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.

Aircraft Accidents and Lessons Unlearned XXV: FedEx 910 and FedEx 630

On October 28, 2016, at 17:51 eastern standard time, the left Main Landing Gear (MLG) of N370FE, FedEx flight 910, an MD-10-10 freighter (F), failed, then collapsed, during rollout after landing in Fort Lauderdale-Hollywood International Airport. Damage to the wing and subsequent rupture of fuel lines and tank, led to a post-crash fire.

FedEx operates two different DC-10 types in its fleet: the DC-10-10F and the DC-10-30F; both were converted to the MD-10 series. The MD-10-10F is a short-range version because it has no auxiliary fuel tanks. All FedEx’s MD-10-10Fs previously flew for other airlines, mostly passenger.

According to the report for FedEx 910, accident number DCA17MA022, the approach and landing were uneventful; the aircraft did not sustain a hard landing; pilot error was not to blame. The post-accident investigation report revealed that a major contributor to the accident was the left MLG outer strut cylinder failed due to an overstress fracture: “a small thumbnail crack, located at the radius between the cylinder inner diameter surface and the air filler valve bore (AFVB) surface,” located at the top of the strut.

In Memphis, July 28, 2006 (ten years prior), FedEx 630, accident number DCA06FA058, an MD-10-10F, crashed on rollout with a near identical left MLG failure. The timeframe for both accident aircrafts’ MLG, between overhaul and accident, matched: FedEx 910’s left MLG was overhauled 8 years, 8 months prior to its accident; FedEx 630’s left MLG was overhauled 8 years, 6 months before its accident.

Following the 2006 FedEx 630 accident, FedEx, Boeing and the Federal Aviation Administration (FAA) acted quickly. FedEx immediately inspected all MD-10 MLG cylinders for defects per Boeing’s Alert Service Bulletin (ASB) DC10-32A259. Boeing also issued a revision to the Component Maintenance Manual (CMM), requiring video probes and eddy current inspections of the air filler valve bore. The FAA issued Airworthiness Directive 2008-09-17 supporting the ASB and CMM revision. FedEx was the only domestic MD-10 large operator, with thousands of MD-10 flights per year. Neither McDonnel-Douglas’s aircraft design nor FedEx’s maintenance program were the cause. The National Transportation Safety Board (NTSB), however, never looked beyond the MD-10.

Both investigations found that the MLG cylinders failed because stray nickel plating was introduced into the AFVB. According to FedEx 910’s accident report, nickel plating with a thickness of 0.008-inch thickness “results in a stress factor increase of 35%”. During the left MLG cylinder’s in-service lifetime, a load event “compressively yielded” the AFVB material, “causing a residual tension stress”. In layman’s terms, the nickel-plating process somehow weakened the cylinder metal’s integrity in the AFVB area. The residual stress led to fatigue cracking.

There are two troubling issues about these accidents. First, is that both accident reports DCA06FA058 and DCA17MA022 were written in a field accident (FA) report format, similar to a General Aviation report – not in a standard major accident (MA) report format. In other words, there was minimal deserved attention to these accidents. Neither accident had a hearing; they had an inadequate number of investigative groups assigned. The reports’ recommendations never mentioned looking at MLG cylinder overhaul processes. Considering the fact that these were two Title 14 Code of Federal Regulation (CFR) Part 121 aircraft, the reports barely registered on the major accident radar.

By comparison, the NTSB blue cover major accident report from December 18, 2003: AAR-05/01 (DCA04MA011), FedEx flight 647, an MD-10-10F, crashed in Memphis under similar circumstances, yet the report highlighted pilot error. However, FedEx 630’s accident report did refer to AAR-05/01, stating, “The fracture of the right main landing gear of this airplane [FedEx 647] initiated from the same air filler valve bore hole location as N391FE [FedEx 630]” A search of the website’s Document Management System found no Maintenance or Structures Group factual reports in the dockets for any of the three accidents; these reports would have given the investigative groups’ individual factual findings. How, with almost identical events just three years later, was FedEx 630 not a major accident?

The second concern was the NTSB’s failure to look beyond the three FedEx accidents. How far did investigators go to prevent possible MLG cylinder failures in other MD-10 aircraft, e.g. Orbis Air’s MD-10? Did both a Maintenance investigator and a Structures investigator take their investigatory groups to examine the MLG overhaul process used by the FedEx contractor or interview the technicians performing the procedures? The DCA17MA022 factual report only spoke to Boeing’s DC-10 CMM revision and the ASB DC10-32A259, actions limited to the DC10 … and only the DC10. Did investigators give serious consideration that similar MLG failures could occur on other airliners, e.g. B777, A300 or MD-11?

Both FedEx 630 and FedEx 910 had resulting fires; both accident aircraft’s cabin areas were engulfed in flames and emergency exits were blocked by the fire. If either aircraft was a passenger airliner, a high fatality rate would have resulted. It is likely that all MLG overhaul facilities used similar plating procedures with similar results when overhauling wide-body MLG for passenger airliners. This suggests that a similar incident would have destroyed a passenger airliner with catastrophic results. Why were the two accidents not major accident investigation reports and why focus just on the MD-10’s MLG?

In 2006, FedEx 630, should have had a qualified Maintenance Investigator, with both air carrier and repair station experience; he/she should have led an investigatory group to explore the MLG’s overhaul facility to determine what issues – at the overhaul facility – if any, may have affected safety at the time, e.g. labor issues, quality control issues, management issues. In the wake of FedEx 910, both Structures and Maintenance Investigation groups, again, with experienced investigators with Title 14 CFR Part 121 and Part 145 backgrounds, should have conducted onsite inspections of the MLG overhaul facility.

Instead, the investigation mischaracterized information, e.g. the overhaul requirements. DCA17MA022’s factual report stated, the “manufacturer-recommended overhaul limit for the MLG assembly is every 8 years or 7500 flight cycles, whichever occurs first. At the time of the accident, FedEx’s MLG overhaul limit was 9 years or 30,000 flight hours, whichever occurred first.” Flight hours and flight cycles are not comparable. In reference to a landing gear component’s airworthiness, flight cycles are relevant; the landing gear is employed every single flight cycle. The landing gear is not used every flight hour, so flight hours do not affect landing gear integrity. FedEx probably received a time exemption from Boeing. Any cargo airliner’s years-to-cycles ratio is less than a passenger airliner’s; passenger airliners average more flight cycles per year. An air carrier-experienced maintenance investigator would have caught that.

Lessons Unlearned? One airline lost three of the same model aircraft to the same contributing factor. It is disturbing that two of these accident investigations were treated as inconsequential and ended up in a field accident report format. It is more troubling, however, that the investigations were treated as less-than-important as a passenger airline accident when one considers that information found in cargo airline accidents is critical to the safety of passenger airlines and the travelling public.

Aircraft Accidents and Getting It Wrong

When I was young, I had a Long Island Newsday route, flinging papers from the basket attached to the front of my blue Schwinn Sting Ray bicycle’s handlebars. Folding the papers, I usually read the headlines, perhaps a few paragraphs, to see what was going on. In those days, the newspaper’s first pages were just that: news. Reporters did not write opinion, speculation or political views. They wrote news.

The amazing thing about this decade is we read everything but news. Political parties have the integrity of a reality show, e.g. Jersey Shore or Here Comes Honey Boo Boo, to name a few. ‘News’ anchors – not opinion talk show hosts – lay naked their political leanings. Gone are the days of Huntley, Brinkley and Cronkite. Today, the ‘News’ doesn’t deal in facts, at least none that aren’t part of the dialog at the time.

On October 29, 2018, Lion Air flight 610, a B737MAX, crashed into the Java Sea. On March 10, 2019, Ethiopian Airlines flight 302, a B737MAX, crashed on land shortly after takeoff. Both flights appeared to suffer from similar events – not identical – but similar. One thing I learned as an aircraft mechanic was that: until facts are learned from troubleshooting, coincidences sometimes are just that: coincidences.

