations located in low wage-paying countries. Remember when there were three pilots in the cockpit? Now every airliner has two; technology and research will reduce that to one pilot … or none. Subtle. How long before machinery completely replaces us? Consider: Except for extending flaps and lowering gear, what can pilots do that computers cannot? What avionics problems can a mechanic troubleshoot that the onboard computer cannot do better? Machines do not take coffee breaks, expect raises, call in sick, time out, demand medical or go on strike.

There are those in Congress who, not only feel the MWL is necessary, but are pushing to raise the federal average minimum wage of $7.25 per hour to $15.00 per hour – a 107% hike. Both sides of the aisle support this. Why? Are business owners so unscrupulous to deny worker raises if a hike truly profited the workforce? What facts – not feelings – support this argument? Consider this: Government shouts about the benefits of raising the minimum wage, but the costs get drowned out by thunderous applause. During the Depression, the MWL boosted the economy; it helped the workforce recover when the country needed such guidelines. Are there factual arguments for keeping the MWL as a law?

Aside from election talking points, does the MWL serve a Government purpose; does the MWL produce tax revenues? The Government can only tax companies, like a ‘Brand X’ Airlines (BXA), just so much. How, then, do they raise more tax revenue? By raising the minimum wage; by exploiting wage earners to generate more tax revenue. The more money BXA employees are paid, the more taxes the Government collects from BXA, like double-dipping. Cynically speaking, this would enable Government to subsidize more entitlement programs. Can this be demonstrated? As an example, consider the NY City (NYC) Triborough Bridge. In 1936, NYC instituted a temporary $0.25 bridge toll to pay for construction. The bridge was paid off years ago, yet the toll remains (now $9.50). Multiply that revenue by all NYC’s bridges and tunnels, the tolls – like taxes – are pure profit. Why, then, is NYC broke?

All can agree that the extra $7.75 per hour has to come from somewhere, but where? From Government? No, the money will come from companies, like our invented BXA. For instance, ramp employees with training, experience and/or seniority, make salaries that exceed the present minimum wage. These ramp employees, like gate agents or mechanics, have responsibilities and skills vital to BXA’s operation. Would these skilled employees see an equivalent pay raise of $7.75 per hour? There are no guarantees their pay would increase. In the end, BXA’s gate agents, mechanics, pilots and even management would see their hard-earned pay differentials decrease, their pay step grades flatten. If BXA did compensate, the money would have to be redirected from elsewhere. Skilled and/or senior employees would helplessly watch their cost-of-living raises dwindle, medical benefits reduced, promotion opportunities vanish and overtime cut. The good news is that elected officials in Congress will keep their pay and perks; celebrities will still make movies. But workers with years of job security in a failing company, will hit the Welfare Lines. Incidentally, isn’t Welfare another government program that outlived its original purpose?

Why? Because Government cannot force employers to compensate skilled or senior worker salaries equal to the new minimum wage hike. Unions might negotiate salary increases, but success is never certain and would take time. Consider this: the first two things to suffer during an airline’s financial crisis are Training and Maintenance. Those are huge consequences.

If BXA continues to fly, how could they save the $7.75 per hour? Some operators closed their doors during the COVID crisis. The ones that survive a minimum wage hike will outsource maintenance to repair stations in other countries, whose leaders refuse to pay a $15.00 per hour minimum wage; more American jobs going to foreign countries. The flying public’s safety could be at risk; these foreign workers’ work quality may be in question, their skills, unknown. Communities that rely on domestic certificate holders could suffer financially. Closings or mergers, like Hawkins and Powers (Greybull, WY), Northwest Airlines (Memphis, TN), Eastern Airlines (Miami, FL), etc. impacted communities.

What about skilled workers? After Air Midwest 5481, much was learned about how worker quality was tied to pay. Cut hours did not guarantee quality. Skilled workers sought higher paying jobs; mechanics, who, for years, built up seniority and experience, looked for jobs in other industries, like elevator or auto repair. Air Midwest was left with unskilled workers who lasted days, not years.  New hires left with their new training; quality dropped; complacency threatened passenger safety; planes were flown unsafely.

Such is the effect of financial instability. Experienced pilots will look elsewhere, decreasing the qualified workforce. Employees raising families will double-up on their work, resulting in more hours worked, less hours resting. One domino strikes the next domino in line until all are knocked over.

Aside from salaries, what other consequences are there for certificate holders rocked by financial stress? As go salaries, so go the quality of benefits – they are usually a package deal. Hospitalization, well visits, prescription copays and paid dental visits will suffer. When employee benefits are reduced, out-of-pocket expenses go up. Home repairs, children’s education, etc. still exist. Food, gas, and utility costs will, directly or indirectly, be affected by across-the-board, across-the-country minimum wage increases.

But what if the minimum wage law was overturned? If no one has conducted a factual argument against/for a minimum wage, this would be the time to have that discussion. Is the MWL hurting wage earners? Businesses? The American economy? What if employees entering a particular field that requires training and security checks, encouraged companies to raise employee pay rather than surrendering their trained employees to their competitors? Would that inspire employees to better their skills, to rise above minimum wage, become irreplaceable, attain higher pay in their present position?

Out of curiosity, why $15.00 per hour; where did that number come from? $1.00 or $1.50 minimum wage increase would be a sensible, doable raise, but an increase of 107%? Who does that benefit … and why? Do the Jane Fonda’s and Rep Ocasio-Cortez’s ideals represent American workers? These questions should be asked. What about the outdated MWL? None of what was discussed in this article was made up; it was based on history. It is very possible. You don’t believe a word said here? Good, then let us have that discussion.

