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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Sabotage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aircraft Accidents and Lessons Unlearned XXIX: Eastern 855

On May 5, 1983, Eastern Airlines flight 855 departed Miami International Airport (MIA) bound for Nassau, Bahamas. The Lockheed L1011, registration number N334EA, was almost twenty minutes out of Miami when the #2 engine low oil pressure light illuminated. The Captain shut down the engine and made the decision to return to MIA.

As the aircraft turned back to Miami, it was climbing through 20,000 feet, when both the #1 and the #3 engines’ low oil pressure lights illuminated. Ten minutes later the #3 engine flamed out; the aircraft was now flying on one engine and still fifteen minutes from MIA; #3 engine’s bearings had turned to molten slag. The crew attempted to restart the #2 engine, but the #1 engine flamed out, its bearings seized. The aircraft descended from 13,000 feet to 4,000 feet without power, not unlike a glider. At 4,000 feet the crew restarted the #2 engine and the L1011 limped back to MIA on one engine.

Losing one engine was normal training for the crew; though not common, an engine-out was not outside the realm of possibility. Even a two engine-out scenario was a training scenario, but it was less likely. All three engines out, even with the same symptom – an engine low level light preceding a flameout – was statistically impossible. And yet, apparently, it was not.

The emergency was brought about by the absence of magnetic (MAG) plug chip detector O-rings, normally installed with the MAG plug in an engine’s oil system following a MAG plug check. This check required the MAG plug be removed from the engine, the magnetic probe checked for metal contamination and then reinstalled with a new O-ring to seal the plug to the engine port. A MAG plug check was (and still is) a normal maintenance item accomplished on the engine manufacturer’s dictated schedule. The three engines had a scheduled MAG plug check performed. The oil in each engine was depleted during the short flight time before the crew turned back for MIA.

All three engines were worked on by two mechanics; one worked on numbers one and three engines and the other worked the number two. The MAG plug kits the two mechanics used on N334EA contained the replacement MAG plugs, but without the O-rings. The mechanics, and other mechanics in Miami, usually received the kits, complete with the O-rings. This was a contributing cause of the accident.

The mechanics, accustomed to having complete MAG plug kits never verified that the O-rings were on the plugs before installing them. They then performed a leak check for the engines to confirm that the plug installations did not allow oil to bypass the MAG plugs. However, the time that the mechanics spent on ‘motoring’ the engines was inadequate: ten seconds; the oil did not have enough time to flow through the system to where the MAG plugs were. A second contributing factor to the accident.

There were these two contributors and one root cause that led to the accident flight. The first contributor: the mechanics’ failure to check the kits for the O-rings. The mechanics had been lulled into a false sense of security by having complete kits handed to them. Both mechanics were still responsible to verify the O-rings were included in the kits and installed with the plugs. The rut the mechanics fell into was complacency. When they performed a redundant task so many times, they assumed they knew the job by heart, e.g. replacing a tire or servicing oxygen. Due to modifications or even accidents, maintenance manuals are revised with different torques or an extra step to prevent a problem already identified. It is the mechanic’s responsibility to make sure the job is done right. No matter how often a job is performed, the manual must be checked for changes and a component for complete parts.

The second contributor: the inadequate amount of time spent ‘motoring’ the engine. The job card should have identified the motoring time needed for a proper engine leak check. From my experience running engines, you can motor an engine for at least two minutes without starting it; after that time the starter could be damaged. Two minutes was enough time for a proper leak check. Another issue was gate time, as in ‘the time before the aircraft is to be on the gate for the next flight’. Rushing through a job to meet an ETC – [pronounced ETIC] (Estimated Time – Completed) – to make a flight departure time, could push the safety limits by employing shortcuts.

The root cause, however, was culture. Had this plug problem happened at other air carriers? Delta, Pan Am, TWA and other carriers flew the L1011; did they have problems with incomplete kits or destroying an engine due to oil starvation? What part did Maintenance Planning play? Management? The Engine Manufacturer, Rolls Royce?

Or did this only happen at Eastern Airlines? Did the culture at Eastern or perhaps only at the Eastern Miami maintenance facility, contribute to the confusion about MAG plug kits? Did the National Transportation Safety Board (NTSB) go to the Eastern maintenance facilities in Kennedy airport, Atlanta or Boston to determine if the problem was limited to Miami? No? They did not? Why not?

Culture issues; they have been contributors to many accidents since 1983. Culture issues have plagued mergers over the last few decades. Culture problems have not been limited to Maintenance but have emerged in Operations (Asiana 214), with cargo contractors (Fine Air 101) and maintenance providers (ValuJet 592). Yet with these and many other accidents, culture issues were never mentioned in accident reports; indeed, culture has never even been looked at as a viable issue. Was it because culture issues never existed or was it because culture issues were never thought to exist?

With Eastern 855, universally accepted complacency was the Eastern Miami maintenance facility’s five hundred-pound gorilla, the elephant in the room. The mechanics’ failure to be diligent and the time-related practice of inadequate leak checks were traceable to the Eastern Miami maintenance facility’s culture. To list all the wrongs that led to Eastern 855’s near ditching at sea would take more than one article could handle; Eastern and the 172 souls aboard flight 855 dodged a major bullet. If other air operators had learned what there was to learn from Eastern 855, many more lives could have been saved.

Randy Pausch, professor of computer science at Carnegie Mellon University, once said about the ‘elephant’ metaphorical idiom, “When there’s an elephant in the room, introduce him.” The industry, e.g. airlines, repair stations, manufacturers, etc. know there are cultural problems in their ranks – they know this. Unlike human factor issues, these are indigenous to the certificate holder and to the groups within.

Safety conversations with Federal Aviation Administration inspectors could result in an unbiased view of an operation’s culture, undetectable from the inside. An outside auditor can identify recognizable patterns that lead to major mistakes. Relying on management to unearth any culture problems would be a dead end when they could be part of the problem. If a certificate holder expects the NTSB to help, they usually show up in connection with an accident. It is unlikely the NTSB would find the culture problem.

Culture issues are the Lessons Unlearned that have led to numerous accidents since May 5, 1983. Although rarely recognized, culture problems have been major contributors to accidents; the root cause overlooked in favor of probable cause. We should not have to wait another thirty-six years for someone to point it out.

Aircraft Accidents and Taking Vacation

Last month I flew with my wife on vacation; I coughed up the money for First-Class. Unfortunately, First-Class is not even a whisper of what it used to be, but that was not the most interesting part of my First-Class vantage point, which was the front-most seats on the right side of the plane – not a regional airliner but a narrow body – right where the passengers first enter the cabin.

