Aircraft Accident and Comprehensive Alaska Safety ASR-20/02

Comedian George Burns once said, “Too bad all the people who know how to run this country are busy running taxis or cutting hair.” The comedic centenarian was poking fun at the abundance of opinionated folks who felt that they knew more about politics than the politicians. Unfortunately, there is a list of others who would place themselves at the forefront of the aviation safety opinion peddlers, claiming their own knowledge of aviation far exceeds that of the Federal Aviation Administration (FAA). That list would include self-described aviation experts and the National Transportation Safety Board (NTSB). The self-described authors cannot change; the NTSB can.

An FAA friend of mine asked me if I really did dislike the NTSB. I said, “I don’t, I really don’t.” What I do find to be the NTSB’s weakness is their inability, after fifty-three years, to explore Root Cause Analysis and comprehend its benefits. The NTSB, instead, ‘bangs the table,’ criticizing aviation concepts that they can’t understand to move agendas which are paths to nowhere.

On February 20, 2020, the NTSB called, “for a comprehensive effort to improve aviation safety in Alaska,” due to Alaska’s high accident rate. The NTSB titled its aviation recommendation: ASR-20/02, “Comprehensive Alaska Aviation Safety Approach Needed”. ASR-20/02 was written to revise the FAA’s processes for overseeing Alaskan operators, particularly Part 135 operators, but it won’t

Per the NTSB report, “From 2008 to 2017, the total accident rate in Alaska was 2.35 times higher than for the rest of the United states. The fatal accident rate in the state was 1.34 times higher, according to NTSB statistics.” The NTSB have taken this track before, particularly when the Sunshine meetings are held. NTSB Board Members exaggerate statistics; they spout half-truths in feigned disgust. As with sunshine meetings, ASR-20/02, unfortunately, is deceptive; it is a chance for Board Members to get camera time, not address a problem. NTSB Chairman Member Sumwalt is a very intelligent man; I do believe his intentions are sincere. However, ASR-20/02 is a mischaracterization of facts; it serves little purpose in proposing solutions.

First, to suggest that fatalities are a product of some gruesome numbers game is a stretch, like comparing apples to orangutans. Fatal accidents are a product of two things: opportunity and occupants. Opportunity means that if an aircraft’s engine quits over hundreds of square miles of forest, as opposed to over hundreds of square miles of clear fields, chances are the landing will not be survivable. Occupants means if a widebody passenger jet crashes with 300 souls onboard it would take 75 four-passenger single engine aircraft accidents to equal that fatality number. This is deceptive; fatality rates are not a product of safety. Fatality rates only elicit emotional responses from the public.

The concept that Alaska presents many distinctive aviation safety problems is not new; no one argues that Alaska’s unique environment makes for unique challenges. To get some perspective, Alaska’s land area is 571,951 square miles, roughly 20% the land area of the ‘lower forty-eight’, the contiguous United States, which has a total land area of roughly 3,000,000 square miles. The FAA oversees the state of Alaska’s non-major air carriers with a few offices with perhaps 100 inspectors.

In addition, Alaska has glaciers, thousands of square miles of forests and lakes; numerous scattered towns that are not accessible by roads – including the capital, Juneau – but are only accessible by water or air. Hundreds of aircraft pilots operate in these extreme conditions, flying into areas that challenge the rules just so as to supply native Alaskans with basic essentials.

The Alaska FAA inspectors cannot provide constant on-site oversight; they have limited resources, e.g. transportation, to reach these places or help establish safe alternatives. The FAA has restrictions to how they can visit these hundreds of operators’ pilots and their maintenance facilities. These inspectors are subject to extreme weather conditions, the same that dictates how Alaskan aviation folks operate, how they can reach their customers. Oil fields in some of the human-challenging locations, test the mettle of the Alaskan aviation community. These are the realities of the Alaskan environment. People working in Washington, DC cannot grasp these challenges.

Then one must understand the FAA as it exists today. Programs have been implemented, such as the FAA’s Safety Assurance System (SAS) program, one of many effective safety programs honed over years to improve safety and communication between the FAA and industry. The FAA introduced the SAS program with the commercial air operators, e.g. major air carriers, using its established industry to fine tune SAS – then called the Air Transportation Oversight System (ATOS) – before incorporating the smaller industry air carriers and repair stations into a next generation program.