The 737MAX accident similarities, 132 days apart, were too much for the media to ignore; they guessed away, especially when pointing fingers at Boeing and FAA Certification. Speculation flew from ‘experts’ and anyone who had an opinion, based on nothing but hearsay and personal grandstanding; the most vocal were those whose technical knowledge of the Boeing 737MAX – indeed, of any airliner – was nil. The guesswork came mostly from those who, in addition to not knowing the aircraft, had never worked for an airline; people who could not understand the hazards that working on a ramp presented.

There were those few on social media who said, “Let’s not speculate. Let the industry learn from facts, not what the barbershop-version of expertise think happened.” They were called arrogant, disrespectful, full of themselves. One ‘expert’ said, “Speculation was every aviation enthusiast’s right.” Incredible.

That was until April 10, 2019, when Aviation Daily, in an article titled: Ethiopian Crash Data Analysis Points to Vane Detachment. Meanwhile, the investigation, despite this early revelation by an investigator involved in the investigation, still moves forward. But what a show-stopper!

The Aviation Daily article stated, “This, says one source, is a clear indication that the AOA’s [angle of attack] external vane was sheared off – most likely by a bird impact.” What does this mean? The AOA departed the aircraft BEFORE the accident. An important sensor that senses the aircraft’s attitude, was lost and possibly caused the accident … sort of like Air France 447, where the aircraft received conflicting airspeeds from sensors before the crash. The source stated that a bird struck the left-hand (L/H) AOA vane. The odds of Lion Air 610 suffering the same event are astronomical: a bird strike that took out either AOA, then upset the B737’s Maneuvering Characteristics Augmentation System (MCAS).

However, the damage was done. Speculators caused irreversible damage to the Ethiopian Airlines and Lion Airlines accident pilots, Boeing, the FAA Certification group, and anyone who fell under the speculation target. Even people, self-pronounced ‘experts’ in other industries were slandering Boeing or the FAA, based on hearsay and not on factual information.

I get it, accident investigations are frustrating; patience is not easily tolerated. Investigations are tedious. I’ve dug through boxes of decades-old maintenance records, an aircraft’s lifetime, looking for the silver bullet. I have interviewed countless mechanics, trying to find the General Maintenance Manual error that sparked a lapse in procedure. I observed many hours of maintenance checks and phase maintenance simulations to find why a work card led to a mistake. But I never ignored facts and rushed to conclusions … no, no, no. Why? Because it destroys hard-earned reputations. Jumping the gun wrecks innocent people’s lives. Posturing for the cameras detracts from the integrity of the accident investigation, can even divert attention away from the root cause, which can put us all in danger.

But the most important reason: Feeding unfounded theories to the accident victims’ grieving families is cruel and so very selfish. ‘Experts’ may excuse the practice as “helping the families find closure” … that is, until the ‘experts’ are, often enough, wrong. They only munch a slice of crow, lay low for a while before landing another News ‘expert’ gig. But the accident victims’ grieving families get to live the heartbreak over and over and over again; directing their rage, often at the wrong party.

How does diverting attention put us all in danger? Remember Atlas 3591? An Atlas B767 aircraft, flight 3591 crashed on February 23, 2019, outside of Houston. For the fifteen days before Ethiopian Airlines 302, Atlas 3591’s mysterious plunge occupied the news. But then the second 737MAX accident shoved Atlas Air 3591 to the background, even though B767s, filled with passengers, fill the sky today. Has the industry followed the latest from the National Transportation Safety Board (NTSB) updates?

Remember American Airlines flight 191? The authorities originally focused on the DC10, instead of on American Airlines’ unapproved maintenance procedures. How long did it take for the NTSB to check if American was using similar procedures on their other airliners, e.g. B747? That’s distraction.

What does working on a ramp (as mentioned in paragraph four) have to do with anything? The L/H AOA sensor is located one foot behind the radome, on a level with the pilot’s feet. Since a damaged AOA sensor causing the accident has a high probability, could a bird knock it out? That’s a low probability – even infinitesimally improbable that it happened on both 737MAXs. Bird impacts have played into many accidents, but ramp activity is more likely. Equipment movement, e.g. ground power units, air conditioning units, air carts, air stairs, catering trucks, even baggage carts, can be hazards around aircraft, especially where time-sensitive turn-arounds occur.

But wouldn’t anyone who damages an aircraft be quick to report the incident? In earlier years, airlines in the US were quick to fire anyone who damaged an airliner, that is, until management discovered that people would damage the plane and then not report it. So no, they might not report it.

In 2010, a belt loader punched a hole in a US-based regional aircraft, compromising the pressure vessel. The plane, full of passengers, took off, but could not pressurize in flight. The plane landed safely, but it should never have taken off with the damage it incurred. For decades ramp activity has caused millions of dollars in damage, lost flights and affected the safety of flying aircraft. Improper equipment movement has damaged wing leading edges, static ports, engine cowls, cargo door thresholds and entry doors. Is it possible that an AOA vane could get damaged in this way? It is very possible, more so than a bird strike. It certainly deserves attention and fact-finding.

The Ethiopian authorities have not finalized their report; the L/H AOA sensor’s departure is still a serious working theory. However, if it proves out, the Speculators have done a great disservice to the industry; they have distracted from the root causes, caused unnecessary harm and wasted everyone’s time. Journalists may someday regain their integrity … maybe. But as for speculators, we are stuck with their useless opinions that aren’t worth the paper they should not be printed on. �](>

Aircraft Accidents and Lessons Unlearned XXIV: British Airways PLC 5390

This month’s Lessons Unlearned looks at a decades old accident, which resulted in zero fatalities. The end result could have been worse, if not for the fast thinking of the first officer. The quality of the British accident report is so different from an American report; the writing style is Elizabethan; no words are wasted or misused. Most importantly, the investigators understand what they are investigating; they know the subject matter, e.g. aircraft maintenance, thoroughly and communicate the problems without leaving any doubt.

On June 10, 1990, British Airways Public Limited Company flight 5390 was a scheduled flight between Birmingham, England and Malaga, Spain. The aircraft was climbing from flight level (FL) 140 (14,000 feet) to FL 230; the co-pilot (first officer) manned the radios while the commander (captain) flew the aircraft. The captain had just released his shoulder and lap belts when the aircraft suffered an explosive decompression; the L-1 windscreen directly in front of the captain departed the aircraft. The captain? He was forced into the new hole by the higher cabin pressure and became wedged half-in/half-out of the windscreen hole; from the waist, up, he was on the outside.

This was not a manufacturer design issue; it was a maintenance issue. The root cause was also discovered with enough time that it should have prevented other accidents – and, yet, did not. This is what makes accident investigation so frustratingly unproductive, the waste of opportunity and learning.

The airliner involved, a British Aircraft Corporation (BAC) 111 was a twin-engine, short-range airliner; it resembled a shorter version of the DC-9, with design basics similar to most airliners, meaning: as it climbs or descends, the BAC-111’s fuselage acts like a rigid balloon. The cabin pressurizes/depressurizes to provide the crew and passengers enough atmosphere to survive high altitudes, keeping the occupants from asphyxiating. Depending on the altitude, the differential pressure (DP) within the aircraft is proportionally higher than the air pressure outside the aircraft.

If all hands survived and the aircraft landed safely, why was this an accident? According to Title 49 code of federal regulations 830.2, “Aircraft accident means an occurrence associated with the operation of a aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury or in which the aircraft receives substantial damage.” This reference applies to US law, but international law definitions are/were similar.

