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 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.

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.