The safety of Part 135 Air Taxis, On-demand operators, which the NTSB has placed on its Most Wanted List, now falls into this SAS program. Other successful FAA programs have been developed, e.g. Safety Management System (SMS), Aviation Safety Action Program (ASAP), Suspected Unapproved Parts (SUP) and the Voluntary Disclosure Reporting Program (VDRP). It would have been a welcome sight if, in my years of teaching at the FAA Academy, I had seen NTSB investigators taking these FAA classes to learn how ASAP, SUPs, SAS, VDRP or SMS programs work; how FAA inspectors oversee Part 135 operators; how the FAA’s success with the industry has increased safety. Why? Because the NTSB cannot improve safety if the average NTSB investigator does not understand how the FAA works.

When will the NTSB employ Root Cause Analysis instead of Probable Cause, aka Probable Guess? One has only to review past accidents in Alaska to understand how the NTSB missed important issues with the Alaskan Part 135 industry, e.g. the Ryan Air Services, flight 103 accident investigation, #DCA88MA004. Part 135 is so very different from major air carrier; in Alaska those differences are magnified. Part 135 issues focusing on paperwork or weight and balance, were overlooked completely. These mistakes resulted in Alaskan Part 135 aviation safety not being improved.

If, by being unaware of FAA programs, the NTSB will continue to miss opportunities, they will pass up numerous chances to improve safety and fail to spot the true threats to aviation safety. By focusing on Probable Guess instead of common sense, the aviation industry will be stuck in pushing ineffective agenda items, e.g. cockpit video cameras.

What, then, would be proactive measures that would improve safety in Alaska? The NTSB could use their influence with the United States Congress to put forth proposals to increase the budget for the FAA in Alaska, hire more inspectors and place them strategically so that they are more effective in the unique environment there. Push Congress for more inspectors to be hired, to supplement the need in Anchorage and Juneau. Those are ideas that would improve safety, common sense ideas that would work.

It would also prove productive if the NTSB hired investigators that were up to the challenge of the FAA’s jurisdiction; hire investigators that worked in the specific transportation industry, not just for Aviation, but for Rail, Highway, Marine and Pipeline, as well. Don’t limit the hiring of investigators to engineers who have no fundamental experience of working airplanes in an air operator or repair station capacity. Have these investigators take an FAA class, work side-by-side with an FAA inspector. Before ASR-20/02 came out, the NTSB should have had NTSB investigators work in the field with Alaskan FAA inspectors, in the most challenging months of the year when the inspecting conditions are most difficult.

It does nothing for safety if the recommendations coming from the Board have no teeth, no insight, no thought put into them. Chairman Sumwalt stated, “We need to marshal the resources of the FAA to tackle aviation safety in Alaska in a comprehensive way. The status quo is, frankly, unacceptable.” One expects the Chairman to add, “Harumph! Harumph!” Instead, the statement, “We need to marshal …,” suggests the NTSB is in this fight, shoulder-to-shoulder, with the FAA, but they’re not. The NTSB needs to be shoulder-to-shoulder, but more importantly, they must be supportive. The NTSB must understand what is going on; they must become experienced; they must be quick to aid with, not just words, but actions.

Is the constant condescension of the FAA’s work really necessary? Nothing is learned if the critic does not know that from which he or she speaks. While it is true that taxi drivers and barbers have opinions, they know can’t accurately judge politicians because they are not politicians. The NTSB does not hire FAA inspectors or the experienced. ASR-20/02 cannot be taken seriously; it won’t make us safe.

Aircraft Accidents and Lessons Unlearned XXXV: Executive Air Charter, Inc Flight 5452

According to National Transportation Safety Board (NTSB) report, AAR-88/07, on May 8, 1987, an Executive Air Charter, Inc. doing business as an American Eagle commuter flight, a CASA C-212-CC aircraft, flight 5452, departed San Juan, Puerto Rico, on a flight to Mayaguez, PR. Unfortunately, that is the last clear account in the report’s History of the Flight section. The narrative of how the aircraft crashed then reverted to hearsay, quoting multiple witnesses. A statement by one witness said the aircraft turned right on final into Mayaguez, nosed over and struck the ground. Multiple witness reports were always unreliable; they contradict each other, or recollections are often exaggerated.