The first incident involved a passenger who stowed an electric wheelchair in the closet across from the First-Class lavatory. Not a problem, happens all the time. The flight attendant (FA), who was the only one in this event who displayed any sense of professionalism and safety-mindedness, confronted a woman, the daughter of the wheelchair’s owner, an elderly woman sitting with said daughter twenty rows back. The FA requested that the daughter separate the battery from the wheelchair and keep it with her; the wheelchair battery was a small unit that stowed easily in the overhead compartment, under the seat or in a purse.

The middle-aged daughter began arguing with the FA, firmly stating, over and over, that she had never been asked by the airlines to do this before, that she leaves the battery attached “all the time”. The FA did not back down and even relented to ask the Captain out to the discussion … you know, to support her.

And this is where it got silly. The Captain, who had every reason to support the FA, to tell the daughter if she did not like the conditions she could disembark, instead called his operations department people to see if the woman could leave the battery attached. My wife kept half an eye on me to see what I would say or do. My safety spidey-sense was tingling but I sat quietly and watched the drama from the aisle seat.

Before anyone insult the FA, understand that there have been documented cases I have read where wheelchair lithium batteries have overheated and burst into flames because the controls were crushed up against a wall, a coat or a box. I have seen wheelchair battery fires that had been filmed where the chair’s controls were locked into the ON position, before causing an unquenchable fire in the belly compartment of the aircraft, fortunately while still on the ground. Even with all available extinguishing agents brought to bear, they could not extinguish the blaze until the wheelchair was completely consumed, almost taking the loading equipment with it.

I understand that this Captain did not represent the thousands of captains who take charge of their flights. In fact, the gate agent should have stopped this incident before the wheelchair was even loaded on board. However, no measure of pressure from a passenger should ever make the crew accountable to anything other than the safety of the plane and those onboard. And before I come under attack, I have been working with the airlines for thirty-seven years. I, as a mechanic, had many dealings with airline captains of either gender who demonstrated absolute control of any situation on their airplane. Are airlines so cowed; are they now folding to the pressure produced by entitled passengers who don’t get what they want? I hope not; there were plenty of young children on that flight whose safety was paramount.

Then there was the return flight.

On the flight back, my wife and I sat in the same seats on the same model aircraft. Before boarding, we were waiting by the gate area. An elderly woman in an airport wheelchair was waiting to board. In the cushion-filled baby stroller she pushed in front of her – that’s an elderly woman … in a wheelchair … pushing a baby stroller – was a Shih Tzu dog. She was apparently not wanting to draw ire from anyone so the Shih Tzu had a leash – a pink leash – with the words ‘Service Animal’ emblazoned in gold letters.

Its name was Bitsy-boo.

But wait, there’s more.

When the woman boarded, she took the aisle seat across from my wife and I … of course. The dog took its place at her feet – she originally had the dog sitting in the window seat until the gentleman who bought the seat showed up. The dog remained loose at the woman’s feet the entire flight, sleeping on the airline supplied pillow and blanket … you know, the one you probably used on your flight, the one you put up against your child’s face. I never use those pillows or blankets because I never see the planes swap them out at the gates. Chalk that up to airline travel experience.

This Shih Tzu rolled its whole fur-covered body all around on that blanket/pillow combo; its … whole … body. The blanket/pillow combo was rubbing up against that nice clean floor. Then the woman took the dog into the lavatory and when she returned to her seat, the dog put its lavatory exposed paws all over the blanket/pillow combo … that other people, some who have dog allergies, will place up against their faces.

According to an August 8, 2019, article in airlines.org: http://airlines.org/news/airlines-for-america-applauds-department-of-transportations-guidance-on-emotional-support-animals/ titled: Airlines for America Applauds Department of Transportation’s Guidance on Emotional Support Animals, Airlines for America (A4A) the industry trade organization for the leading U.S. airlines stated, “Airlines for America applauds the Department of Transportation’s enforcement guidance on emotional support animals (ESAs). The availability of fraudulent ESA credentials online has enabled people who are not truly in need of animal assistance to abuse the rules and evade airline policies regarding animals in the cabin. With over a million passengers bringing ESAs on flights last year, airlines and airports saw a sharp increase in incidents such as biting and mauling by untrained animals.”

The flood of ridiculous ESA approvals have made modern politics look sane by comparison. ESAs, e.g. peacocks, full grown sows, cats, exotic birds, snakes, turkeys and even miniature horses – I kid you not, look it up – have represented a selfish corruption of the Americans with Disabilities Act’s intent, to allow passage for trained service animals to accompany their owners, e.g. a blind person’s seeing eye dog or a veteran with post-traumatic stress disorder. These are people with a true need and their animals are specially trained for dealing with emergency situations. Why is this important?

I took part in a Federal Aviation Administration (FAA) cabin fire simulation. The FAA demonstrated the reality of an onboard fire and evacuation; it was quite illuminating. The simulation could not reproduce all the effects of a real onboard fire, e.g. noxious smoke, debilitating heat, screaming, disorientation, injuries, shock and the constant shoving, but what it could duplicate was real enough.

I could barely see the hand in front of my face. The floor lights were hardly visible and were distorted in the smoke. The direction of voices became confused. People stepped in front of me, knocking me aside or others pushed me from behind. It was nearly impossible to determine where the exit was. Most evident was the subliminal instinct for survival, not just mine but everyone’s survival.

Now imagine a real onboard fire with all the effects the FAA could not duplicate. Then add in a Shih Tzu named Bitsy-boo, scared senseless, dragging a pink ‘Service Animal’ leash, tripping children separated from their parents, biting whoever is in its way, causing other passengers to pile up on the floor like cordwood. The body count adds up; the count is not limited to the old and feeble but includes the young and helpless.

Common sense does not always prevail; in some cases, common sense takes years to be brought forward; look at Congress. Meanwhile the innocent suffer for the selfishness of the entitled. There are no ‘constitutional rights’ when it comes to aviation; no one owes anyone, anything, whether it’s a soft drink, a full-length movie or a place for your pet to sleep. What is required, however, is that everyone who flies must be offered the chance to do so in the safest manner possible. That is what you pay for each time you purchase a ticket. As a travelling public, is that what we are getting?

Aircraft Accidents and Lessons Unlearned XXVIII: TWA Flight 6

Photo by Bill Larkin

On May 6, 1935, a Transcontinental and Western Air Incorporated Douglas DC-2 crashed near Atlanta, Macon County, Missouri. The Secretary of Commerce, as per section 2 (e) of the Air Commerce Act of 1926 dispatched two investigators to the site. All information for this accident was taken from the Air Commerce Bulletin Volume 7, Number 1, published in Washington, DC, July 15, 1935.