Aircraft Accidents and Lessons Unlearned XLVI: British Midlands 92

British Midlands flight 92 resting on a bank short of East Midlands Airport’s runway 27

On January 8, 1989, British Midlands flight 92 (BRM92), a Boeing 737-400, registration number G-OBME, crashed one-half mile east of East Midlands Airport (EMA) near Kegworth, Leicestershire. The flight crew was attempting to land following an ambiguous engine failure with ‘moderate to severe vibration and a smell of fire’ on climb. In addition, the aircraft experienced longitudinal and lateral flight control issues normally associated with aileron and elevator input.

As BRM92 was diverted to EMA, the flight crew misidentified the failed engine as the number two engine (No 2) and shut it down. When BRM92 turned right to approach from the east, the number one (No 1) engine’s power was increased; at this point the mistake was discovered. 2.4 miles from the end of the runway, the flight crew tried, unsuccessfully, to relight the number two engine. The number one engine lost power and the aircraft bellied in short of the end of runway 27.

On page 148 of the Department of Transport Air Accident Investigations Branch’s accident report 4/90, the Cause stated, “The cause of the accident was that the operating crew shut down the No 2 engine after a fan blade had fractured in the No 1 engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during the final approach to land.

The investigators added two contributing factors:

  1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their [flight crew’s] training and experience,” and,
  2. They [flight crew] reacted to the initial engine problem prematurely and in a way that was contrary to their training.

That the investigator team (IT) described the flight crew’s failed reaction to the problem was curious; it demonstrated the IT’s unfamiliarity with an inflight engine vibration event. It also put into question the IT’s experience from a B737 pilot’s perspective.

The root cause of the BRM92 accident was not that the flight crew shut down the wrong engine; the flight crew’s reaction was contributory. The root cause: The No 1 engine failure was brought about by the fan blade separation; this failure of the No 1 engine translated into the pilots’ confusion. Assuming the Operations investigator understood, firsthand, an air carrier pilot’s training – there have been Operations investigators without this experience – why the IT focused on training as a major contributor was not made clear in the report.

The IT report relied heavily on speculation, not facts. For instance, on page 57, the report section 1.16.1 Engine Tests to Identify the Cause of Fan Blade Fatigue, documented testing the IT accomplished to identify why the suspect blade – number 17 – failed. The report determined that there was no “… material or geometric deficiency in the blade, or to any maintenance related actions.” Here the IT ruled out the blade’s material, geometric integrity and any maintenance performed. The report then stated that the manufacturer checked the fan abradable liner; “No evidence of any such influence [fan abradable liner] was found.” The IT’s engine test results established that a fan imbalance recorded on BRM92’s Flight Data Recorder (FDR), was, “… consistent with that obtained on testing an engine with a single fan blade outer panel missing.” These tests produced probable causes; they were not conclusive. How, then, does an engine’s fan suddenly become out of balance? A fan blade could have become loose in its mount; a metal abnormality subject to temperature could have caused a failure or a migrating crack reached too far across the blade’s span. These and many more reasons could have led to the imbalance, but the report did not say. The suspect blade was recovered; metallurgical tests, even in 1989, could have narrowed the focus on why the suspect blade became damaged.

The IT investigators were as listed: Investigator in Charge; Operations (qualified?); Engineering – Powerplants; Engineering – Systems; Engineering – Structures; Medical – Survivability and Flight Recorders. No one represented Aircraft Maintenance; there was no one on the IT who had balanced engine discs or blended fan blades. This conscious decision by investigative agencies to compromise safety by dismissing Aircraft Maintenance investigators has always been an unfortunate mistake.

Accident investigations, such as Ethiopian Airlines 302, Lion Air 610, National Air Cargo 102, and others, were demonstrative of how investigators, lacking experience in any and all maintenance issues, continue to make investigatory mistakes, leaving aviation less safe. All Federal Aviation Administration (FAA) Airworthiness (Maintenance) inspectors are certificated for aircraft maintenance, yet Aircraft Maintenance is still dismissed. The National Transportation Safety Board (NTSB), by contrast, benefited from experienced aircraft mechanics during only one period, when former Board Member John Goglia (1995-2004) was on the Board. Member Goglia’s guidance and experience exposed the NTSB to the correct diagnosing of maintenance issues, like blade blending and fan balance.

In cases where blades are blended; fans are balanced or vibration troubleshooting is accomplished, engineers are not involved. Engineers, if consulted by the manufacturer, overhaul facility or air operator, could be a mile away from the engine, several states away or separated from the aircraft by twelve time zones. I know this because when I worked engine vibration issues in the 1980s, there were no engineers anywhere nearby; Aircraft Maintenance consulted the maintenance manual, prepared the engine, ran the engine and balanced the engine’s fan with no help from engineering.

There is a lot to be said about identifying vibrations during high-stress situations, like during the landing cycle. BRM92’s FDR showed that while climbing through 28,300 feet, the moment the engine failed, there were “… significant fluctuations in lateral and longitudinal accelerations.” There were no fire alarms – either audio or visual, that normally accompany an engine failure – to call attention away from flight controls to engines. Smoke in the air conditioning system and the vibration could have suggested an air cycle machine failure, the flight control problems to aileron, elevator or hydraulic issues. Could the crew have turned their attention to the engine instruments only after the No 1 vibration settled?

The report stated the number five factor that, “… contributed to the incorrect response of the flight crew” was, “They were not informed of the flames which had emanated from the No 1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin”. If the flight crew was interpreting information available to them in the cockpit, making decisions during a high-stress diversion and landing, why would they consult the cabin attendants? That statement made no sense.