American Eagle (Executive Air Charter) 5452, accident number DCA87MA030, is one of the most important accidents to yet be analyzed; the NTSB Archive information was not available. The fatalities in American Eagle 5452 were minimal, yet this accident report represents the Achilles heel in the NTSB’s investigatory process: the absence of experience, particularly in Aircraft Maintenance and aircraft-specific issues. Report AAR-88/07 failed to provide quality safety recommendations or findings.

Reading through report AAR-88/07, there is confusion on what was actually discovered that pointed to Aircraft Maintenance actions as the most prominent probable cause, aka probable guess. Was the right hand propeller out of adjustment? Was the right governor bad from the repair station? Did the flight crew make a mistake?

On May 1 through 5, the right hand (#2) Honeywell-Aerospace TPE331 turboprop engine was swapped due to previous discrepancies. During run tests, the right propeller was replaced because of extensive propeller vibrations. The propeller governor was also adjusted. The plane test flew successfully before flying four consecutive revenue flights on May 5th. On the first revenue flight, the captain reported problems with the right propeller; Maintenance adjusted the propeller’s governor. On the day’s last flight, Maintenance adjusted propeller blade angles to address another problem.

On May 6th, the airliner flew eight scheduled revenue flights without any discrepancy. On May 7th, the aircraft flew two flights and the captain reported a problem; Maintenance readjusted the propeller blades, then eight revenue flights with no issues. The aircraft crashed on the first flight on May 8th.

Each time the pilots wrote up a discrepancy, the mechanics addressed the problem. This is important; it not only demonstrated that Maintenance was addressing pilot discrepancies immediately, but that several legs had been flown without incident. The NTSB engineer did not realize that repeat write-ups can happen, that a problem can resurface because conditions at altitude are different than conditions on the ground; cables can tighten in colder air or engine vibrations at flight idle can offset settings that were perfect during ground operational checks. Adding to the technical confusion, were numerous trouble-free consecutive flights that were flown … without incident. Which brings us back to the baffling History of the Flight section and its confusing description of the crash. What this points to is the fundamental inexperience of NTSB investigators to understand the mechanics’ actions.

Per section 1.12.1, General Information, “The right wingtip first struck the ground 643 feet short of the runway threshold and 67 feet to the right of the extended runway centerline.” The aircraft traveled about 100 feet, presumably in an upright position. The fuselage remained intact, except for the cockpit. All passengers survived with minor injuries.

It is uncertain why this information was not relayed in the History of the Flight section. It could have been easily established by observing ground scrapes, wreckage distribution (found in Appendix D), fuel spatter, localized fuselage damage, techniques that were taught at the NTSB Academy investigator classes. Instead, AAR-88/07 dedicated twice as much report space to conflicting witness descriptions, amounting to some speculation in the recording of facts. The impact evidence was not corrupted; ground impacts are evidence intensive, as opposed to water impacts, because the evidence is preserved. More importantly, evidence found at the impact site did not support Aircraft Maintenance being to blame.

The NTSB employs only engineers to conduct aircraft-specific investigations, e.g. Powerplants, Structures, Aircraft Maintenance and Systems. This is a major problem for the investigatory process. An aircraft engineer, who designs airliners, has experience that is limited to designing a single system of an aircraft’s dozens of systems. Furthermore, they were never exposed to airliners operating in the airline environment. Since they never did, they did not know what to look for as cause for an accident. This calls for an analogy.

In the 1981 movie, Raiders of the Lost Ark, in a rush to capture the map to the Ark of the Covenant – which was engraved on a medallion – the Nazi interrogator, Toht, accidentally burns the map into his palm. Using this imprint, the Nazis forge a new map and begin digging … in the wrong place. Why? Because the rest of the map’s instructions were on the backside of the medallion.

For over five decades, the NTSB has used engineers to investigate aircraft-specific issues. This is akin to digging for answers in the wrong place. It is true engineers have access to aircraft blueprints, but maintenance investigations have little to do with blueprints; they are about people, work hours, maintenance manuals, inspection programs, training, etc. The Federal Aviation Administration (FAA) places such a high importance on Aircraft Maintenance, that half the FAA workforce is dedicated strictly to overseeing that specialty. An engineer who investigated aircraft maintenance issues would be just as ineffective if he investigated pilot issues just because the engineer designed the aircraft the pilot flies.