This accident investigation was accomplished in the days when accidents were common, not because of what was NOT available in technology but because the aviation community was learning how to convert a new industry into a civilian use. The United States’ entry into World War II was six years away and the fruits of the Chicago Convention of 1944 were exactly three years after that. Navigation equipment, autopilot, weather forecasting were decades in the future and even further along from perfecting.

After refueling at Albuquerque, New Mexico, the plane was cleared to fly to Kansas City, Missouri, despite the western night frequency of the aircraft’s two-way radio was non-functional. This prevented the flight crew from communicating with any ground stations for weather information or flight instructions.

When the flight reached Wichita, the ceiling dropped to 600 feet, a much lower ceiling than allowed for such a flight was authorized to fly, which was 700 feet. To be clear, weather forecasting in 1935 was antiquated by today’s standards; no Doppler radar, no satellite imaging and no 24-hour communications from other airports across the US. What exacerbated the situation was the airplane’s lack of air-to-ground radio communications, leaving the flight crew blind and deaf to any obstacles in the flight path. The air carrier’s ground station in Kansas City managed a one-way communication on the company frequency, directing the flight crew to attempt a landing at Kansas City despite the ceiling being so low.

Low on fuel, the pilots brought the aircraft below the clouds at Kirksville; for more than two miles, the aircraft flew low over slightly rolling terrain in scattered fog and mist. While navigating a low depression near the ground, the aircraft dipped its left wing to go around fog; the left wing dragged into the ground, throwing the aircraft out of control.

The investigation relied heavily on witness statements from those in Kirksville who saw the plane as it appeared and disappeared through the low clouds. Estimated altitudes, air speeds and engine noises proved to tell the final seconds of Flight 6. The days of cockpit voice recorders and flight data recorders were years away; minimum equipment lists were the result of accidents such as this.

Transcontinental and Western Air (TWA) flight 6 was unique for two reasons. First that the limited investigatory technologies available at the time did not hinder the investigators from completing a timely and efficient report; indeed, the report was completed in three months with valid recommendations The second reason was one of the accident victims, forty-six-year old Senator Bronson Cutting (R-NM), his death on this flight helped redirect a major change for the aviation industry.

The accident investigation was excellent in its simplicity. In the absence of any other fantastic outside contributors, e.g. ground witnessing of an engine fire; a barn or other farm structure in the airplane’s path or lightning strikes, the investigation focused squarely on the facts. Because the investigation did not veer into any bureaucratic nonsense or was belabored by ‘expert’ grandstanding, the recommendations were straight to the point; they hit the problems square on the head without any maybes or analytical side stepping. TWA flight 6 was a case study in root cause analysis in the days before root cause analysis.

Root cause analysis, used regularly by Federal Aviation Administration (FAA) inspectors, breaks down a problem to its lowest denominator, often by asking WHY, then subsequently asking WHY to every answer until the final answer cannot be broken down any further. This is evident in the findings where the cause was not the airplane dragging its wing into the ground but in that the airplane had been flown so close to the ground due to radio problems before dispatch (Recommendations b, c and d).

From this accident effective recommendations were written, including:

  • The installation of instrument approach facilities at airports;
  • Licensing of airline dispatchers;
  • Improved fuel reserve regulations;
  • Rules dictating pilot flight-time limitations.

These recommendations were proactive; more importantly, they stayed on topic, which was aviation safety. The same cannot be said today about recommendations today that tend to go off topic and wander into agenda items. Furthermore, today the focus is on ‘probable’ cause, not root cause; this is the equivalent of a ‘maybe’ cause, what might have happened, not necessarily what did happen.

It is also indicative of how accident investigation has become overly complicated. This accident took less than three months from the tragedy to the publishing of the recommendations and findings. The average National Transportation Safety Board (NTSB) aviation investigation takes over a year; months pass before an initial update is even released. For instance, Atlas 3591 occurred over five months before this article and no update; this is unbelievable.

The NTSB uses every available technology and dozens of investigators (TWA flight 6 – two investigators), yet in the time between an accident and the first update, a reoccurrence of the same circumstances that caused a first crash can be duplicated.

The second consequence of the TWA flight 6 accident was the death of Senator Bronson Cutting (R-NM). The death of a member of Congress was not remarkable except for the Senator’s loss became the catalyst to move towards separating Commerce from Transportation. The Civil Aeronautics Authority Act of 1938 was adopted in the aftermath of Senator Cutting’s passing. This Act formed the Civil Aeronautics Board, the predecessor of today’s FAA.

The transfer of aeronautics from Commerce to Transportation took responsibility for aviation out of the commerce field; aviation agencies had moved from the oversight of business (under Commerce) to the oversight of safety. With the admission of the US into World War II, other changes would occur, including the introduction of the International Civil Aviation Organization (ICAO), which launched the US and its allies into the international air market in 1945.

TWA flight 6 was a standout accident investigation, especially for its time. Qualified investigators were focused, their attention on safety and what needed to change. Findings and Recommendations were clear; their purpose was to improve aviation, not mire it in ambiguities. The fledgling industry embraced new technologies, modifying their techniques to adopt the new technologies and foster innovation. Most importantly, there was no arrogance, no pride. Aviators knew their limitations and those investigating accidents knew theirs. And because of this, the aviation industry grew to what it is today.

Will it stay safe?

Aircraft Accidents and Memories

Fifty years ago, Apollo 11 took off for its historical moment: the first two men to walk on the Moon. I say two because it was not a one-man gig. Anyone cognizant in the Summer of ’69 has fond memories of Neil Armstrong stepping off the ladder and onto the parched white surface of our favorite satellite. His first words were emblazoned on our American hearts for decades as we cheered, “U-S-A! U-S-A!”, while giving raspberries to Russia.

It is hard to forget important events, those that stand out as milestones, both tragic, like nine-eleven, and wonderful, like the 1976 Bicentennial. Unfortunately, we forget the tragic lessons too early; sometimes we choose to, and others are lost to a preoccupation with other matters. The less spectacular the tragic event, the sooner we push it to the back of our minds. In aviation, if the fatality rate, for instance, is low, we, in the aviation industry, tend to forget.

Incidentally, does anyone remember Atlas flight 3591? One hundred and forty-seven days ago? Outside Baytown, Texas? The Miami-to-Houston flight, a Boeing 767-375BCF, suddenly plunged into the swampy waters of Trinity Bay with little indication of an emergency.