The accident report estimated that the captain was forced out of the cockpit with the equivalent of 5,357 pounds of pressure. At 17,000 feet of altitude, the DP between the aircraft’s interior and exterior was far less than, e.g. the DP of China Air 611 at 35,000 feet; China Air 611, a B747, suffered an in-flight structural breakup from explosive decompression. This does not trivialize flight 3590. It emphasizes that the windscreen’s departure did not occur at the BAC 111’s upper DP range; a minimal amount of DP ejected the windscreen. At 17,000 feet, it is estimated the window had only 8.77 pounds per square inch of air pressure pushing outward on the windscreen.

The window was secured by 90 countersunk bolts secured into #10 Kaylock anchor nuts. Of these ninety bolts, thirty were recovered, either with the window or in the aircraft windshield frame. Eighty-four bolt shanks were 0.026 inch narrower than the anchor nut’s width while six bolts were 0.1 inch too short. The eighty-four bolts with the wrong shank width did not have the thread depth to engage the anchor nut threads. These bolts slid out with minimum resistance. The six short bolts had the correct thread width yet did not engage enough of the threads for security. Though more stable, they were six bolts doing the job of ninety.

Flight 5390 was the first flight following the replacement of the previous L-1 windscreen. There was no doubt as to the probable cause of the accident: incorrect fasteners. What was more important was the root cause: the maintenance practices employed at British Airways. There is much to be written about the torques used; how the bolts were torqued and the differences between fine and coarse threads. However, these matters stray from the root cause.

Due to Flight 5390’s non-fatal status, its successful landing worked against its lessons learned; nothing is more disinteresting to sensationalists than a close call. Because the public rapidly lost interest, the story quickly became unattractive. However, this is a mistake that plays over and over in aviation safety. For instance, cargo aircraft accidents usually attract less attention due to the low number of fatalities, yet the accidents occur in equipment flown by major passenger airlines. On February 23, 2019, Atlas Air flight 3591, a B767 cargo airliner, mysteriously crashed. It was soon forgotten in the wake of two B737-MAX accidents, even though the B767 is flown extensively by the Big Three: Delta, American and United.

A random check of British Airway’s and other airlines’ BAC 111s found multiple errors in the manufacturer number for the windshield bolts being used. This fact should have raised concerns, not only with British Airways, but with many airlines, particularly those following similar maintenance programs. In addition, per the accident report, post-maintenance pressure checks were not required on the BAC 111 following a windscreen replacement. How could British Aircraft Corporation not require a pressure check on a replaced windscreen’s integrity? How many other aircraft had questionable return-to-service checks?

Because of workloads and available mechanics, the maintenance manager took it upon himself to work the windscreen replacement; this is where an experienced airline maintenance investigator shows his/her particular advantage to an engineer. This culture displayed many problems someone with a mechanic background could easily have identified, e.g. human factor issues; manpower; distribution of work; familiarity of the aircraft; effectivity differences of one BAC 111 to another BAC 111 and the pressure to meet a flight. These are the risk factors, that when lined up, lead to disaster, as it did for Flight 5390.

Both the shift supervisor and the avionics supervisor – both management, not workforce – replaced the windscreen. After determining the removed bolts were damaged, the shift supervisor searched for replacement hardware (bolts) in an uncontrolled hardware carousel. He found the narrow bolts and used them to replace the old hardware. The two supervisors then used uncalibrated torque tools to torque the windscreen bolts. Similar errors were made fifteen months later (September 1991) that led to the Continental Express (Britt Airways) Flight 2574 accident near Eagle Lake, Texas.

Although the Birmingham maintenance area manager dedicated 80% of his time focused on Birmingham, “The Area Manager did not monitor the day-to-day work practices of his subordinates, but relied on the trending of parameters such as numbers of Acceptable Deferred Defects, repeated defects and failures to meet schedules as indicators of quality.” This disconnect began to manifest itself years later in accidents, e.g. Air Midwest 5481, where the station manager worked different shifts from the workforce, disqualifying himself from the actual work and relying instead on data parameters. The Federal Aviation Administration itself, risks falling into this trap, relying heavily on data retrieval and avoiding good old-fashioned surveillance.

British Airways 5390 was due to a windscreen installation; Air Midwest 5481 was due to elevator rigging errors; Britt Airways 2574 occurred because of communication breakdowns and a failure to follow the job. However, the lessons unlearned are the same: a lack of maintenance job familiarization; a rush to get the job done and training issues. More importantly, the communication of lessons within the industry, both domestic and international, is key to preventing similar accidents. Operations accident causes are easily communicated; pilots talk, even outside their airline. Airworthiness accidents are not communicated as well, at least not outside one’s own airline. To depend on accident investigation bureaus, whose attention is focused on the tragedy, e.g. victim numbers, and not on the lessons to be learned, is a recipe for failure and the reoccurrence of events that should never have reoccurred.

Aircraft Accidents and UAS Data, Part Six

Last week’s web posting addressed the third study Article written by Wallace, Kiernan, Haritos and Robbins, titled: Small Unmanned Aircraft System Operator Compliance with Visual Line of Sight Requirements; the Article was printed in the International Journal of Aviation, Aeronautics and Aerospace, Volume 6, Issue 2 in 2019. This Article, when combined with two previous articles, presented issues with the Unmanned Aircraft System (UAS) and the hurdles to be cleared by the aviation industry to avoid accidents. These facts are long overdue. The aviation community has been placed in a reactive position, which, safety-wise, is not a good place to be.

The unmanned aerial vehicle (UAV) is unique in the autonomous world; they are miniaturized air transportation vehicles. There are fixed wing versions that fly like an airplane and others that operate on rotors. Since UAVs operate within the three axes – X, Y and Z – safety concerns differ from the UAV’s counterparts, e.g. model trains, radio-controlled cars or radio-controlled boats, which pose little threat to the rail, highway and marine industries. To the point, the Rail community is unconcerned with model HO trains breaking free from a basement and causing a 100-car freight train derailment. Yet, a hobbyist’s UAV, hovering near an airport approach, is a real threat to life and safety.

The lesson of First Lieutenant Thomas Selfridge was sobering; aviation was young and imperfect; it was dangerous, yet promising. Once mail was moved by air, we as a civilization could not regress, but improved air mail to become the norm. Pilots still ran out of fuel, crashed into objects at night or were lost in fog. As the DC-8 and the B707 made trans-ocean travel safer and quicker, aviation moved beyond the DC-7 and Boeing 314 Clipper. Older aircraft were pushed out, making way for progress. Still, TWA 800’s lessons reminded us that aviation was still imperfect.

As the UAS industry evolves, we must continue focusing on safety first. My opinion: UAVs are becoming an irreplaceable part of commerce, particularly in the capitalistic environment. Jobs and technological opportunities represented by the UAS are countless; dozens of careers are in the making. However, despite numerous opportunities, dangers are just as abundant. None more critical than the inability for effective oversight.

We are reminded that manufacturers and air operators in the aviation industry have been just as responsible for safety as the Federal Aviation Administration (FAA) has. Decades of regulatory evolution resulted in an oversight system as close to streamlined as can be. The FAA learned to work with the aviation community for the mutual benefit of lowering accident rates and community safety. Is the system perfect? No, but considering the industry’s diversity, aviation is very safe. FAA policies and programs are regularly revised to meet the aviation’s changing demands. FAA aviation safety inspectors (ASIs) are available, seen; they are involved.

Still, the aviation community is concerned, not just with the UAS industry, but with the Congress’s plan to spread the FAA even thinner. To quote JRR Tolkien, “Sort of stretched, like butter spread over too much bread.” To be clear, this is not a small endeavor; the UAS industry is complex, with too many amateurs playing deep below the radar.

Overseeing the entire UAS industry and the aviation community, simultaneously, is impossible. My analogy would be to imagine the Federal Highway Administration suddenly being responsible for the direct policing of every underage speeder, drivers without licenses, fender-bender investigations, reckless drivers, etc., on every road in America while working Monday through Friday, 8:00 to 16:30 local. The FAA is the premier aviation agency in the world. However, is the United States Congress falling on its collective swords putting UAS oversight all on the FAA? Do they understand the magnitude of that responsibility?