Airframe vibrations are not as revealing of engine problems as one would believe. When running a turbofan-powered aircraft on the ground, out-of-balance vibrations are more discernable because of the on-site conditions. Vibrations translate to the ground through the landing gear; the rigidity of the solid ground resists, reflecting the vibrations back through the landing gear and amplify through the airframe. An out-of-balance engine is much easier to identify in this situation for two reasons: First, the mechanic is well aware of which engine has the balance problem; the vibrations are expected. Second, the other engine(s), operating with correctly balanced fans, make the unbalanced engine stand out.

The report referred to several conflicting problems; per the FDR readouts, the IT felt the pilots’ attentions were misplaced. However, lateral and longitudinal fluctuations pointed to flight controls; smoke, that smelled like burning, without a fire alarm pointed to pneumatics or air conditioning. What kind of burning did they smell: plastic, metal, rubber, fuel? These separate events could have been why the pilots would not have looked at engine instruments first, which allowed the instruments to settle down. In flight, the airframe absorbs the engines’ vibrations, confusing their source; there is no ground resistance to reflect the vibration back. Engine vibration sensors may have originally isolated the disturbances, but vibration sensor measurements were not infallible. In addition, did the pilots’ confusion stem from the No 1 engine’s vibrations quickly dissipating? Did both pilots suspect another cause, such as the ailerons or elevators? Were their attentions pulled from the engines because there were no alarms? By pulling the No 2 throttle back, did this further mask the out of balance No 1 engine?

The report’s Safety Recommendations were ineffective; of the thirty-one recommendations, there was nothing that would have changed the way aircraft were inspected, pilots were trained, instrumentation reported anomalies or systems were certified, that would have increased safety. It appeared that by repeating what requirements were already in place, only with sterner words, was supposed to improve oversight and inspection, but the effort did not advance either.

Aircraft Accidents and Safety Ignorance

A trained Service Animal, aka, a seeing eye dog, assisting his disabled owner.

On January 3, 2021, Representative Emanuel Cleaver (Missouri) concluded the Congressional opening prayer by saying “A-men and A-women.” Why would a former minister feel it necessary to apply gender to Amen, which translated from Hebrew and Greek means ‘So be it’, Verily or Truly. Ignorance like this reflected Georgia Representative Hank Johnson’s oblivious remark; he oversaw technology regulation and feared that Marine troops on Guam would “become so overly populated that it [Guam] will tip over and capsize.” Some may say, “Oh, that’s just Hank” or “That’s just Emanuel,” but this is not funny. These elected officials decide on budgets for Defense, Homeland Security and Transportation, vital government committees that need serious-minded officials. These legislators represent the ignorance we too quickly overlook.

Realizing ignorance of the lawmaking process at the highest levels exists, how secure is the flying public that the same ignorance is absent when deciding aviation safety measures or policies, that our elected officials are not displaying safety ignorance? I recently flew from the northeast, at 6:00 AM eastern; twelve dogs of all types and sizes populated the gate waiting areas. No service dogs helping blind or physically disabled persons anywhere. No service animal harnesses, only leashes. This terminal demonstrated a growing trivialization of a just law, the Americans with Disabilities Act (ADA) of 1990.

I see dogs and cats all the time in the hardware store. I do not know why a pet is needed for choosing plumbing fixtures, but then hardware store pets do not threaten my safety. Bring a chihuahua into a restaurant? That would not be cool; that … is a public health issue. Bringing pets – or what many call an emotional support animal (ESA) – on a plane? That is a public safety issue. We see flight attendants review emergency procedures before flight. Why? Because safety instructions are crucial for humans to survive a crisis. Are ESAs trained for disaster? Is their instinct for self-survival ever considered?

In the 50s, Lassie always managed to relay to the Martins, through barks and whimpers, that Timmy was in danger again. Could that brave Collie have led Timmy through a smoke-filled plane to the emergency exits? Not likely. Why? Lassie was not trained to deal with emergencies; she would not know an escape slide from a bowl of Alpo. Instead, Lassie would, with her incessant barking, cause the injury (and probable death) to Timmy, most of the passengers and the flight crew.

Has anyone ever questioned why ESAs are given unrestricted access to airplane cabins? It started with the ADA; many legitimately disabled persons’ needs had been dismissed, those with physical or mental disabilities. The ADA, being signed into law, was a good thing. However, like all good things, there are those who would exploit matters for their own selfish ends, despite the safety threat to others.

How do people, with no concept of aviation safety, write the rules that put us at risk? How do the ESA owners get diagnosed with mental and/or emotional disabilities? The usserviceanimals.org website makes registering an ESA simple; “A doctor in our network may be able to prescribe an emotional support animal with just one phone call.” In one phone call?! Is that a MEDICAL doctor? In the next bullet the line changes to, “… mental health professional [MHP] who approves you [the customer].” The website changes direction from a ‘doctor’ – type unknown – to a ‘mental health professional’, which could be anyone in the mental health field. If it was a qualified MHP, wouldn’t the website say how qualified?

Are these real doctors who are diagnosing the mentally or emotionally disabled … with a phone call? How? How do MHPs diagnose mental or emotional disabilities over the phone? Diagnoses are being made by questionable MHPs, who then fill our aircraft with safety hazards. Would an ESA owner’s mental or emotional disability diagnosis follow them through life? A blind person cannot drive a car; can mentally or emotionally disabled people drive cars or own guns? Maybe Homeland Security should track these emotionally or mentally disabled persons, require them to undergo enhanced security checks. Why? Did we all forget Germanwings 9525’s and Egypt Air 990’s first officers? Are unqualified people making aviation safety decisions, putting us at risk? Do airlines check these ‘doctor’ qualifications? Per the website, the applicant must, “… have a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” … to travel with an ESA. Are some ESAs trained as attack dogs; are they weapons? What training does an ESA undergo to become a real service animal? How rigorous is the service animal’s training? These are valid safety questions.