The National Transportation Safety Board (NTSB) launched immediately. According to the NTSB website, they were at the accident scene within hours with the usual cadre of NTSB engineers; they found the flight data recorder and cockpit voice recorder and after several days of recovery returned to NTSB Headquarters. On March 5, 2019, the NTSB website posted a report titled, ‘NTSB Laboratory Completes Initial Review of Cockpit Voice Recorder, Recovers Flight Data Recorder’. The report just stated that the recorders’ data were being reviewed.

But then something happened: Ethiopian Airlines flight 302. The B737-MAX crashed shortly after takeoff on March 10, 2019, a mere fifteen days after Atlas 3591. One hundred and fifty-seven people lost their lives on Ethiopian Airlines 302, but it was worse because another B737-MAX crashed over four months earlier. On October 29, 2018, Lion Air flight 610 crashed with a loss of life at one hundred and eighty-nine. In four months, the B737-MAX was involved in two similar accidents costing three hundred and forty-six lives. The B737-MAX was grounded; intense scrutiny of the aircraft had begun.

As it should have. It was one thing to crash under different circumstances, but the two MAX accident causes were too close for coincidence. And yet, the NTSB was not the lead investigatory group on either accident. They did assist, but the lead roles belonged to the National Transportation Safety Council (Lion Air) and the Ethiopian Civil Aviation Authority (Ethiopian Airlines).

What, then, was on the NTSB’s plate? The NTSB’s Director for the Office of Aviation Safety, in a speech at the 2018 Embraer Safety Stand Down in Wichita, Kansas, said of the Title 14 Code of Federal Regulations (CFR) Part 121 operators that accidents among these air carriers, “is a very short conversation. It’s the sound of crickets … they’re just not happening anymore in the U.S.” Unbelievable! That ‘inspired’ comment was good to know because then that meant that the NTSB was not too busy to update the industry about the Part 121 operations flight Atlas 3591, seeing as, you know, Part 121 accidents, “they’re just not happening anymore in the U.S.”.

Where were the updates? Consider American 587, the A300-600 that crashed November 12, 2001. Long after terrorism was ruled out, the NTSB provided seven updates in the first five months after the accident. Atlas 3591 has had only one update in the five months since February 23, 2019. On March 12, 2019, the NTSB posted to its website for Atlas 3591, accident number DCA19MA086, the only accident update, concluding with the final sentence, “Additional Information will be released as warranted.” That additional information has not been updated for one hundred and thirty days.

Why, then, has Atlas 3591 practically disappeared off of the NTSB’s update pages? What were the differences in the four flights just discussed? American 587 resulted in 265 deaths; Ethiopian Airlines 302 had 157 deaths; Lion Air 610 resulted in 189 killed. Atlas 3591 had three pilot fatalities. There is no suggestion that accident priority is focused on fatality counts, although when I worked as an NTSB investigator, I investigated at least two Title 14 CFR Part 121 accidents that received … less than adequate NTSB Office of Aviation Safety attention: Colgan 9446 and Emery 17, two and three pilot deaths, respectively. It would be unethical to pick which accidents are to receive full NTSB investigation resources by the fatality count, especially when accident investigation generally has nothing to do with the lives lost; it is about why the plane crashed.

To be candid, it is obvious 99% of the time, why accident victims perish, e.g. blunt force trauma, asphyxiation, post-crash fire. These injuries are consequences of the accident; in most cases, they are not the cause of the accident. A lot of accident related information can be gathered from the victims, e.g. damage to the face and hands, smoke in the lungs or symptoms of an explosive decompression; again, these injuries are the results of the accident, they are not the cause. All victims’ families want to know why their family member died just as much as how they died. In my monthly series Lessons Unlearned, I do not mention victim counts. As an NTSB accident investigator, it did not matter how many people were killed in the accident I investigated, whether it was the three pilots in Emery 17 or all 265 in the plane and on the ground with American 587. Emotions were distractions; sorrow was a luxury I could not afford if I wanted to be partial, effective and analytical. My job was to find the accident’s root cause … period. That happens to be the NTSB’s job as well. Or does the NTSB settle on probable cause?

Why would Atlas 3591 be important? Because it is not about the fatality numbers; it is about the chances, as in: What are the chances another B767 has a similar problem? Shouldn’t the question be: What are the chances another CARGO B767 has a similar problem? No, it should not. Cargo aircraft only differ from passenger aircraft because of the upper deck; one has seats and the other has cargo restraining devices. Some differences may be a little deeper, but not too deep. The truth is that what caused Atlas 3591 to fall out of the sky could very well cause a passenger version to fall out of the sky, as well. Which means finding Atlas 3591’s root cause could save hundreds of lives.

One might argue that the cargo aircraft could have been out of balance due to freight misloading. Not likely from what the industry knows of Atlas 3591 so far. If the aircraft was nose heavy, the pilots would have noticed long before arriving at Houston and would have benefited from the spent fuel. Tail heavy? True, burning off the fuel would have moved the center of gravity aft; with flaps extended and airspeed reduced, this would have presented a recipe for trouble. However, the NTSB did not report that the plane suffered an aerodynamic stall, but that it fell nose first. The March 12th update stated, “FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent.” If the NTSB has contradicting information, then it is important they provide it.

The point of this speculation is to drive home the point that, aside from any phantom cargo issues, the events that caused Atlas Air 3591’s B767 to crash might very easily happen to a passenger B767. There are, at last count, over eleven hundred B767s manufactured, most of them in passenger service. Some versions of the B767 can carry 375 people; that’s almost as many fatalities as Ethiopian Airlines 302 and Lion Air 610, combined.

Many B767s are ETOPS qualified, meaning Extended over Water Twin Engine Operations. An ETOPS airplane is qualified to fly on one of the two engines, while cutting across the ocean. The ETOPS aircraft does not operate on only one engine; in an emergency, however, where the second engine fails, an ETOPS aircraft can operate on the remaining engine to the nearest airport that may be hours away.

Determining the root cause(s) of Atlas 3591 cannot be ignored or delayed; they must be discovered. The memories of the accident are short lived; people forget just what they should not, that this is in the best interests of the flying public; a tragedy waiting to happen … again. The NTSB needs to stop worrying about the B737-MAX; it is grounded and not flying anytime soon. Get back to Atlas 3591 because it is … that … important!