From the maintenance that took place on May 5th through May 6th, the NTSB engineer concluded that the “evidence indicates[ed] that the carrier’s maintenance personnel were inclined to take the most expedient means to correct an engine rigging problem …” There was no evidence to support this assertion, no interviews. The NTSB engineer came to this conclusion without factual proof as a basis.

The 1.6.2 Maintenance History section of AAR-88/07, the pilot discrepancy reports stated the various mechanical problems found by previous pilots logged in the maintenance logbook; the pilot write-ups were documented. However, even though mechanics addressed the pilots’ concerns each time, the report did not say what the mechanics’ actions were. This raises questions: What did the mechanics do to fix the problems? What did the mechanics document in the logbook? What did the maintenance manual instruct the mechanics to do? Did the maintenance manual give proper steps to adjust the propeller?

This is where the NTSB engineer did not dig in the right place. Many maintenance manuals were written with poor instructions. As an aircraft sees time, the manuals are revised to correct the manual instruction errors. As to the quality of maintenance, larger airlines have the benefit of more experienced mechanics, those who base their work practices on ‘tribal knowledge’; the tricks of the trade that the manuals cannot demonstrate, e.g. blocking cables. Especially these days where major airlines can afford to draft the most experience, like sucking oxygen out of the room, there is no one to pass on the tribal knowledge to the mechanics at the smaller airlines, such as regional airlines.

This is key to understanding how despite a newly replaced engine and propeller being installed, major problems had surfaced. What was important was to find out why they repeated and fix the problems, e.g. manuals or training, that led to the repeat discrepancies. That did not happen.

This is why the safety benefits of this accident were non-existent, too much guesswork, just like the reliance on witnesses for the accident description. The NTSB engineer who investigated Aircraft Maintenance issues did not cover the bases; he allowed speculation to replace facts; he shrugged off researching the maintenance program or maintenance manual quality. The NTSB engineer did not have the fundamental experience to pursue the answers. He did not know where to dig.

This accident was a lost opportunity to improve safety. The accident came at a time when regional airlines were still growing into what they are today, where numerous regional airlines fly in contract to the major airlines. Instead, it became a lost opportunity to capture and fix problems with the young regional airline industry. This problem has now grown and possibly spread to more airlines.

Aircraft Accidents and ICAO

ICAO Annexes

In this month’s Lessons Unlearned XXXIV article, Avianca flight 52’s Root Cause was examined. More important was a discussion on how the Federal Aviation Administration (FAA) moved proactively to improve international aviation safety, worldwide. During the January 1990 accident’s investigation, while the National Transportation Safety Board worked its Probable Guess on why Avianca 52 ran out of fuel (HINT: the engines burned the fuel up in flight), the FAA began an aggressive campaign to correct the international air carrier industry’s ability to keep air travelers safe. The FAA corrected for decades old laws written in the pre-jet days of the Douglas DC-6, before international passenger travel took off.

Why couldn’t the FAA prevent the Avianca 52 accident; it happened in the United States (US)? The short answer: the FAA did not have the authority, the power to tell another country’s oversight agencies how to manage their country’s air carriers, especially countries who were Members of ICAO … yet.

Who or what is ICAO? Briefly, in 1944, the US hosted fifty-five States (for clarity, a ‘State’ will be referred to as a ‘Country’) in Chicago. The Chicago Convention addressed travel in the post-World War II era. From this convention, the International Civil Aviation Organization (ICAO) was established. ICAO, per the icao.int website, “works with the [Chicago] Convention’s 193 Member States and industry groups to reach consensus on international civil aviation Standards and Recommended Practices (SARPs) and policies in support of a safe, efficient, secure, economically sustainable and environmentally responsible civil aviation sector. These SARPs and policies are used by ICAO Member States to ensure that their local civil aviation operations and regulations conform to global norms …”

How, from the ashes of Avianca flight 52, did the FAA improve on international safety? Three important results of the Avianca 52 accident:

1) The International Aviation Safety Assessment (IASA) is a program established by the FAA in 1992. The program was designed to evaluate the ability of a Country’s Civil Aviation Authority (CAA) or other regulatory body to adhere to international aviation SARPs for personnel licensing, aircraft operations and aircraft airworthiness. Most important, the IASA program allowed the FAA to audit other country’s CAAs, to assure they were performing quality oversight of their air operators. The IASA program allowed other countries to audit foreign operators entering their respective country.