Was the ADA hijacked? There are real disabled people who deserve the ADA’s benefits; serious people with real handicaps, e.g., the blind, the deaf or heroic soldiers who suffer from post-traumatic stress syndrome. What challenges have ESA owners been forced, by chance or birth, to overcome? Are these ESA-reliant folks putting their needs above others? The truly disabled depend on this sensible ADA law’s benefits; the ADA was secured by those who truly earned the right; it recognized deserving disabled’s challenges to their independence, their justifications to freedoms in our society. Anyone who pretends to have disabilities corrupts the ADA. These ESAs present safety problems that endanger us all.

It is to wonder that the flying public accepts the presence of numerous untrained ESAs on countless flights every day – without question. Why? Because we trust our legislators – even ignorant ones – to ‘do the right thing’ for the people? Legislators should have given all safety hazards their full attention by vetting the safety risks. Legislators should have had qualified professionals analyze the aviation safety risks, then, employed this data to protect the flying public from all safety threats. Instead, to evaluate the ESA risks, the United States Department of Transportation (USDOT) created the Air Carrier Access Act (ACAA). This law contained guidelines to approve – not even question – persons to carry ESAs onboard commercial flights. Was the ACAA a legitimate answer or was it just another promise that Guam would not capsize?

In September 2019, (per the USDOT website) the ACAA Advisory Committee (AC) was formed, a group of professionals, some even with aviation ties. The AC counseled the aviation community on who is a disabled person and how their care animal should be treated on a commercial flight. Data analysis and emergency evacuations were not factors to the AC; they did not promote aviation safety.

There were nineteen AC members. Representing the airlines were an International Air Transport Association (IATA) lawyer; a General Counsel for Airlines for America – another lawyer; a Vice President, Airport and Government Affairs; and a Corporate Compliance Disability Program Manager, whatever that is. The nineteen AC members had no operations experience, no one qualified who could – or would – speak to the safety risks of introducing numerous untrained animals into the chaos of an air crash emergency situation. There were no experienced commercial pilots, no experienced flight attendants, not one Federal Aviation Administration (FAA) Principal Operations Inspector (POI). A pilot, a flight attendant or FAA POI would know firsthand the dangers incurred during an aircraft emergency; they are professionals who are responsible for an airlines’ evacuation procedures, the safety of thousands.

The AC, however, had lawyers.

During two airline accidents, Delta 1086 and British Airways 2276, passengers stopped to grab their luggage and laptops in the middle of a post-crash evacuation. These people intentionally defied the evacuation procedures, blocked the aisles and endangered passengers’ lives … for laptops. Would an emotionally-challenged pet owner be just as irresponsible? Would an ESA logjam an aisle? Would an owner try forcing a pet carrier through a narrow CRJ overwing exit; let the pet free to dart between passenger’s legs or trip them with a leash? Could dogs barking drown out the flight attendant’s instructions? All this confusion in a cabin thick with acrid smoke, blinding and choking everyone; where each second means life or death. We are talking about ESA owners diagnosed as being mentally and/or emotionally disabled.

What requirements must airlines fulfill in determining if an ESA is a legitimate service animal, other than, you know, trusting the ‘reliable’ resources of the US Service Animals website’s MHPs? Per the USDOT website, the airline can trust, “the credible verbal assurance of an individual with a disability using the animal.” THIS is safety ignorance; an airline, responsible for thousands of passengers’ safety, trusting an eight-year-old child with an emotional disability. But it gets better; the airline representative can assure an ESA is a service animal by, “looking for physical indicators such as the presence of a harness or tags.” Out of the three airports I flew through that day, only two ESA dogs, out of dozens, had a harness or tag that said, ‘Service Animal’. The rest were on exercise leashes; one Pekingese was even in a baby carriage. What do the airlines do to assure the ESAs are legitimate service animals? Who knows? In fairness, they are probably not allowed to do anything. The growing number of ESAs mean safety events will happen. There will be human fatalities. It is not a matter of if, but of when.

The FAA and the National Transportation Safety Board (NTSB) must conduct joint studies into the risks these ESAs pose to passenger safety. The FAA and the NTSB have the best resources to do the analytical leg work, like the FAA test beds in Atlantic City and Oklahoma City, where controlled testing provides qualified data. The FAA and the NTSB should then develop guidelines; FAA Doctors should decide whether these MHPs are capable of making diagnoses. ESA owners should have their ESAs properly trained for emergency situations or revoke their ESA status. Finally, the FAA and the NTSB should present these findings to the US Congress to have them look at the facts and act accordingly.

The US Congress wrote the ADA with its ambiguities, they should correct the ADA’s inconsistencies. Truly disabled individuals deserve to have their handicaps recognized for the hardships they are, not to be grouped with those who claim a right they do not deserve. And when the ADA is corrected to be what the ADA was meant to be, we, the traveling public, can all say, “AMEN.”