Aircraft Accidents and Lessons Unlearned XXVII: United 811

On February 24, 1989, while climbing out of Honolulu, Hawaii, passing 22,000 for 23,000 feet of altitude at 300 knots of indicated airspeed, United flight 811, a Boeing B747-122, tail number N4713U, suffered an explosive decompression. The forward cargo door separated from the lower fuselage. At its departure, the door damaged the right wing, numbers three and four engines; the right wing’s leading-edge devices, the fuselage, the right horizontal stabilizer and the vertical stabilizer as it fell away. Due to the violent nature of the door’s separation, a fuselage section above the cargo door, measuring thirteen feet lengthwise and fifteen feet vertically – to the first-class passenger windows’ level – tore free and away from the aircraft. The captain executed an emergency descent with a left turn to return to Honolulu where the plane landed safely, per Accident report AAR-92/02; accident number DCA89MA027.

Navy radar in the vicinity of Honolulu tracked the debris as it fell into the Pacific Ocean. The forward cargo door had been split in two pieces; the two sections were recovered from the ocean floor nineteen months later, on October 1, 1990. Within a year and a half, the National Transportation Safety Board (NTSB) had the necessary pieces to connect the dots, figure out how the door failed. More importantly, they could learn, Why.

Cargo doors are intricate devices, whether they are hydraulically operated main cargo doors, manually operated narrow body belly doors or electrically operated wide body belly doors; precise mechanical motions are synchronized to take place at specific times. However, the fundamental workings of a cargo door are simple: sequential order. The first sequence is the door open/close actuator which raises and lowers the door. As the closing door reaches the doorframe, the door actuator cuts out; a second sequence occurs where the door is pulled in tight against the frame. This signals the third sequence: the locking device; the door is captured and secured in place.

Three forces would have worked on Flight 811’s forward cargo door, causing the catastrophic results. The first is the internal pressure of the aircraft acting to open the door; over one hundred pounds per square inch were pressing against the 99” by 110” door’s inside surface. Simultaneously Bernoulli’s principle explains the second force acting on the door’s exterior, like lift on a wing: “An increase in the velocity of a stream of fluid [air] resulted in a decrease in pressure;” the decrease in pressure on the outside pulled the door away from the fuselage. Once the door was ‘pushed’ open, the third force, the airstream around the plane, tore the door away at 300 knots.

Much of AAR-92/02 report’s damage descriptions were confusing; the pictures used were poor quality and suggested that the NTSB investigators should have employed more technical drawings that would have translated better. Unfortunately, the NTSB failed to use maintenance experienced investigators to explore the maintenance issues.

The report’s maintenance records were documented between December 5, 1988 and December 30, 1987. Eleven times between these dates, the forward cargo door was written up as non-functioning electrically, resulting in the alternate method being employed: manually closing the door, a proven safe practice. However, United ignored the repetitious nature of these write-ups and failed to fix the problem, instead they postponed the fix indefinitely. The NTSB investigators did not pick up on this history finding, then failed to show any forward cargo door maintenance history from December 30, 1988 to the accident.

Instead, the NTSB maintenance investigator focused on a trivial matter as stated in Finding 16, “The smooth wear patterns on the latch pins of the forward cargo door installed on N4713U were signs that the door was not properly aligned (out of rig) for an extended period of time, causing significant interference during the normal open/close cycle.” As stated above, the door was under several forces during each flight. The cargo door’s latches were going to make ‘smooth wear patterns’ as the door leans into the latches. The latches also contacted the pins as the latches moved around them. This was normal.

AAR-92/02 related to a similar incident involving Pan Am flight 125, a B747-122, where, during flight, the cargo door was open one and a half inches along the bottom edge with the latch cams unlatched. Pan Am 125 returned to its origin due to a problem with pressurization. The NTSB used this incident as a ‘told-you-so’ moment to both Boeing and the Federal Aviation Administration (FAA), to say that the NTSB’s warning was unheeded, that the same thing happened with United 811.

However, Pan Am 125 and United 811 were fundamentally different. Was the event of Pan Am 125 dangerous? Yes. But to compare the two flights was a distraction; it focused away from United 811’s unique issues, that would have pointed to United 811’s root cause. On Pan Am 125, the door was never completely closed, pressurized air bled out of the gap, decreasing the pressure that would have pushed the door open. The pressurization forces were entirely different because the opening never allowed the forces to build up on the door. The NTSB’s attempt to draw comparisons did nothing to increase safety or knowledge of the root cause; instead it wasted time.

Throughout the report, the NTSB investigators stumbled through the various conclusions, some findings having had nothing to do with the accident, e.g. Fire and Rescue truck paint schemes. With the cargo door’s recovery, the root cause should have been definitive. Instead the NTSB resorted to a guessing game, probable causes were made in error that focused on one or two inconclusive reasons for the explosive decompression but, in the end, AAR-92/02 established nothing.

What, then, caused the forward cargo door to depart United 811? Without the evidence available at the time to study, all one can do is speculate and speculation is useless. It was clear that the use of megaphones (Finding 24) or the Fire and Rescue trucks’ camouflage paint job (Finding 23) never contributed to the accident. However, as a former aircraft mechanic, one who had worked many cargo doors, there were several issues I expected the NTSB should have focused their attention on.

The last maintenance performed on the cargo door was the replacement of a mid-span latch pin due to gouging. Wearing was a common consequence of normal cargo door use but gouging meant the door may have had a single latch out of rig, perhaps more than one. Gouging could have also signaled a timing problem, that the latch was out of sync with the other latches. Did the NTSB ask to see the replaced pin, if that was possible? What about the new pin; was it showing early signs of gouging. According to the maintenance records, since 1984, “… a full cargo door rigging check had not been accomplished.” If an NTSB investigator experienced in maintenance were available, he would have found the gouges to be an item of interest, certainly of a more focused examination.

The most unusual item in the maintenance history, however, was the adjustment of the S-8 switch on December 14, 1988; the NTSB investigator did not give this a second look; the S-8 switch and the gouged pin never made it into the Findings. The S-8 switch was the Hook Close Switch; this switch sequenced the two ‘Pull in’ hooks to rotate over the doorframe pin, which pulled the cargo door flush with the fuselage. If they resembled the B727 main cargo door’s ‘Pull in’ hooks they had duck bill shaped grooves that captured the pin and, as they rotated, pulled the door tight against the doorframe. The locking cams then easily rotated to the closed position, which secured the cargo door in place.

What if the S-8 switch was adjusted incorrectly on December 14th? What if the ‘Pull in’ hooks rotated early or late; would it have captured the pin or, instead, would the hooks have slid behind the pin? Why did the NTSB not assure the S-8 switch had been inspected by a quality control inspector? If it was not, was that a policy violation; a preventable cause? We will never know.