2) The ICAO Universal Safety Oversight Audit Programme (USOAP) was developed. USOAP is an ICAO program which was launched in January 1999; ICAO would perform audits of the various Member Contracting Countries’ compliance with all ICAO Annexes – except for Annexes 9 Facilitation and 17 Security. A Member Contracting Country is a country that belongs to/who has followed rules founded in the 1944 Chicago Convention.

3) A revision to ICAO Annex 1 Personnel Licensing for the establishment of minimum English Proficiency for pilots and air traffic controllers. One major issue in Avianca flight 52 was communication; the flight crews’ descent into confused English when talking to Air Traffic Control.

The Avianca flight 52 accident also highlighted the importance of establishing a legal means for a Contracting Country to delegate its oversight responsibilities to another Contracting Country with the finalization of ICAO Article 83 bis, June 1997.  This determined the responsibilities for oversight functions between the two Countries in an agreement: The Country of Registry (where the aircraft is registered) and the Country of the Operator (where the aircraft is operated from; the air carrier’s home).

A US-based air carrier, e.g. Delta or FedEx (Country of Operator), can register their aircraft in a country where they operate flights, e.g. Canada or Japan (Country of Registry). The airline can also have maintenance performed in that country of registry.

During the period of Avianca 52’s investigation, the FAA’s Assistant Administrator, Anthony Broderick, moved to ensure foreign air operators flying into the US were in compliance with ICAO standards as they related to that Country’s responsibilities towards their Air Operators. His push was met with heavy resistance, not only domestically, but on the international stage. Numerous groups within, and outside of the FAA, stated that Broderick’s mission was not legal because of sovereignty rights; that the FAA did not have the right to audit and determine if a sovereign Country was in compliance with ICAO.  In fact, ICAO established the international air navigation standards, but ICAO had no regulatory authority.

Broderick was resolute. Using the Department of Transportation (DOT) Air Transport Agreement Article 6, and ICAO Articles 32 and 33, as the legal basis, he declared that the US did in fact have the right to expect Countries, from which all air operators flying to/from the US, had a CAA that was compliant with the ICAO Annex SARPS as contained in Annexes 1, 6, and 8. Pushback on CAA inspections from other Countries was met with Broderick’s response that no air operator from that protesting Country would be granted authority to operate to/from the US. That Country’s US operations would cease and desist.

Broderick’s aim was to assure that any foreign country’s air operator wanting to conduct commercial air operations to/from the US, must obtain two authorizations from the DOT:

            a. Economic Authority from the Office of the Secretary of Transportation. ‘Economic’, in this case related to, “concerned with the organization of the money, industry and trade of a country.”

            b. Safety authority from the FAA, commonly referred to as Part 129 Operation Specifications. Title 14 Code of Federal Regulations Part 129 is referred to as Operations: Foreign Air Carriers and Foreign Operators of US Registered Aircraft Engaged in Common Carriage, which includes all rules found in this Part’s sections. The requesting air operator had to acquire Operations Specifications per Part 129.

Broderick’s team first visited other countries’ CAAs, where they found inefficient oversight agencies. The team discovered foreign operators, operating to/from the US, with either an ineffective CAA or a CAA in name only; there was inadequate staffing, technical knowledge and surveillance capabilities. The FAA did not expect to find air operators flying to/from US sovereign airspace with no certification or oversight from a Country’s CAA. These initial findings were found to be the norm, not the exception.

The next objective was to get approval for the IASAs and the USOAPs to raise the bar for foreign oversight agencies to become equal to or above the minimum standards established by the 1944 Chicago Convention. Both programs were designed to repair the years of neglect other countries had subjected their air operators to.

IASA focused on a Country’s ability – not the Air Carrier’s ability – to adhere to international aviation safety standards and recommended practices found in three very significant annexes: Annex 1 Personnel Licensing; Annex 6 Operation of Aircraft and Annex 8 Airworthiness of Aircraft to the International Convention on Civil Aviation.