To adequately meet the FAA’s needs to oversee both the legacy aviation industry and the growing UAS industry, FAA employee numbers would have to increase four to five times its present manpower. In addition, the FAA’s budget would have to increase considerably, not just to meet the increase in hiring, but to purchase/lease technologies to track the UAVs; renting the available space for attaching the technology to buildings, towers, etc. This data input is crucial to surveillance; it is analyzed to build safety programs for the UAS industry. Another issue: current UAV tracking technologies are manufacturer-specific, e.g. a ‘Brand X’ UAVs can only be tracked by a ‘Brand X’ UAV tracker. Congress would have to budget the FAA with some serious cash to build UAS safety systems, just as the aviation industry uses.

What about the local and privacy laws the UAVs could be violating? How does the FAA square the circle with local law enforcement? Are all laws governing UAVs going to be federal laws or local? Who has jurisdiction? Who prosecutes? Who appears in court? How are UAVs registered? Will all UAVs be required to sport an ‘N’ or equivalent registration number? At present, Title 14 code of federal regulations (CFRs) Part 107 has not addressed this yet.

The Authors’ three Article’s analyzed three unique problems: Article One – pilot awareness of UAVs in their environment; Article Two – tracking UAVs near a small commercial airport; Article Three – potential hazards related to operating UAVs beyond the visual line of sight. The sobering truths of these Articles force the aviation industry to accept undeniable facts: the FAA lacks the technology or the manpower to successfully oversee the UAS industry a-a-a-and the aviation community; large government fails to comprehend the vast scope of this monumental task.

Perspective: A major airline’s FAA certificate management office (CMO) employs roughly eighty to one hundred ASIs, working Monday through Friday, 8:00 to 16:30 in their time zone. These ASIs oversee: thousands of mechanics and pilots; hundreds of aircraft; follow dozens of safety programs, while flying to hundreds of airport ramps – worldwide – 24/7, 365-1/4 days a year. ValuJet Airlines flight 592 crashed on May 11, 1996; ValuJet was strictly a domestic airline. A fundamental reason behind the disaster was the airline’s unchecked growth, e.g. new aircraft and contracting maintenance, that exceeded the ValuJet CMO’s ability to monitor and prevent the safety problems due to ineffective oversight. Twenty-three years later, adequate oversight of the growing airlines continues to be major challenges.

Can the UAS industry receive successful FAA supervision? No. Congress isn’t looking at the reality; elected representatives – with no aviation experience – are relying on the advice of ‘experts’ – with no aviation experience, to make decisions affecting the safety of the travelling public. Congress is pushing the UAS industry off on the only agency that handles aviation ‘stuff’. That’s the only criteria they care about: the FAA handles aviation ‘stuff’.

Can’t the FAA hire more ASIs? First, the FAA hires ASIs who are experienced in their industry to ensure effective aviation oversight. The UAS industry is so young; there aren’t many UAS professionals to hire from. Besides, the UAS industry pays better. Second, the FAA is already seriously understaffed.

The CFRs governing the UAS industry fall under Title 14 CFR Part 107 Small Unmanned Aircraft Systems and its forty-four subparts; these subparts will grow through time and experience. The aviation industry has been regulated under Parts 21, 23, 25, 26, 27, 29, 31, 33 and 35 just addressing airworthiness and certification; Part 43 addresses Maintenance as does Part 65 and 145. Pilots fall under Parts 61, 63, 67 and 68. The certification of air operators’ operations and maintenance programs come under Parts 119, 121, 125, 129 and 135. There are CFRs for schools, medical certification, rotorcraft operations and agriculture. Each Part has dozens of subparts, all based upon different certifications and experiences, e.g. day-to-day issues and accidents.

Can the FAA extend its limited resources to shepherd the UAS industry through its evolutions, and assure the flying public that a ValuJet 592 will not happen again? Will the FAA be guaranteeing safety or effectiveness in its oversight? The US Congress is betting on it. What are they using as ante?

Aircraft Accidents and UAS Data, Part Five

Beginning in November 2016, with Aircraft Accidents and UAS Data, Parts One and Two; then in October 2018 with Aircraft Accidents and UAS Data, Parts Three and Four; I tried to make use of valuable research into the safety aspects of the Unmanned Aircraft System (UAS) vehicles as reported by the Authors: Ryan Wallace, Kristine Kiernan and John Robbins, all of Embry Riddle Aeronautical University and their colleague, Tom Haritos of Kansas State University. Their third Article, titled: Small Unmanned Aircraft System Operator Compliance with Visual Line of Sight Requirements, was printed in the International Journal of Aviation, Aeronautics and Aerospace, Volume 6, Issue 2 in 2019.

To summarize, the first Article dealt with a series of controlled tests that determined if pilots could see, with the naked eye, an unmanned aerial vehicle (UAV) in their flight domain (X, Y and Z axes), even when the test pilots knew the UAV was there. The second article dealt with overseeing different UAVs operating around a commercial airport’s airspace using the latest technology.

The Authors are professionally supportive of UAS success, both in a commercial venue and as recreational devices for, e.g. hobbyists. The Authors are, as demonstrated by their research, dedicated to safety, not only to the UAV operator, but to all the aviation community that UAVs interact with. And that’s the rub: those invested in UAS as commercial entrepreneurs are committed to safety, to expanding their businesses as a benefit, not a hazard. Can the same be said for all UAV operators?

The third Article begins by examining an accident – not incident – involving a small UAS (sUAS) operator and a military helicopter. The September 21, 2017 event involved a DJI Phantom 4 UAV being flown in the evening from as far away as 2.5 miles from the operator, “well beyond visual line of sight (BVLOS)”. The operator flew the UAV solely with a user interface map – no visual contact – into one of a UH-60M military helicopter’s rotor blades. The speed with which a flying helicopter’s rotor blades turn spells disaster when they hit a comparatively stationary object; the damaged blade(s) causes an imbalance in the rotor system, control issues and a loss of lift. The danger exists to the flight crew, anyone flying nearby (‘wing’ man) and anyone on the ground within the crash circle of the falling helicopter. If the out-of-control helicopter happens to be over a city? Numerous fatalities!

The article’s Problem statement: “The potential hazards associated with BVLOS flight represent a clear danger to manned aircraft operators and other National Airspace System (NAS) users. Currently, no data exists to accurately assess the distance at which sUAS operators are flying their aerial vehicles. The authors sought to determine … appropriate waivers or risk mitigation.” A telling Problem statement, especially if one understands the implications. Why is it that “no data exists” in a time when military UAVs could be controlled from across the world for decades?

According to, miniature and micro UAVs have been around since 1990. Remote control aircraft have been around longer, according to, since at least 1985. The technology for controlling a UAV remotely has moved from line of sight to miles from the operator. Why did it take thirty-one years (2016) for industry and the Federal Aviation Administration (FAA) to publish rules for safe UAV operation, e.g. training or operation requirements? Why has it taken thirty-four years for studies to be published that examine the real risks of introducing UAVs into the NAS?

The article’s Purpose statement: “The Purpose of this study was to assess sUAS operator practices with an emphasis on the range and visibility characteristics between the operator and aerial vehicle. This data will be used to establish a baseline of UAS operator flight behavior as well as generate UAS policy and safety recommendations.”

The Purpose statement is also revealing; not just the third Article by itself, but when combined with the first two. These Articles are not anti-UAS; they are anti-complacency. The aviation industry has ignored the UAS industry; UAVs have obviously evolved to the point of major concern. At this time, the aviation industry cannot be proactive, but instead, as always, are reactive. The UAS industry has never been the problem; it was the ‘we’ll-deal-with-it-later’ attitude that has the aviation industry behind the eight ball.