AAR-92/02 was typical of many accident reports reviewed on this site: heavy on the blame but light on the root cause. Later accidents continued to display signs of previous accidents, not because FAA inspectors did not do their jobs, or the industry did not do what’s right but because time and energies were misdirected; opportunities were wasted on inexperienced guess work. Aviation will not become safer when the resources to make it safer are ignored or ill-used.

Aircraft Accidents and Consequences

In the 1957 cartoon, Ali Baba Bunny, my hero Daffy Duck learned an important life lesson. Having recently acquired a Sultan’s fortune, he cleaned a tarnished lamp, releasing a genie. Afraid the genie was after his new-found riches, Daffy stuffed the genie back in the lamp, thus “desecrating the Spirit of the lamp”, angering said genie, who pointed out that Daffy would now suffer the consequences. Daffy responded, “Consequences, schmonsequences, as long as I’m rich.” The genie then shrunk Daffy to the size of an oyster, denying him the chance to enjoy the wealth he was now too little to transport.

It is amazing how people constantly desire things that lead to more dire consequences. If only they had the foresight to see beyond the wish. They are like children who repeatedly forget important lessons, e.g. ‘DO NOT touch a hot stove’. W.W. Jacobs said, “Be careful what you wish for, you may receive it,” which applies to the Daffys of the world, all good intentioned people looking for the short-term fix, that evolve into uncontrollable long-term problems.

In a June 5, 2019, a Maintenance, Repair and Overhaul’s website MRO-Network.com article titled: U.S. Lawmaker to Introduce Bill on Aircraft Maintenance Disclosure (Goldstein, Broderick), U.S. Rep. John Garamendi (D-California), a senior member of the House Transportation & Infrastructure (T&I) Committee, wanted to reintroduce legislation “… that would require [air] carriers to disclose more information about their maintenance activities to the public.” This lofty, indeed silly, goal only echoed a sensible American’s view of U.S. lawmakers as, “a bunch of Sideshow Bobs stepping on a field full of rakes.” Important Note: Sideshow Bob is another cartoon character intent on embarrassing himself.

My articles are not usually this cynical, but this bill is too ridiculous. Congressman Garamendi was quoted as saying, “As a person who spends at least 5,000 miles a week on an airplane, I want to know that airplane is well maintained, and I want to know where its maintenance was done, so I can hold that airline accountable.” Question: How does one spend 5000 miles a week on an airplane anyway? It appears the congressman’s “5000 miles a week” claim is his only aviation experience qualifier. Per his website, since 1974 Garamendi has been a career politician, who moved from bureaucratic position to bureaucratic position to … wait for it … a bureaucratic position. He has zero experience in aviation or business. The congressman says he is a ‘Rancher’; that is either a career choice or a tasty salad dressing. Either way, Garamendi has had nothing to do with commercial aviation.

Aircraft accidents are tragic events. Meeting with family members who have lost a child or spouse is heart-wrenching and humbling. However, in any tragedy’s aftermath, one should never overcompensate with impractical band-aid solutions; it is inane. Numerous lawmakers, unfamiliar with aviation, cultivated emotional crusades for ‘change’ that duped the victims’ families and provided false solutions, all the while exploiting the families’ losses.

The bill”, the article says, “would require carriers to display notices providing the public with the location at which aircraft most recently underwent heavy maintenance, as well as the dates of such maintenance. That information would have to be “prominently displayed” on carriers’ websites and boarding documents, and airline workers at the ticket counter would be required to communicate it clearly to passengers.” Who thinks up this stuff? This statement illustrates, with blinding clarity, Garamendi’s ignorance of what goes into maintaining commercial airliners.

A displayed notice is not like listing a burger’s ingredients on a fast food menu or what fat content French fries have. Major carriers, e.g. American or Delta, have roughly eight hundred aircraft – each – in their fleets. Those aircraft may be maintained in ten to fifteen different major repair stations, worldwide. The ‘display notices’ list will get quite long, considering that any airport could receive any tail registration number in any airline’s fleet on any given day. That is fifteen times the number of airliners per an airline’s fleet, e.g. one hundred and fifty B737-800s.

It is not clear whether the requirements would extend to the component level,” stated the article. What a foolish reflection; of course it would extend to the component level. If not right away, soon enough. Remember, this is the US Congress; They’re not happy until you’re not happy. In that case, multiply the fifteen repair stations by hundreds of certificated component repair stations contracted to the major repair station. Ailerons removed for reskinning and balance are not outsourced to the landing gear overhaul shop. Countless contractors chrome cylinders, repair composites or specialty service thousands of components in each aircraft. Then there are all those numerous engine and propeller repair stations. Do each of these contractors make Garamendi’s ‘display notices’ list? “Be careful what you wish for …

So, the question is: Why? Why pursue this information? Does listing each contract repair station give Jane C. Passenger a warm feeling of security before her business flight? Would Joe Q. Tourist even recognize terms, e.g. metal quenching, balancing or resin infusion to forego that Disney vacation? What about Congressman Garamendi; would he understand what overhauling an Inertial Drive Generator requires? My high school buddy regularly flies to Ireland for business; maybe I should get him a deck of ‘D’ phase check work cards, you know, to read on the plane.

The silliness continues because it doesn’t stop here. Next, they will want airframe and powerplant certificate numbers because …  something-something about safety. List their work hours or what trade school they went to; what branch of the service they trained in. Need more safety? Pilots’ should post their photos just like a taxi driver. Why? Because Garamendi’s years of inexperience tells us it’s safer.

Then Garamendi speaks candidly, “… there is a ‘structural problem’ at the FAA posed by the agency’s sometimes contradictory dual mandates of protecting safety while promoting U.S. industry.” That statement is followed by Garamendi’s underlying theme, “We’ve made a choice to allow that conflict to exist within the FAA, which led to 346 people losing their lives because getting [the MAX 8] up and running was more important than getting the issue resolved.

Ahh, there it is! He’s an expert! A throat-catching emotional crusade, using those families’ pain for his agenda. Those MAX 8s are grounded, still being investigated. But Garamendi knows what happened because aviation ‘experts’ speculated about the MAX 8 crashes. Garamendi will now save us all.

This is the danger of inexperienced speculation. This is why speculation is wrong. Speculation leads to foolish ends. Speculation fans the flames of fear while crushing reason.

What is even more frustrating, beyond the shameless mendacity, is the time, energy and money wasted on this lawmaker’s efforts. As our country struggles through many important challenges, Congressman Garamendi wants to skew our attention to … a shiny set of keys; a bridge to nowhere; a distraction.