Broderick established the legal basis for FAA policy for ensuring foreign air operators who requested economic authority to operate into the US. The FAA-founded IASA program was established in 1992. Details on the FAA IASA may be found here: www.faa.gov/about/initiatives/iasa

The failures that led to Avianca 52 became obvious to FAA Assistant Administrator Tony Broderick and his team shortly after the accident. If the Avianca tragedy had not happened or its evidence had not been recoverable, e.g. the airliner had crashed in the ocean, the shortcomings of Colombia’s CAA and countless other Countries’ oversight agencies and airlines may have remained unknown for decades.

However, the diligence of a select few at the FAA turned tragedy into a true learning moment. They acted when no one would act; found numerous safety failures where no other investigative or oversight agency would have looked. If not for the persistence of safety minded professionals, many thousands of passengers and flight crews may have died in accidents around the world, possibly for unknown reasons. These actions are why accidents are investigated. These actions also highlight the need for experienced individuals who know what to look for and how to fix the problems.

Aircraft Accidents and Lessons Unlearned XXXIV: Avianca Flight 52

Avianca 52 laying against a hillside in Cove Neck, NY

On July 19, 1989, at 2134 (9:34 PM) eastern standard time, an Avianca Airlines Boeing 707-321B, flight 52, which originated in Bogota, Colombia, enroute to JFK Airport, crashed almost twenty miles northeast of the airport. The aircraft, mechanically sound, crashed due to fuel starvation. The airliner ran out of fuel.

The National Transportation Safety Board (NTSB) determined in accident report AAR-91/04, “… the Probable Cause of this accident was the failure of the flight crew to adequately manage the airplane’s load, and their failure to communicate an emergency fuel situation to air traffic control before fuel exhaustion occurred. Contributing to the accident was the flight crew’s failure to use an airline operational control dispatch system to assist then during the international flight into a high-density airport in poor weather.” The other contributing factor should have come as no surprise since the NTSB uses the same “cause” in all major accidents: “… contributing to the accident … was the Federal Aviation Administration (FAA)”

The NTSB entered unchartered waters with Avianca 52. They approached this accident with little regard for what was important in the understanding of what happened or what the consequences were for getting the investigation wrong. This was the first tragic event that challenged, indeed called attention to, decades old Annexes created in the Chicago Convention of 1944.

At this time, I would like to thank my friend Oscar, who is my guru for all things International Civil Aviation Organization (ICAO). He used this accident in class as a case study to those understanding international aviation issues. There were three take-aways from the Avianca 52 that the FAA and ICAO put into place:

1 – The FAA International Aviation Safety Assessment (IASA) Program, which determined the quality of a foreign country’s oversight of air carriers operating inside another country, e.g. AVIANCA operating in the United States, and whether, e.g. Colombia’s oversight agency followed the safety standards of ICAO. This led to the development of ICAO’s Universal Safety Oversight Audit Program (USOAP), a means to audit aviation safety oversight, with scheduled and mandatory audits of ICAO States’ (Countries) safety oversight systems.

2 – Improving English language requirements for international flights as per ICAO Annex 1. English language has always been the universal language of aviation since the Chicago Convention in 1944; the cockpit voice recorder transcript demonstrated a breakdown in communication.

3 – The pushing of ICAO Article 83 bis. This was an amendment to the 1944 Chicago Convention and finally addressed issues that, in 1944, were unexpected with international travel. It allowed for specific oversight responsibilities be transferred between two States (Countries): the State (Country) of Registry and the State (Country) the aircraft is operating inside of. This allowed, not only provided for continuous oversight in foreign countries for airlines, but it would eventually include repair stations.

In the time between the accident and the NTSB report, Congressman Jim Oberstar (D-MN), Chairman of the House Transportation Committee (HTC), called then Associate Administrator in the FAA, Anthony Broderick, before the HTC to answer questions about what the FAA did to ensure foreign operators flying within the US were safe. Broderick’s response was that each State (Country), if they are ICAO members, has a Civil Aviation Authority (CAA), which had oversight to ensure the various foreign operators flying in the US were safe. The FAA had no authority over another country’s CAA; that the FAA was not authorized to audit a foreign CAA for compliance with ICAO standards. Avianca fell under the oversight of Colombia’s CAA.