Aircraft Accidents and Lessons Unlearned XLV: Eastern 212

Eastern Airlines DC-9

On September 11, 1974, at about 07:34 Eastern Standard Time (EST), 11:34 Greenwich Mean Time (GMT), Eastern Airlines flight 212, a DC-9-31, registration N8984E, crashed while on final approach into Charlotte International Airport. The Eastern 212 accident report: AAR-75/09, stated that Eastern 212 crashed due to a controlled flight into terrain – CFIT, a term given to an aircraft – mechanically and operationally sound – that is intentionally or unintentionally flown into the ground; the aircraft does not crash due to mechanical or control issues but crashes due to negligence. The National Transportation Safety Board (NTSB) determined in its Probable cause, “… that the probable cause of the accident was the flight crew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline in that the crew did not follow prescribed procedures.”

There was no denying that the two-pilot flight crew engaged in non-operational political conversations below 10,000 feet. AAR-75/09 said, the “… crew conversed on non-operational topics [or subjects]”; they engaged in talk that distracted from the landing. From the limited information drawn from the recorders, the previously concluded discussions did not distract them from the landing sequence. At 07:31:07 the non-operational conversation ended; at 07:33:57, the flight crew reacted to the pending crash. For two minutes and fifty seconds before impact, the flight crew did not engage in non-operational conversation; they were focused on the landing approach.

Flying today, flight crews are required to maintain a ‘sterile cockpit’ below ten thousand feet, meaning that the flight crew must have workable silence – no distractions. Jumpseaters and flight attendants must avoid interrupting the crews’ duties (unless for emergencies) while completing the takeoff sequence or while making the approach as the work intensifies; this applies to both instrument and visual approaches. The report stated, “This accident exemplifies the absolute necessity of strict adherence to prescribed procedures, particularly those pertaining to altitude awareness, during an instrument approach.” Non-operational talk was not the failure to adhere to prescribed procedures. In fact, it was their engagement in operational talk that doomed the flight. These conversations proved to be the ‘failure to follow prescribed procedures’.

It is nearly impossible, from report AAR-75/09, to determine at what altitude different crew conversations recorded by the cockpit voice recorder (CVR) took place at. On page eight it was stated, “The malfunction [in the flight data recorder (FDR)] rendered the vertical acceleration trace unreadable but caused little difficulty in the readout of other parameters.” From page one to page five, NTSB investigators pieced together a detailed log of actions and times chronicled of what had happened on flight 212 until the crash at 11:33:58 GMT. Although the recording of conversation and times can be followed, the altitudes at which the information was presented was confusing.

Why is this a problem? Distractions, such as the kind the NTSB said Eastern 212’s crew experienced (“poor cockpit discipline”), that led to the crash, might be compared to texting while operating a train or dialing a phone while driving. Operational consequences of pilot distractions in flight would be when they ‘bust’ an altitude (when a pilot unintentionally flies above or below their assigned altitude) or miss their air traffic control (ATC) radio transmitted instructions. There were no signs that ATC was ignored; at 07:22:00 and 07:31:09, the Eastern 212 captain acknowledged ATC’s directions to turn or descend; he responded to ATC. The flight 212 pilots knew where they were supposed to be … or thought they did.

The NTSB was correct, that the pilots failed to follow procedure. For instance, per Eastern En Route Procedures, “During descent, the pilot not flying will call out the assigned altitude upon going through the last 21,000-foot level prior to the assigned level. The last 1,000 feet should be at a target rate of 500 feet per minute.” The first officer was the flying pilot; it was his leg. The captain (pilot not flying) should have been focused on his responsibility, calling out the altitudes, at the least monitoring them. This was where the failure occurred; during an instrument approach the pilots’ attention should have been on the instruments instead of on visual ground references.

The procedure for the Final Approach Fix required, “… the pilot not flying (captain) will call out the altitude deviation from ‘bug’ speed as appropriate, and the result of the flag scan.” This, clearly, was not done; this failure alone should have called attention to another possible failure – ‘possible’ because it was never investigated – that the first officer and captain were reading two separate altitudes.

There is an ancient superstition that “bad (or good) things occur in threes”. Perhaps in this case, it came true, or as some in the Human Factors world may say, “the holes of the swiss cheese lined up”. The first contributor was the failure to follow procedure, to monitor the instruments.

There was ground fog obscuring the terrain during the approach; the pilots’ focus on ground references proved to be the second contributor to the accident. Ground fog should have had little to do with the instrument approach, but since the pilots decided to look out the window, it led to the third contributor: the distraction of the Carowinds Tower.

This approach was an instrument approach, so ground references were unnecessary, yet the flight crew discussed a 340-foot amusement park tower called the Carowinds Tower. For over one minute, the pilots’ attention was outside the cockpit and on the distant ground reference, not on the instruments. If, indeed, they did sight the Carowinds Tower, would that have given them a false sense of altitude as being over one thousand feet? From their perspective viewing the Tower, were they looking down, looking from the side or looking from a great distance? Should the Tower question have drawn their attention back to the instruments? Should this have caused the pilots to check their instruments in relation to each other?

In section 1.12 WRECKAGE, the wreckage distribution was discussed in great detail. All flight controls were in their normal positions, no evidence of fuel contamination, engine reversers were stowed, all this physical evidence pointed to a normal approach. The report did state that, “Most of the aircraft’s systems and instrumentation were destroyed.” It described how several of the captain’s instruments were reading normal but made no mention whether any investigation into the first officer’s instruments could be or had been looked into. Did the first officer not react to aural altitude warnings because his instruments read differently than the captain’s? Was the first officer, who survived, interviewed post-crash?

There was one other confusing detail: the changes in altitude as recorded by the FDR. Per AAR-75/09, at 07:31:54 the FDR recorded the aircraft at 2,750 feet; at 07:32:41, the FDR showed altitude at less than 1,000 feet. But at 07:33:17, forty seconds before impact, when the CVR recorded the first officer request, “Fifty degrees Flaps;” the altitude recorded by the FDR at this time was 1,480 feet.