But let us assume Congressman Garamendi’s intentions are honorable, that he wants to stop the scourge of accidents. Perhaps, then, he and his colleagues should look to really improving safety by:

  • funding the Federal Aviation Administration (FAA) manpower; expand the number of qualified inspectors to increase the surveillance activities that repair stations and air carriers need;
  • giving help to the FAA to oversee the increasing number of unmanned aerial vehicles;
  • looking into who will oversee the aerial taxi industry that will be tested in Dallas next year;
  • stop shaming the transportation oversight agencies tasked with the safety of the transportation industry;
  • help the oversight agencies with acquiring improved technologies;
  • realistically fund programs for, e.g. NEXTGEN, and other transportation improvements.

It’s funny (not ha-ha funny) but lawmakers, like our good Congressman, will not entertain these suggestions; it is easier to fabricate agendas. Aviation safety comes second. To quote my hero Daffy Duck when talking about dishonesty, “It’s dith-th-th-th-pick-a bull!” �

Aircraft Accidents and Lessons Unlearned XXVI: Northwest Airlink 2268

On March 4, 1987, a Fischer Brothers Aviation Incorporated Construcciones Aeronáuticas, SA (CASA) C-212-CC aircraft, doing business as Northwest Airlink (NWA) flight 2268, crashed on landing at Detroit Metropolitan Wayne County Airport in Romulus, Michigan. The aircraft was operating Title 14 Code of Federal Regulations Part 135 supporting Northwest Airlines, a precursor to regional airlines.

Unfortunately, beyond accident report AAR-88/08, the National Transportation Safety Board (NTSB) Archives had no other investigation records. Archived factual reports gave the reader a view into how the NTSB investigators, e.g. tested the aircraft systems to gain facts or reviewed pilot training for procedural failures. These factual reports gave a first-hand look at the investigators’ experience in the investigation specialty, e.g. powerplants, maintenance, operations.

One disappointing pattern going back thirty-two years, was the NTSB’s ‘blame the Federal Aviation Administration (FAA) for … something’ routine. These regular allegations either did not apply or were too vague, using phrases like, “The FAA did not provide proper oversight.” What does that even mean? The NTSB did this too often; it worked against safety if the FAA is always tagged without any valid reason, except to be based on an investigator’s lack of aviation experience. Ritual cries of ‘Wolf!’ are empty; industry, indeed the public, become immune to this rhetoric.

The [NTSB] determines that the probable cause of the accident was the captain’s inability to control the airplane in an attempt to recover from an asymmetric power condition at low speed following his intentional use of the beta mode of propeller operation to descend and slow the airplane rapidly on final approach for landing.”

The investigators held the captain and his flying skills responsible for the accident. In section 2. ANALYSIS. sub-section 2.1. General, the operations investigator documented that a DC-9 lifted-off of Runway 21-Right where NWA 2268 was cleared to land, that the DC-9 departure met separation standards between the two aircraft. “Consequently, the air traffic control handled the flights properly and no wake turbulence or ‘jet blast’ effects would have contributed to the accident.” This directly contradicted the Probable Cause, which stated, “Factors that contributed to the accident … the presence of a departing DC-9 on the runway …” How did a DC-9 contribute to the accident (page 47), when ten pages earlier (page 37) it was absolved of any culpability?

Stark incongruities, e.g. the DC-9’s presence, drove technical problems with this report. Investigators’ flare for ambiguous analysis and speculation were partly understandable because recorders were not installed. While this may limit evidence, it does not make investigating impossible; it must not hinder fact-finding. The report was littered with allegations that drifted nowhere; they had nothing to do with the accident. Recorders would not have changed these investigating problems.

Other claims had no documentary evidence or were based solely on hearsay, e.g. in relation to a steep approach, AAR-88/08 stated, “This documented practice induced by whatever motivation on the part of the captain, might explain the manner in which the approach was flown.” If Fischer Brothers found the captain had engaged in reckless behavior, the report showed no paper trail, no discipline dispensed. Instead, the Finding’s ‘documented practices’ were fellow pilot interviews; second-hand undocumented information, hearsay; certainly not information that should contribute to analysis. A non-fact, based on assumptions, had no place in this accident report.

In subsection 1.17.3, Crewmember Interviews, the operations investigators interview twenty-two company pilots to determine the accident captain’s flying habits. The report states, “The majority thought highly of the captain.” However, seven interviewee observations were bulleted by the investigators, referring to unconventional flying habits the captain exhibited. The investigators felt the comments important to mention, yet they failed to discover if the flying habits were unorthodox, dangerous or even if they contributed to the accident. They were a path to nowhere.

The operations investigator’s familiarization with the accident aircraft was rudimentary; he understood only the accident aircraft’s basic operating principles. Thus, it was critical to assure the accident pilots’ training was the best; that management was diligent in arresting unsafe behavior. Why? Every accident needed – and demands today – to be the last accident of its type … ever. An accident investigation must guarantee there is never another TWA 800, United 232 or an Air France 447.

Since the NTSB did not hire an airframe and powerplant certificated investigator until 2001, it is safe to say the NTSB investigator who looked at maintenance issues was not experienced in the subject matter. Investigators who ‘looked at’ maintenance were engineers for Systems, Powerplants and Structures, as per AAR-88/08. In section 2. ANALYSIS. sub-section 2.5. Aircraft Maintenance, the report stated, “Although the airplane was found to have been maintained in accordance with the airline’s approved maintenance program and no evidence was found of a component or system failure, three areas concerning the airplane’s performance and airworthiness do deserve comment.” In truth, no, they did not. If the three areas were complicit in the tragedy, then they deserved mentioning. However, this was an accident report, where facts and recommendations must relate to the accident. Anything else diverts from the urgency of the accident’s findings. In addition, the investigator reviewing maintenance was not experienced in maintenance. What light could this investigator’s analysis have shed on safety?

First issue: the most recent flight idle descent check. The investigator assumed the idle check, “… indicated that it [the operator] was attempting to follow prescribed maintenance procedures.” There was no maintenance history documented in the report supporting this speculation. Incorrect idle settings did happen …  still do. The pilot then wrote up the problem in the aircraft maintenance log (AML) so maintenance could fix it. The investigator did not mention AML entries. If an idle issue did exist, it could have been the result of normal wear-and-tear, requiring replacement or rigging. This was normal.

Second issue: the flap system. The report states, “Although there was no recorded history of recurring flap system difficulties experienced by Fischer Brothers and no pilot reports of a similar nature …”. What did this ‘finding’ have to do with the accident? Why mention it? Every aircraft and engine had flaws that surfaced through long-term operation. They were signs of wear-and-tear. To highlight each quirk would require writing multiple reports that had nothing to do with the accident investigation.