HTC Chair Oberstar did not like that reply; he told Broderick to come back with a better answer.

What resulted was that Broderick took a team to other CAA offices around the world, armed with knowledge of the Air Transport Agreements’ Language, and one-by-one talked to each of them to determine the quality of oversight each provided to its operators in country and thus a better understanding of how they conducted oversight in other countries. The results were not promising; one CAA did not even employ Operations inspectors to oversee pilots, flight training, etc.

Broderick then put in work a program to ensure foreign operators had effective CAAs with qualified Airworthiness and Operations inspectors or they could not fly into the US. Under the International Aviation Safety Assessment (IASA) Program, the FAA could now ascertain another country’s quality of air carrier oversight; the FAA could now determine if the international CAAs were complying with ICAO’s 12,000 International Standards and Recommended Practices, especially those found under Annex One (Personnel Licensing), Annex Six (Operation of Aircraft) and Annex Eight (Airworthiness of Aircraft). Airlines that were assessed were those who had filed an application with the US Department of Transportation for a foreign air carrier permit, such as Avianca.

If the foreign CAA met ICAO standards, the air carrier was granted a Category One authority by the FAA. This allowed the air carrier from the assessed State (Country) to either initiate service within the US or continue to provide service into the US.

How did the NTSB miss this; why was this not in the report? Simply put, the NTSB did not do its homework. They did not try to understand the complexity of a foreign operator conducting service inside the US. The NTSB assumed the whole time that the FAA had authority, when it did not. The NTSB assumed that foreign CAAs’ oversight of air carriers was up to the standards of the FAA, which they were not. The Chicago Convention of 1944, the origin of ICAO, had taken place over forty-five years before, in the days of post-war, propeller-driven passenger airliners. The international aviation world’s perceptions of international travel were in desperate need of change.

It was unfortunate that this opportunity was squandered, this chance to generate positive change. It was a tragic opportunity that the aviation community did not wish to repeat in order to relearn what was missed with Avianca 52.

Yet, there was one more missed opportunity that was wasted, which was the pursuit of the Root Cause. All investigatory efforts were focused on the Avianca 52 flight crew’s poor command of the English language – their conversations sounded confused. The focus was on the desperation of flying with no fuel – a truth that was undeniable. The investigation, like a poor marksman, kept missing the target: Root Cause. What happened one hour and seventeen minutes before the crash, well before the fuel tanks went dry, well before things went south as the window of opportunity continued to narrow?

The answer will never be known because the question was never asked. Why did the crew not divert to Boston a half hour earlier? As the fuel fell to a decision-point level, what person – or persons – made the decision to stay in a holding pattern over Long Island? Didn’t one of the pilots argue to fly to the diversion airport? Was the culture inside the cockpit conducive to discussion or was the captain unshakeable? Was the airline responsible for driving the crew to land at JFK at all costs?

Culture continues to overpower common sense. Accidents such as Air Florida 90, Asiana 214, Lion Air 610 and Air France 447; each a tragic event where a sound aircraft was flown into the scene of the accident by indecision and poor communication skills. Cultural influences that caused Air Florida 90 only a few years prior to Avianca 52 were, and still are, an unknown, treated by the aviation community as a myth; an old wives’ tale akin to gremlins and the Bermuda Triangle.

It is past time the NTSB takes ‘culture’ seriously. Accidents, like Avianca 52, demonstrate that fifty-three years of the NTSB’s business-as-usual investigatory practices need to enter the twenty-first century; they need to embrace the reality of cultural divides within the industries they investigate. But industry is not hopeful; with apologies to Abba Eban, the NTSB “never misses an opportunity to miss an opportunity.”

Aircraft Accidents, Rip van Winkle and Longevity

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

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

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

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

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

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

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

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

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

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

What about the NTSB thirty-five-year veteran?

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned XXXIII: Swissair Flight 111

Swissair MD-11 in reconstruction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Ginger Rogers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned XXXII: Northwest Airlink Flight 5719

Picture by Douglas Bader

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and UAS Data, Part IX

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

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

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

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

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

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

The article raised three questions:

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

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

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

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

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

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

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

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

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

Aircraft Accidents, UAVs and Finding Nero

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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