The article utilizes several methodologies to determine operator-to-UAV visual detection efficiency of, e.g. BVLOS and hazards. The Authors state under Hazards of BVLOS Flight that, per a study by Terwilliger in 2012, “Flights beyond visual line of sight have the potential to be particularly hazardous, since they limit the situational awareness of operators. Known as the soda straw effect, the reduced field of view of visual information can diminish hazard recognition and ultimately decrease operational situational awareness.” As I interpret this, the operator controlling BVLOS, stands a good chance of becoming a safety hazard; the operator’s ability to detect hazards is diminished by buildings, natural obstructions, e.g. tree lines or hills, and the distance beyond their visual acuity.

In order to operate a UAV BVLOS, the FAA can issue a waiver to the operator as per Title 14 Code of Federal Regulations (CFR) Part 107.200 – Waiver Policy and Requirements. This waiver, granted by law, can supersede the restrictions of Title 14 CFR Part 107.31 – Visual Line of Sight Aircraft Operation, where the remote pilot, visual observer and/or the controls operator “… must be able to see the unmanned aircraft throughout the entire flight …”

Part 107 is ambiguous at best, about what an operator employing a waiver uses to ‘see’ the UAV’s operating area when BVLOS. Are ‘Brand B’ UAVs only able to be tracked with ‘Brand B’ equipment? If ‘seeing’ is, e.g. a camera mounted to the UAV, can the camera ‘see’ in all directions along the X, Y and Z axes? How would it detect a bird or an ultralight aircraft? How does the UAV avoid hazards or escape becoming a hazard itself?

The Authors’ first article demonstrated the hazard a UAV may present to a General Aviation aircraft under the best visual conditions. The second article established the hurdles of tracking UAVs inserted into a smaller commercial airport’s operating area. This third article highlights the increasing challenges the FAA faces in overseeing the UAS. All three articles increase the urgency of mounting problems, long overdue for addressing. However, one thing the Authors cannot study is the most unpredictable UAS threat to aviation and public safety: Operator Maturity.

For the sake of this article, the subject of terrorist UAV manipulation is off the table; it is a valid argument, but not to the point of FAA oversight and industry coexistence. In the first paragraph of the third Article, the Authors referenced the accident between a UAV and a military helicopter. The operator, per accident report DCA17IA202AB, “was intentionally flying the drone [UAV] out of visual range and did not have the adequate knowledge of regulations and safe operating practices.” This means the operator did not have a waiver to operate BVLOS per Title 14 CFR 107.200.

Is this the first instance of UAVs being operated carelessly through the NAS? No. The FAA has documented hundreds of nightly incident reports where UAVs were operated in the approach and departure paths of commercial airliners at airports, e.g. O’Hare or JFK. These reports date back more than five years. The UAVs, playing chicken with the passenger airliners, were seen by witnesses or flight crews, but it was impossible to locate the UAVs’ operators with existing technologies.

Why would individuals perform these unsafe acts? For years local police in many states have chased individuals aiming laser pointers at helicopters and airliners; these individuals attempted to disorient or temporarily blind pilots during the most critical stage of flight – Landing. A three-year old video showed a ground operator hovering his UAV – BVLOS – directly over the main rotor of a traffic helicopter while it flew over a populated area; the video was captured by a rival station’s helicopter cameras, which then followed the UAV down to the operator, who hid behind trees so as not to be taped.

The third Article is important in understanding why Title 14 CFR Part 107 was written and why these regulations must be applied. UAS individuals are in a larger world, full of situational awareness challenges, where UAV operators are never in any personal danger and won’t suffer from their unsafe actions. This remains new territory, for the UAS industry, the aviation community and the FAA.

Next week we will look at the challenges of oversight by the FAA.

Aircraft Accidents and Lessons Unlearned XXIII: Atlas Air 3591

On February 23, 2019, at 12:45 PM Central time, Atlas Air flight 3591, a Boeing 767-375ER, accident number DCA19MA086, crashed in Trinity Bay outside Houston, Texas. All three persons aboard were fatally injured. That’s it. There is nothing else to report; there is nothing else known.

Yet, even in the early stages of this investigation, there are three lessons unlearned from other accidents that we need to adhere to, to remember. The first lesson, often forgotten, whether intentionally or unintentionally, is compassion; that there are real people hurting because of this tragedy. The second lesson is that speculation is bound to take place; make it count. The third lesson is that, although this was a cargo accident, it deserves the attention of any major or minor accident.

Compassion – One thing I learned early on as a major accident investigator for the National Transportation Safety Board (NTSB) was to look beyond the accident to the families who must now be dragged into the spotlight while their family member’s final decisions are scrutinized by everyone from the pilots’ union to local barbershop regulars. When we allow this type of sensationalism, it destroys innocence, invites doubt and heightens grief. And, it diverts attention from evidence important to finding a root cause. I am reminded of the circuses surrounding such tragedies as Malaysia Airlines MH370 or Germanwings 9535, when the media and their experts felt it necessary to be investigators-without-a-clue and providers of false hope. To everyone within range of my written voice: Let this play out folks, with professional patience, and let the families grieve in peace.

Speculation – there are two types of speculation, good and bad. Good speculation occurs when small groups of professionals, e.g. mechanics or pilots, discuss the accident in the privacy of the line shack or ready room; generating a discussion. There may be those familiar with the B767 or any aviation professional who can glean from what is known about the accident and adjust their Routine – that infamous ally of Complacency. Perhaps a pilot will reread their emergency procedures, again; a mechanic will double-check the maintenance manual paperwork or maybe a pre or post-flight walk-around will take a little longer to complete, allowing the flashlight to closely trace the hydraulic lines in the wheel well. Any boost to our awareness is welcome. Feel free to talk amongst yourselves. Please, keep it professional.

When I investigated China Airlines flight CI611 in 2002, the aircraft still rested on the ocean floor when I arrived in Taiwan. There were no recorders to review yet; they hadn’t been recovered. But, the Taiwanese Aviation Safety Council (ASC) investigators and I didn’t wait for the recorders. Instead, we reviewed all the maintenance accomplished on the accident aircraft, going back as far as we could. We did visual inspections of sister B747s in the fleet and the ASC investigators interviewed mechanics and pilots to see if there was anything to focus on. We were proactive; we speculated in a way that saved time and exploited our resources. That’s good speculation.

Then there is bad speculation. Turning on the evening news to find some self-described aviation expert, proudly holding his model of the accident airplane, maybe with the correct paint scheme, as he waits for the cameras to focus on him. We all know the type: he expounds on opinion with little attention to fact; looking sober while struggling to remember that the model’s vertical stabilizer points up in flight. To the point, this speculation is harmful, not only to the truth, but to the distraction it gives to the investigation. As with Malaysia Airlines MH370, how many experts did it take to make the search crews go round in circles as the recorders’ batteries died? As with TWA 800, how many expert theories did the nation have to listen to, from terrorist bombs to missiles, before the investigation moved forward?

The aviation news website, AvWeb, posted an article on February 26, 2019, referencing a report in Business Insider. Several Atlas pilots – seriously, PILOTS – criticized Atlas for high workloads and low pay. Is this type of selfishness really necessary, to make this tragedy about pay and workload? Perhaps selfies will get these pilots some extra attention. Did their complaining point to root cause or were these pilots just wanting facetime? They presented no evidence; speculation was unnecessary. How do union negotiation issues at this tragic time contribute to the investigation?  They don’t.

Houston’s NBC news affiliate, KPRC-Click2News, posted amateur video on its website: four seconds of Atlas 3591 descending, accompanied by an interview with a former NTSB accident investigator, who was spit-balling without evidence, e.g. “Maintenance issues and mechanical malfunctions, while they are rare events, can and do occur.” What information did that statement provide? None. He then made assumptions about cargo airline work hours, saying, “The effects of fatigue can also be acquainted to someone that is drunk because it impairs not only logical thinking, decision-making, but can have motor skill impairment, as well.” This expert’s logic is all over the place. Maintenance issues? Night shifts? Pilots are, “someone that is drunk”? His dizzying ‘expert opinion’ covered everything but oatmeal food poisoning. Did the ‘expert’ ever fly for a cargo airline? I’m asking because he contributed ab-so-lute-ly nothing to the investigation.