Third issue: incorrect feathering spring assemblies installed in the propellers. The report stated that the single springs “… could have delayed movement …” of the propellers’ blades. “However, the degree to which the propellers’ recovery could have been delayed could not be determined,” That was two “could haves”. ‘Could have’ was considered factual? The investigators made conclusions about a ‘problem’ that they could not even prove contributed to the accident. The investigators never mentioned why the springs were installed or if they had been approved through engineering or modification.

Reviewing the Recommendations, the Probable Cause referred to questionable landing procedures and obstacles, yet they never addressed the approach that contributed to the accident. If the investigators determined the approach raised concerns from a safety standpoint, there should have been safety suggestions that reflected this, e.g. a call for each principal operations inspector (POI) to confer with manufacturers to assure operators’ pilot approach training – not just operators of the CASA C-212 – met the manufacturers’ designs; introduce this improved training into the POI’s operator’s flight training. Report AAR-88/08 did not make us safer. The confusion of what belongs in a major accident report versus facts over allegation make this report inconsequential. This is tragic; nine people were killed and nothing was solved. s

Aircraft Accidents and UAS Data, Part VII

Well, it is official: we have become a civilization of uncommunicative idiots. Don’t believe it? The next time you’re in a restaurant … any restaurant, take a look around; people are not engaged in conversation; they are looking at their cell phones; surfing social media and texting. The ability to converse with our spouses, parents, children, etc. has escaped us. In a crowd, we are solitary figures, just like Paul Simon sang about in “I Am a Rock”. And the inability is leaking into our professional conversations, just when we need to keep the lines open.

The unmanned aerial system (UAS) conversations, to date, have always been monopolized by lobbyists and the inexperienced – often the same people. They make ridiculous assumptions, dodge facts, employ sarcastic reasoning and take shots at their ‘opponents’ as if the conversation were an adolescent game. When professional courtesy is not offered, it is not returned, on either side of the argument. However, problems long unaddressed, still exist.

Fortunately, a UAS and the national airspace system (NAS) conversation has been cultivated by serious-minded people. A fourth study Article has been written by Ryan Wallace, Kristy Kiernan, John Robbins, all of Embry-Riddle University; Tom Haritos of Kansas State University and Jon Loffi of Oklahoma State University, titled: Evaluating Small UAS Operations and National Airspace System Interference Using AeroScope. The Article was printed in the Journal of Aviation Technology and Engineering 8:2 (2019) 24-39. In the four studies the Authors keep moving the conversation forward, providing invaluable data to promote practical solutions.

The first sentence in the report states, “A recent rash of near mid-air collisions coupled with the widespread proliferation of small unmanned aircraft systems (sUAS) raise concerns that integration is posing additional risk to the NAS”; a brief, common sense problem statement. Until both sides of the argument can accept this fact and stop transferring blame to any culprit, from President Trump to Climate Change, we will never solve the real problems. The Authors looked at and compared many factors to aid their data-seeking.

“In this study, the authors partnered with a UAS technology company to deploy an AeroScope, a passive radiofrequency detection device, to detect UAS flight activity in an urban area.” The Authors employed the latest technologies in their study. However, even with the most advanced tracking system, the ‘Bad Apples’ are still successful at playing Hide-and-Seek, mostly because, as the study highlights, the technology is not commonplace in the field yet.

The report stated that while this technology was used in a limited area, “The authors assessed 93 potential violations of 14 Code of Federal Regulations (CFR) Part 107 regulations, including controlled airspace breaches, exceeding maximum flight altitudes, and flight outside of daylight or civil twilight hours.” These are sobering findings. The regulation-busters are not disciplined professionals, e.g. aerial photographers, realtors, they are amateurs, people who represent the UAS industry’s ‘Bad Apples’. And while the UAS industry must deal with its own lawbreakers, the law makers need to get their joint houses straight before the circular firing squad sets up.

Three situations to consider: 1 – the Federal Aviation Administration (FAA) has been given responsibility for the UAS industry. 2 – Prior to this writing a UAS entrepreneur applauded the Daytona Police Department for their professionalism in dealing with drones. 3 – Tim Bennett, Program Manager for the Department of Homeland Security (DHS) Science and Technology Division, recently spoke to NBC News, confirming what had been stated repeatedly: that drones are a threat to passenger jets near airports. The NBC reporter also spoke to entrepreneurs generating technology that finds drones being flown illegally. Other technologies are being designed to bring those drones down.

The FAA, a local police department and the DHS, each involved with unmanned aerial vehicle, aka drone traffic. This represents major attention at drones, but who has ultimate authority? The FAA has authority in the NAS; the local police in communities below the NAS, e.g. indoor arenas, city streets, while DHS has authority of terrorist prevention. Then there is the Federal Bureau of Investigation (FBI), the military, the Secret Service, etc., all with their own jurisdictions. Kind of like when two outfielders call the fly ball, only to have it drop between them in the confusion. The truth is the UAS industry needs all the supervision it can get because the UAS is not like anything else we have seen; it mixes professionals with amateurs, each wanting to penetrate the NAS. Wait until flying cars and aerial taxi services enter the fray.

One may suggest that the more eyes, the better. However, jurisdiction is a funny thing, funny in the way that it can get laughable. Add to the confusion the introduction of cooperating government agencies; the concept is an oxymoron, e.g. jumbo shrimp or pretty ugly, which is how a jurisdiction issue could end up.

There was a promising point in the NBC report: entrepreneurs developing technology. The Authors partnered with a UAS technology company to … What? Find a solution to a problem that they both shared. Does anyone else see solutions? Recently I took part in a discussion where the theme was that the FAA failed the UAS community. I stated, “If the UAS industry is waiting for the FAA to create the UAS technologies, they will have a long wait. The FAA does not have the manpower, money, time, expertise, etc. to meet the task.

The UAS entrepreneurs, who know the technology and the capabilities, must step up, create the means to track and. if necessary, police their own.” The rest of the aviation industry does this; they have been doing this for decades, e.g. discovered solutions to Stage III noise reduction or improved engine reliability for twin-engine overwater flights. The aviation industry policed their own safety programs, e.g. air operators auditing those who are contracted to them. They built better mouse traps and have opened their world globally.

The UAS industry has the money, risk-takers and technologies to accomplish these things. They must weed out the bad apples and prove to the other NAS users they belong there. The studies are a first step to understanding the need and represent the blueprint for pursuits in multiple directions; they are footwork already trod. The UAS industry needs to decide to take the next steps and keep those communications going.