It is understandable that terrain varies in height, especially in hilly or mountainous areas. Was the first officer confused into thinking the aircraft was higher than the altitude alerts called attention to? Were the two pilots’ instruments reading differently?

One last observation: in regard to the pilots’ neglect of the altitude aural warning, the report stated, “Based on pilot testimony taken at the hearing, it appears that the crew’s disregard of the terrain warning signal in this instance may be indicative of the attitudes of many other pilots who regard the signal as more of a nuisance than a warning. If this is indeed the case, the Board believes that airline pilots should reexamine their attitudes toward the terrain warning alert, lest the purpose for which the device was installed be defeated.” The takeaway from this statement was that the pilots should accept all warnings because they are designed to save lives. However, too many alerts in increasing numbers of tones might become so much noise that work contrary to their purpose. Consider a car alarm that constantly goes off or a smoke detector that senses smoke where smoke does not exist. Are all alerts necessary; do they work only when necessary? Are they overkill? Do they alert pilots to problems or are they redundant? Can important alerts be silenced or ignored too easily? These are questions for not only the airlines, but the manufacturers: Are there too many redundant alerts?

It is to be noted by reviewing the AAR-75/09 report that the NTSB, in these early days, made a great impact on aviation safety with less arbitrary input; focus was on both quality investigations and quality investigators; they used their qualified resources wisely, their experience constructively. These early investigators demonstrated that, like some cockpit warnings and alerts, less might be better. 

Aircraft Accidents and 2020

A scene from the 1951 MGM movie Quo Vadis

The beauty of reading: an ability to immerse oneself in the pages of classic literature. Arrogance makes us assume that novels from the 1800s and earlier are not applicable to today, but that … is incorrect. Ralph Waldo Emerson wrote, “Fiction reveals truths that reality obscures;” Henryk Sienkiewicz’s book, Quo Vadis (1896) is just such fiction, set against Emperor Nero’s reign. ‘Quo Vadis’ is Latin for ‘Where are you going?’; Saint Peter asks this in a vision. The back story has Nero authorizing Rome’s burning in 64 AD. Faced with a furious citizenry, Nero used propaganda and influence to blame the fire on the Christians, a defenseless religious people. Soon, hundreds of innocent Christian men, women and children were slaughtered in the most brutal ways. Quo Vadis is a timeless tale that demonstrated how false narratives destroyed civilizations, just like today, in the year 2020.

In March 2019, the Boeing B737-MAX was grounded after two high-profile air disasters: Lion Air 610 and Ethiopian Air 302. In what could only be described as an international kangaroo court, Boeing was dragged into the media’s hysteria and subjected to inept opinions – lean on knowledge, fat on ignorance. The MAX was exposed to inept analysis from investigators with no access to – let alone knowledge of – Boeing’s designs. Finally, the maladroit conclusions of the Ethiopian and Indonesian accident investigators, proved prejudicial and unqualified. Did anyone read reports KNKT.18.10.35.04 and AI-01/19? Did anyone understand the mistakes that could not be concealed?

How biased: government-run airlines investigated by government employees. Aside from the fact these government employees were not discerning about the latest technologies, governments are opposed to finding blame in themselves and less likely to admit blame when confronted. Ethiopian and Indonesian government investigators were woefully unqualified to analyze the Boeing’s latest designs of digital-based turbine engine aircraft. In addition, the investigators were engineers, ones who did NOT … could NOT … understand what they were looking at.

What was myopic was that engineers do not play active roles in aircraft maintenance, airline operations or take part in day-to-day airline activities. How many pilots on delay tell Operations to send out an engineer? How many mechanics rely on engineers to troubleshoot everyday system problems? Adding insult to injury, these accident investigators/engineers were bureaucrats who shifted blame from their airlines’ deficient training and antiquated culture practices, i.e., from themselves … to Boeing.

Then it got worse. In stepped the media and their non-aviation news ‘experts’, who amassed confusion and stoked public fear. Armed with hearsay, the media discredited Boeing and set the industry back twenty months before the Federal Aviation Administration rescinded the 737-MAX’s grounding order on November 18, 2020. By then Boeing’s reputation took a crippling hit in public trust; they lost billions in redesigns. Who did this was irrelevant; What they did was imperative, followed closely by Why.

How did industry ‘fix’ the MAX? Did they turn to mechanics experienced with digital aircraft technology or pilots with thousands of flight hours in digital aircraft? No, industry trusted the very work group that designed the ‘problems’ into the MAX: the engineers.

It was evident from both reports (and to those paying attention) that the investigating engineers, the media and the ‘experts’ did not understand the technology.

The inexperienced accident investigators, reporters and aviation ‘experts’, those who could not explain the B737-MAX’s technology to themselves, lacked the ability to explain the technology to others. And yet, these people seized control of the conversation and drove the narrative. Why were we so quick to accept the incompetent media’s word, let them steer us to the cliff’s edge and over?

The destructive mainstream media strategies of, e.g., CNN, Fox News, MSNBC and other major news channels and publications, can so easily destroy reputations that take decades to rebuild. Have any of these reporters ever turned a wrench; landed in zero visibility; taught up-and-coming aviation people? Did they play us – all of us – as fools?

The year 2020 marched on, and suddenly we had run out of pocket change; stores across the nation could not even break a one-dollar bill. Had the United States Mint run out of cupronickel or was someone trying to force us to pay with credit cards or debit cards? How curious.