The question of cargo airline flight hours has long been hauled into the accident investigation spotlight; pilot unions, former NTSB investigators and uninformed bureaucrats have lamented the unfairness of operating airplanes in the early morning hours, even though these successful overnight flights, number in the millions since the mid-seventies. I have worked in FedEx’s Memphis Superhub and their Newark Metroplex during those allegedly notorious shift hours. I never observed pilots or fellow mechanics walking drunkenly gate-to-gate; sleeping at the controls or crying out, “Oh, the humanity!” In Omaha, I never saw an exhausted pilot do a half gainer off the crew stairs after his two hour morning flight. As an FAA inspector, I spoke with pilots and mechanics from UPS and other cargo airlines; I never met these lethargic individuals, lurching about beside me as we performed the pre-flight walk-around.

And didn’t the accident occur at 12:45 in the afternoon? Are we ignoring the facts; afraid they will get in the way of speculation and tarnishing the accident pilots’ experience and reputation?

Cargo Accident – I investigated Emery 17, accident number DCA00MA026. Of the Board Members at the time, only Member John Goglia took the investigation the full distance, insisting on a proper hearing. The results of that investigation should have had long term results that should have shaken the aviation community to its core, possibly preventing later air disasters. Why? Because cargo accidents happen in the same airplanes, at the same airports and in the same air space used by passenger airlines; they are affected by the same consequences of that industry.

The NTSB needs to take this accident seriously … very seriously. They need to not only determine probable cause, but they must determine root cause. This accident can’t be about the number of people killed, but about how this affects the entire community; how what is found affects everyone’s safety.

Then there is that four-second amateur video. This video is only a tool, nothing more; a video that supports the investigation, not an investigation that supports the video. The NTSB must not make the same mistake that they made with National Air Cargo flight 102’s amateur video. These videos don’t show the accidents; they show what took place after the accident began.

This accident investigation has just begun. Let us all be professional, compassionate, patient and exercise common sense. We, the aviation community, demand it. The families of the deceased? They deserve it.

Aircraft Accidents and the A380

The concept of a Supernova is incredible.  They are the result of a Supergiant star that has reached the end of its life, collapsing upon itself before exploding into the greatest astronomical event known to man.  All the heavy elements it creates are flung out across the cosmos; these building blocks of Life then spring from the star’s death.

After sixteen years of production, the Airbus A380 will fade away, a victim of its own delusion of grandeur.  To be honest, Airbus shouldered an impressive undertaking designing and building the flying behemoth, but Airbus’s timing was a tad off … by about thirty years.

Many of its fans spoke of a wonderful experience, flying on the largest airliner, though it is unclear how different one airliner is from another as seen from the inside.  Several A380 operators boasted many comforts, including passenger showers or a tended bar in First Class.  The coach passengers were seated as tightly as any other airliner, with a maximum seating of 853 passengers.  The A380’s safety record may stand firm, but the small number of A380s flying does not demonstrate a superior safety history.

For its size, the maximum payload was somewhat disappointing; the A380 operator’s empty weight was 611,000 pounds and a maximum take-off weight of 1,268,000. This allowed, depending on the distance dictating the maximum fuel needed to carry, a maximum payload of 184,000 pounds, which is 14.5% of the maximum takeoff weight.  Add to this the four engines required to move the colossus, the fuel economy was reduced by two engines.

The aircraft is impressive; however, in airliner years, it came of age just in time for its funeral. With an assembly line shut down date of 2021, the A380 had only one more year’s success (2005 – 2021) than its less popular older brother, the A310 (1983 – 1998).

There are more impressive lifetimes, such as the B707 and the DC-8, both of which introduced the transatlantic jet age.  The B747, which bragged piano bars and lounges in the early 1970s, was the VIP of wide body elegance; it evolved through different looks to meet different needs, from the B747SP to the new 747-8.  The B747’s arrival put Boeing up front in a technical superiority that lasts to this day.  Boeing’s success lived on in the B737, B757, B767, B777 and B787, each one answered the travel industry’s needs, especially as international travel demanded twin-engine operations over water.

The A380 tried unsuccessfully to out-Boeing Boeing; it arrived at a time when fuel economy meant everything; that twin-engine aircraft were better for the growing passenger travel industry.  The A380 was late to the party with its four engines and lengthy boarding/deplaning times, plus the limited number of airports capable of landing and parking the super jumbo.

But most importantly, Airbus missed Boeing’s one important lesson from decades before: As time marches on, build to need, but then refit to last beyond the original purpose.  Airbus has sold the A300 as a freighter since the early nineties; the A310 has been converted from passenger airliners to cargo, but Airbus did not make all the conversions, leaving the supplemental type certifications to other vendors.  Perhaps, someday, Airbus will move to convert their A320s or A330s to cargo aircraft, but in this arena Boeing is miles ahead.  It may be possible that the A380 can make a comeback in cargo hauling, but, it too, will be post production.

Ironically, Airbus had firm orders to two of the largest cargo movers in the world: FedEx and UPS.  In 2006, the two airlines saw what Airbus failed to recognize, that the A380 was designed to haul freight, period.  However, Airbus flunked the rollout; delays soured the airplane to the two cargo airlines, causing them to look elsewhere and not look back.  FedEx opted for a brand new cargo versions of the B777 and B767, while UPS continued its B767 fleet buildup and invested in the new B747-8.

If you strip away all the luxuries loaded into an A380, the empty weight of the airliner drops considerably; 853 seats, overhead bins, carpets, all but one bathroom, these all add up to thousands of pounds of useless weight, payload weight the airline never makes money from (this was why the piano lounge concept died in the seventies; it cost too much in fuel).  Replace those non-essential creature comforts with main deck cargo loading systems and a forward 9-G bulkhead; the cargo aircraft’s empty weight will increase, but not even close to the passenger version’s empty weight.  Less aircraft weight means more profitable cargo weight can be loaded.

Rarely, if ever, does a cargo flight ever reach its maximum payload weight for the simple reason that bulk prevents it, i.e. ten pounds of feathers takes up more room than ten pounds of bolts.  The interior empty square footage of a wide body airliner is incredible; boxes and envelopes can be stuffed into every square inch of space, never coming close to meeting the maximum payload.  The extra weight allowance assures fuel needed to reach further can be pumped into the wings, thus guaranteeing a greater distance reached for moving freight.  This comes in handy when contracting to a shipper, like the Military.  Cha-ching, cha-ching!

The profit a heavy box brings to an airline far exceeds that of a passenger taking the same amount of space.  To the point, a passenger and his seat takes up 41,472 cubic inches of volume and the average weight is 185 pounds per passenger – the seat is not added in; the airline never makes money off the weight of the seat, whether they fill it or not.  A coach ticket between Los Angeles to JFK airport costs an average coach passenger about $200, while a First Class passenger pays $1000.  That is between $200 to $1000 per passenger that the airline makes, minus the cost of Wi-fi, flight attendant pay, drinks, weight of carry-ons, emergency oxygen systems, weight per minimum number of bathrooms, gate agents and airport gate rental fees.

What profit does a box of equivalent dimension and weight as the above mentioned passenger, make for a cargo airline?  A box with the same volume of space (41,472 cubic inches) and weight (185 pounds) costs an overnight cargo shipper, according to the shipping service requested, between $2200 and $4000.  There was a saying we had in the cargo airlines: Boxes don’t eat, drink, or complain … EVER!