The COVID-19 tally of those infected had risen. However, the COVID death toll had flattened. Because of available testing we were now receiving accurate numbers of those who contracted COVID … and lived … or had been unwittingly living for months as COVID-positive. Why, then, are we still wearing masks; avoiding restaurants; listening to politicians about COVID safety? Are we no longer concerned about the 2020-21 strain of the annual flu or does the annual flu season not happen anymore?  

Cynical tactics were never more evident than with the November 3rd election night. It does not matter who each of us voted for president: President Trump, Senator Kamala Harris or Mickey Mouse. Who we voted for was irrelevant; What we voted for was imperative, followed closely by Why.

What transpired on election night should scare the living hell out of every American citizen. We can no longer trust that a two hundred-year old, reliable voting system is still used. Even if we believe – or do not believe – fraud occurred, the question of fraud was raised with convincing evidence. That demanded that a serious investigation be run.

Late night comedians assured us that the election was legit; Daytime talk show hosts laughed at the suggestion of any fraud. Their years of questionable political superiority aside, the concept of fraud should have even made them shudder; indeed, they did not know the difference between criminal lawsuits and civil lawsuits, when searching for the truth. As these personalities focused on the distraction instead of the election, celebrities, e.g., singers, movie stars and other entertainers, assured us with their trustworthiness, that all was well, that we needed to move on. Any one of these people who balked at the possibility of fraud with disdain and sarcasm was not looking out for the People.

Meanwhile, the media seemed unusually quiet; they stood with hands in pockets, staring at the floor while shuffling their feet, intent to ignore all that was going on. On November 10th, the New York Times said, “Voting fraud is extremely rare.” Extremely rare?! Just how rare is ‘rare’? How extreme is ‘extremely’? Why would fraud be allowed at all, even when extremely rarely?

A week after the election, the Michigan Secretary of State’s spokesperson stated emphatically that “We have not seen any evidence of fraud or foul play …” Can his analysis be believed? Where is his proof? Another politician said, “… it would be nearly impossible to do voter fraud.” Nearly impossible is not a denial; it is a distraction. Perhaps these politicians did not understand the technology. Or, perhaps, they did. Perhaps they knew how easily the technology could be corrupted to sway the election.

Who promised to fix the ‘broken’ election system? The very group that broke the system: Politicians, whose agenda-driven power brokers divided this nation along racial, gender, demographic and income lines, were now going to save us. Government bureaucrats would, again, ‘fix’ the mess they made.

Then there were corporate executive officers, like Mark Zuckerberg (Facebook) or Jack Dorsey (Twitter), who manipulated social media to allow only the news they wanted us to hear. Two men, who made their billions without discipline, who somehow tripped and fell face first into billionaire status, provoked the political outcome of their choosing and played their customers in the process.

Other bad actors played more damaging strategies. They demonized Police Officers, called them ‘racists’, despite minority police officers in, e.g., New York City, making up 57% of the police force. Domestic terrorists burned our cities, looted businesses and unashamedly annihilated our way of life. While these terrorists launched unprovoked attacks on innocents, Hollywood and sports figures bailed them out, lifted them up and supported their rampages. This action was allowed, encouraged and applauded.

The media and politicians have desensitized us. We shrug off the assaults and victimizations of Mexican children smuggled across the borders by Coyotes. The shocking drive-by gang-related shootings of adolescent children attending birthday parties or barbeques became lost amid calls for defunding the police. We ignored at what point a life is valued. Our immunity to all that is shocking … is shocking. Have we become so apathetic? Does our nation’s upheaval not interest us anymore?

As in the novel, we should all be asked, “Quo Vadis;” “Where are you going?”. As the story played out, corruption and fraud turned an entire civilization against itself, led the average Roman citizen to betray his or her neighbor for power. How different are we? It is becoming a crime to want the same successful principles our earlier generations lived and died to defend. The year 2020 may have shown us – hopefully, not too late – that we are in danger of a decline of our decency and morality towards one another. So, should we ask ourselves, “Populus autem Americae, Ubi Sumus Iens?”

Translation: “People of America, where are we going?”

Aircraft Accidents and Lessons Unlearned XLIV: Korean Air Cargo 6316

Korean Air Lines MD-11

On April 15, 1999, Korean Air Cargo flight 6316 (KAL6316) crashed shortly after take-off from Shanghai Hongqiao International Airport (SHA). The McDonnell-Douglas MD-11 aircraft was operated as a scheduled international cargo flight between Shanghai and Seoul, Korea. The aircraft was airworthy; the flight crew was qualified and trained. This should have been an uneventful routine flight.

The accident report, 99-091-0, was accomplished as an investigation per the International Civil Aviation Organization (ICAO) Annex 13 provisions by the Civil Aviation Administration [the People’s Republic] of China (CAAC). Participating with technical support were the Korean Civil Aviation Bureau (KCAB), the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), Boeing (who had purchased McDonnell-Douglas at the time), Pratt and Whitney Engines and Korean Air. The report shows that the NTSB was tasked with reading out the flight data recorder (FDR) and the cockpit voice recorder (CVR).

There were three people on the cargo aircraft during the accident flight. The Captain had a total of 4,856 flight hours in the MD-11. The First Officer (FO) had 1,152 flight hours in the right seat of the MD-11. Both pilots had recently undergone training and were qualified to fly the MD-11. The third person was a technician (mechanic), flying with the aircraft; he had twenty years with Korean Air working their trunk aircraft, including the MD-11. The technician was not heard on the CVR; mechanics are not known to fly in the cockpit, even on cargo flights, so any input he might have provided was absent.