It might have been incredibly profitable if Airbus designed the A380 as a cargo airliner for so many reasons.  The four engines would have been a benefit giving heavy freight a better range; less landings equals more straight flight time and less wear-and-tear on the airliner.  The interior volume could have been better utilized and not wasted on profit-killing luxuries.  The A380 might have given Boeing’s B747 a good competitive race, particularly at airports where shipments meet, e.g. coastal maritime shipping ports or straight routes into Middle Eastern Asia and the Far East.  Unfortunately, Airbus designed the A380 to show up the B747, to be the biggest jumbo jet made.  It was a gamble that, not only did not pan out, but may have cost Airbus too much profit. Through its many evolutions, the B747 introduced the age of wide body passenger flight in the seventies; it then pioneered another age: international freight hauling.  Its versatility made Boeing the true supergiant of the airliner industry; the B747’s fame continues to shine like a supernova; its influence will breathe life into the future of cargo airliners.  The A380, however, will fade to obscurity, becoming what a supernova leaves behind – an impossible to see, Black Hole.

Aircraft Accidents and Lessons Unlearned XXII: ValuJet 592

On May 11, 1996, a ValuJet DC-9-32 aircraft, registration number N904VJ, crashed in the Florida Everglades near Miami, Florida; a tragic end to a standard flight.  Oxygen generators in a Class D cargo compartment started a fire, which engulfed flammable items, including an aircraft tire.  The crew tried to get in front of fire-caused electrical and mechanical failures while the passengers were stuck in a metal tube filled with smoke.  It is unsure that anyone survived to impact in the Everglades.  The National Transportation Safety Board (NTSB) accident report AAR-97/06 (DCA96MA054) lists several probable causes of the accident in a rare two-paragraph form – more than necessary to answer the question: Why did ValuJet 592 crash?

The probable cause (PC) first paragraph states: the accident “resulted from the airplane’s Class D cargo compartment that was initiated by the actuation of one or more oxygen generators being improperly carried as cargo…”  Wait … What?  The bullets to this statement are that Sabretech (ValuJet’s repair station) had improperly labeled, packaged and loaded the oxygen generators on the aircraft; the oxygen generators were not made safe and should have been considered hazardous material.  ValuJet failed to properly oversee Sabretech and that the Federal Aviation Administration (FAA) failed to require smoke detection and fire suppression systems in Class D cargo compartments.

The second PC paragraph stated that “contributing to the accident” was the FAA’s failure to monitor ValuJet’s and Sabretech’s programs; the FAA’s breakdown of adequately responding to previous oxygen generator fires with programs to address these issues.  Last, that ValuJet failed to ensure Sabretech was aware of the ‘no-carry’ policy and provide proper hazardous training.  THESE are THE probable causes of the accident.  To those experienced in commercial airline operations, NTSB report AAR-97/06 reversed the significance of the two paragraphs, placing Operational Error second.  Why?

To understand the probable cause’s first paragraph, Class D cargo compartments, like that found on the DC-9-32, have been used in jet aircraft since the Boeing 707, i.e. 1957, almost forty years prior.  They are not containerized; the freight is loaded by hand, separated by netting and other restraint devices from movement that causes center of gravity shifts.  Cargo compartments don’t cause fires; if used as designed, they could not be the ValuJet 592 accident’s PC.  Neither the Class D cargo hold, the tire or the oxygen generators led to the accident; they were symptoms of a bigger problem: the Root Cause.

The term: probable cause, is a misnomer; it is a band-aid.  Probable, as defined by Oxford Dictionary, is: “likely to be the case or to happen”.  With accident investigation involving months and years worth of testing and analysis, the travelling public deserves more than “this is likely to be the” cause.  Discovering Root cause is much more effective; it is laser sighting.  An analogy: Break a weed on the surface (probable cause), the weed disappears for a while, but eventually returns.  To kill the weed, you dig the root out of the ground (root cause) completely; that’s how one stops the problem permanently.

The Class D cargo compartment, the oxygen generators and the tires were coincidences; three innocuous items brought together by Operational mistakes that led to disaster.  The worst kind of mistakes, they come from ignoring rules and policies, i.e. Operational Error.  THAT is why ValuJet 592 crashed.

Report AAR 97/06 supported its PC/Class D theory by referencing, first, a Saudi Arabian Airlines L-1011 which caught fire in 1980 in the C-3 cargo compartment during flight.  The source of fire was not determined, which begs the question: Why was it referenced?

The second example occurred February 3, 1988; American Airlines Flight 132, a DC-9-32, had an in-flight fire on final approach; the fire was started by a hydrogen peroxide solution (an oxidizer) and sodium orthosilicate in close proximity.  The combined chemicals didn’t burn, but, the report suggests, ignited combustibles in the luggage.  The root cause: the chemicals were not labeled as Hazardous, which was strictly Operational Error.  The accident report AAR-88/02, however, cited in four Recommendations about cargo compartments, focusing away from the Hazardous materials and Operational errors.

The decision to improve Class D compartment integrity was a good direction to take; any moves to improve safety are always welcome.  Shipping deflated aircraft tires is not dangerous nor is the shipment of oxygen generators.  Class D compartments should have been upgraded to make them safer, not because the Class D compartment ‘caused’ the accident.  Citing the Class D as the cause, probable or otherwise, distracted from the real culprit: a total disrespect for procedure, e.g. shipping hazardous materials in a cargo bay not rated for hazardous materials.  The issue became skewed.

Why the NTSB went in this direction was puzzling; logically, it made no sense.  It is like blaming the iceberg for the Titanic disaster; the iceberg did not hunt down and jump in front of the Titanic; the ship sunk due to human error in design (unsealed watertight compartments), in manufacture (inferior rivet materials) and in safety (moving too fast for available visibility).  A similar perpetrator that caused Titanic’s sinking was responsible for ValuJet 592: Culture.

A word search was conducted on report AAR-97/06, looking for the word, ‘culture’; it came up one time, in an FAA letter to ValuJet.  But culture was the one concept that escaped this NTSB investigation.  Why?  Because investigators MUST be experienced in commercial aviation.  How many investigators had/have worked for air operators or repair stations?  How many investigators had the career experience to relate to what was happening at ValuJet in 1996?  How many investigators have never: met a flight time; worked with competing cultures; dealt with union issues; experienced FAA inspector oversight; deferred a component; worked multiple flights; midnight shifts; got pressured from management; met a ‘hard down’ airplane; screaming flight planners; aircraft-on-ground (AOG) situations; weather; deicing; working with contractors and being solely responsible for an aircraft’s airworthiness?  In NTSB accident meetings I attended, culture issues were a foreign concept.  Then seven years after ValuJet 592, my NTSB maintenance investigatory group saw similar culture issues with the Air Midwest 5481 accident.

Why is culture so critical to ValuJet 592’s tragedy?  Because the accident happened during a time the contract maintenance provider (CMP) became an industry norm.  For years airlines accomplished their own maintenance or worked closely with other airlines with established facilities.  However, with the rise of low-cost airlines, e.g. Peoples, Air Tran, Southwest, and international expansions into foreign markets, overhead costs associated with maintenance were first to be targeted, e.g. manning, employee benefits, pay and heavy maintenance equipment; business expenses that could be transferred to the CMP.

While the NTSB did not know CMPs existed, the FAA had limited CMP experience, grasped even less about outsourcing.  This was further confused by the expanding Regional airline (RA) contracts.  Industry gave more responsibility to RAs and CMPs with no vested interest in the air operator.  The contractors learned expensive lessons about how far an airline would go to save money.  ValuJet’s CMPs outsourcing practices created problems with training and authorizations to conduct work.  ValuJet’s oversight of its contractors suffered, adding layers for the FAA to keep tabs on, all while ValuJet bought more aircraft and expanded.  This is how shipping oxygen generators as company materials got through the net.  Multiple cultures that repelled or clashed with each other, obscuring problematic issues.

Culture should have played a pivotal role in AAR-97-06’s probable cause because the FAA allowed ValuJet, a low-cost carrier, to get away from them.  ValuJet’s place in the market grew … at an irresponsible rate.  The airline exploited a good market, its popularity accelerated expansion.  ValuJet’s failure to oversee its contractors masked the FAA’s ability to oversee, especially outsourced maintenance.  If these red flags were mentioned in AAR-97/06, could the FAA have recognized similar problems with Air Midwest 5481 or Emery 17?  We will never know.

It is encouraging to know that one accident can prevent another, but only if the issues are recognized the first time.  The cycle should have been broken, repeat problems addressed and prevented.  We have seen/are seeing accidents that repeat themselves.  This just makes missed probable causes all the more frustrating.

Aircraft Accidents and the Rule of Law

I really dislike social media; it’s ridiculously political, unnecessarily sarcastic and lacking in common sense.  Consequently, as an author, I have to maintain a presence in social media, while trying to remain apolitical.  But sometimes it just gets silly.  I read an aviation tweet strongly condemning the President for misspelling the word ‘hamburger’.  To me, that is very silly.  In a moment of uncharacteristic exasperation, I responded: “With the dangers facing aviation in the government shutdown, we’re reduced to condemning the President’s spelling?”  This prompted a critic, someone else, who questioned my morals; he condemned me for being unfeeling towards illegal immigrants (I still don’t get that stretch).  His question, which he insisted I answer: “What are you [meaning me] so afraid of?”

Ah, the emotional argument.  At this point the corner had been turned; my common sense kicked in and I recognized the pointless argument.  Shaking my head, I ‘walked’ away and turned off my cell phone.

However, I would like to answer my critic who questioned my morals because, the truth is, I really am afraid.  What I’m so afraid of is Ignorance, specifically ignorance of the Rule of Law.  And, as a young aviation enthusiast, my critic should be worried too … so very worried.

As I’ve mentioned earlier, my grandparents arrived in the United States around 1910; they didn’t cross the Rio Grande River, they crossed the Atlantic Ocean, before processing in through Ellis Island.  As poor and desperate as they were, they followed the Law.  They walked into the United States’ immigration process with their eyes wide open, voluntarily, gladly and without regret.

Ignorance of – or the flat-out dismissal of – the principle that “law should govern a nation” drives a breakdown in society.  The United States is a nation governed by laws; that’s a Fact.  We always have been and always will be.  To convince a specific population, e.g. illegal immigrants, to ignore the Rule of Law, to repeatedly reenter the United States illegally, suggests that they will ignore all Laws, even a Sanctuary City’s Laws.  This disrespect for Law promotes offenses against innocence, like Kate Steinle’s murder.  What happens when the illegal aliens’ entitled disrespect for the Law reaches that fevered pitch, making senseless murders, like Kate Steinle, to become the norm, not the exception?

The Rule of Law applies across all departments of government: Commerce, Justice, State, Defense, Transportation, Interior, Labor, Homeland Security, Veterans Affairs, etc.  These departments all have their Laws, which we call Regulations.  They define what is fair, guaranteeing the safety of the people.  The continuous involvement of government employees in the affairs of the United States guarantees no foreign or domestic threat can interrupt the United States’ citizens’ integrity and safety.

However, these departments’ effectiveness is being neutralized by this shutdown, major interruptions that are due to ‘issues of the heart’ not the head; of opinion, not fact.  What are the fundamental factual arguments behind these furloughs?  What will the long-term effects be as a result of these lost weeks?

An aviation investigation took place several months ago … or weeks … or years; WHEN and WHERE are not important, but an aviation repair station (RS) was caught by the FAA intentionally conducting repairs unsafely, overhauling aircraft components against the manufacturer’s recommended instructions.  This had been going on for years.  The RS charged $2000 to overhaul a component unsafely, on hundreds of like components, annually.  Over the years their profits equaled hundreds of thousands of dollars just on that one component model … and they were approved to repair hundreds of other component models.  The Federal Aviation Administration (FAA), through time consuming research of records, caught the RS only once; the RS received one monetary fine of $5000.  Why did the RS defy the Law?  The RS found it cost-effective to defy the Regulations they were certified under.  The RS felt it was cheaper to pay the fine than obey the Law.  And these violators of the Law were not the exception.

In this case, the faulty overhaul did not result in an aircraft accident.  But other similarly operated repair stations did cause aviation accidents, with numerous fatalities. Would it matter how many Democrats were killed? Or Republicans? How about Socialists, Independents and Constitutionalists, would it matter? If the RS was in a largely Israeli/Jewish neighborhood in Brooklyn, should the FAA be called antisemitic or Nazis for investigating?  No, because aviation safety is not about matters of nationality.  If the RS was in Salt Lake City, should the FAA be called anti-Mormon or immoral?  No, because aviation safety is not about matters of faith.  If the RS was in a Cuban neighborhood in Miami, would the FAA be racist?  No, because aviation safety is not about matters of ethnicity. Their job is safety … period.

I’ve been researching aviation accidents for decades now.  Except for some weather-related accidents, I have found that the number of aviation accidents due to human negligence are almost at 100%.  ‘Almost’ was due to technical reasons: human error inputs into the airframe or powerplant designs, i.e. someone did not follow Title 14 of the Code of Federal Regulations (CFR) Parts 21, 23, 25, 26, 27 and/or 29.  The other 99.99% of accidents were due to someone not following the Law, aka, the CFRs.  This means that each accident’s root cause was due to deliberate violations of the CFRs by a mechanic, pilot, quality control inspector, flight planner, maintenance planner, air traffic controller, load master or manager.  Hundreds of travelers, perhaps thousands, since the 1960s, have died tragically because someone disregarded or was ignorant of Aviation Law.  A hard, true, unfeeling and impartial Fact.

These accidents occurred despite the direct oversight of overwhelmed FAA inspectors, who were also understaffed.  No, this isn’t an excuse for the FAA; it is another fact, that many FAA inspectors oversee as many as thirty-five Part 135 operators, twenty or more Part 145 certificate holders scattered across hundreds of miles; that Certificate Management Offices for major global 24/7 airlines with thousands of pilots and mechanics, only employ around eighty to one hundred FAA inspectors to oversee them all.  If past accidents are any reflection on the airline industry cultures, the desire to ignore Aviation Law will continue, especially when the FAA inspectors are absent during the government shutdown.

The Government Shutdown; how inconvenient.  As of this writing, the January 2019 government shutdown is now in week four.  The Department of Transportation, particularly (for this article) the FAA, has furloughed hundreds of inspectors who are not conducting surveillance, not visiting training facilities, not performing safety audits, not reviewing manuals and not overseeing ramp activities.  These duties keep backing up.  When the furlough ends, FAA inspectors will not only have to comply with what they have scheduled, but with what was left to chance during the furlough’s duration.

Mechanics and pilots are not receiving their certificates, air carriers are not receiving their supplemental type certificates, engineering questions are not being answered and planes are sitting without permission to ferry to maintenance bases.  This costs, not only the air carriers money, but thousands of pilots, air traffic controllers, mechanics and manufacturing jobs that are on hold until the furlough ends.  Even then, the backlog will take months to clear.  Is all this financial suffering in the private sector due to some elected officials’ idea that it is ‘immoral’ to follow the Rule of Law?

Laws and Regulations are made for good reason; this is embodied in events from the Titanic to 9/11.  All Laws have to be equally applied, to everyone.  If the FAA were to lose itself in emotion, their mission would be nothing but pounding the table.  Instead they research the Regulations, being fair and assuring that all certificate holders dealt with are following the CFRs – not just those who do, but those who try not to.  The contrast between following the CFRs or ignoring the CFRs, is the difference between concluding your flight safely at Point B or at a smoking hole.

And, in answer to a certain critic, that is what I’m so afraid of.