The CAAC made efforts to remove all other possible contributors to the accident: weather, navigation aids, communication, air traffic control, recent maintenance, long-term maintenance, aircraft airworthiness, fuel distribution, fuel contamination, weight and balance. All these possible contributors were eliminated, one-by-one, as unlikely causes. The CAAC report was thorough in this process; as the Arthur Conan Doyle quote stated, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” What remained was most improbable: two qualified pilots, who got so behind events, that they unintentionally crashed the aircraft.

Per page 10 of the report, the aircraft impacted the ground at a twenty to forty-degree, nose down attitude, wings level. All primary instruments on the MD-11 are digital; the ‘gauges’ are video displays that are fed data from the Flight Director, Air Data Computer, etc. Any FDR data captured during the accident flight was lost in the post-crash fire. The only analog instrumentation – the sole ‘snapshot’ recovered – were the standby gauges; the standby altitude/airspeed indicator was locked at 398 knots at time of impact.

All flight control components had been meticulously examined for proper condition and to determine no sabotage had occurred. The engines had no issues during flight. The aircraft was properly balanced; it had achieved an altitude of 1370 meters (4500 feet) during the 2-1/2 minute flight; the crew did not talk about control issues caused by being tail or nose heavy; there was no evidence of a stall. No mechanical or technical issues were discovered. By all evidence, the aircraft was in an airworthy condition. On page 48, the report stated, “The above mentioned evidences indicate that the accident airplane’s sudden dive was at the wish of the crew rather than other causes.” A most improbable truth.

On page 9, the report stated that the only usable recording device was the CVR; “… no useful information could be retrieved from the recovered portions of tapes of the FDR …”. The Korean to English translations of the CVR recordings were choppy; conversation, terms and sentence structure did not convert smoothly from the Korean pilots’ native language to English. Even so, the conversations were mostly recognizable, yet the tell-tale urgency and other voice inflections were missing, leaving the reader to guess at what the pilots were reacting to, indeed talking about. This is unfortunate; reactions, such as excitement, doubt, rises in pitch or volume would have been more telling. Another unfortunate fact was that the mechanic was not in the cockpit; the pilots [appeared to be] worried about instrument readings.

The report was correct in highlighting that the Captain did not conduct a pre-takeoff brief; the pilots did not run through the departure, including expected turn points or emergency plans. As it happened, this flight had unforeseen events that contributed to an increasing state of confusion. The report also stated that the root cause of the accident was confusion about altitudes; the air traffic controller relayed altitude in meters while the FO stated to the Captain altitude in feet – 1500 meters versus 1500 feet. This was unquestionably another contributor to the flight crew’s inflight confusion. However, there was more going on during the flight than questions about altitude.

At 16:03:06 (4:03;06 PM), the crew initiates a left turn, but the FO was confused about when to complete the turn. At 16:03:37, the Captain stated, “It might turn upside down. What’s wrong with this?” At 16:03:54, the FO said, “Slat, why doesn’t it work? Slat, slat up.” Finally, at 16:04:05, the Captain said, “Well, what’s wrong with this airplane today?” All three statements occur within one minute; the first is stated at one minute into flight and the last stated thirty seconds before impact. Through this, there were no communications with air traffic to report problems.

The flight crew never elaborated on what they were seeing. For example, was the ‘slat problem’ that the slats would not retract or was it an indication problem? What ‘might turn upside down’? What was the Captain seeing that he asked, “…what’s wrong with this airplane today?”

Even before takeoff and the ensuing confusion, the FO got meters-to-feet wrong. During engine start, with the towbar still attached, the Tower says to go to nine hundred meters; the FO tells the Captain nine hundred feet. This was not due to heavy workload; the pilots were loading data into the computer and they were entering the wrong information. Just like the later confusion of altitude, the Captain did not challenge the FO or tell him to confirm the numbers. Cockpit resource management (CRM) appeared to be non-existent; no challenges, no questioning and a lot of guessing took place.

On November 22, 1968, Japan Air Lines flight 2 ditched in shallow water in San Francisco Bay, two and a half miles short of the runway in heavy fog. The DC-8 landing was determined to be the result of poor flight crew communication during an Instrument Landing. The FO and Second Officer did not question the Captain, a result of cultural issues within the cockpit; the Captain would not … could not … be questioned. There was no CRM; it did not exist. In 1999, CRM should have been standard practice.

The FO on KAL6316 did not insist on a pre-takeoff briefing even though it was required by Korean Airlines procedures. The FO confused meters with feet of altitude, possibly giving the Captain the wrong altitude to enter into the Flight Management System. The FO became confused again, this time with the air traffic clearance before entering the information into the Flight Control Panel. Just like with the pre-takeoff brief, there was no challenge, no verification. Instead the pilots just changed settings without confirmation.

The CAAC was correct in its Probable Cause, but they did not go far enough. It was culture that brought down this aircraft. Complacency did not bring about the failure to perform a pre-takeoff briefing; culture made the briefing unimportant. This was evident because neither pilot pushed for the briefing; neither one questioned the briefing’s absence; neither one seemed to care. Every subsequent problem hinged on the briefing and the briefing hinged on a culture that demanded it be done.

Recommendation 4.2 spoke to the briefing, requiring pilots conduct them. This recommendation was good, even though briefings had been required for decades. Briefings should not have had to be recommended because this aircraft should not have crashed. Recommendation 4.6 was also good, requiring air traffic to speak to one measurement, metric or standard – not both.

The CAAC did a great job with this report; they hit every mark on the investigation. All investigatory bodies still need to accept the existence of culture as a root cause and study culture’s effects on safety. Until they do, culture will continue to elude the most efficient reports, thus eluding being addressed and fixed.