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Proactive Aviation Safety, Belatedly

Too many organizations get serious about aviation safety after the funerals for employees killed in chartered carrier crashes. Illinois State University (ISU) may be the latest to substitute genuine oversight for hope in the reliability of the charter operator.

The aftermath of the crashed flight

The aftermath of the crashed flight

On 7 April, 2015, a Cessna 414A twin-engine airplane, operated by Make It Happen Aviation, crashed approximately two miles from its destination, Central Illinois Regional Airport in Bloomington, Illinois. The single pilot and all six passengers were killed. Among the victims were the deputy athletics director and the associate head coach of the ISU Redbirds basketball team. Team boosters comprised the other passengers. They were returning from the final four college NCAA basketball tournament in Indianapolis.

The crash occurred shortly after midnight in foggy weather, with light rain and visibility for half a mile. The flight was descending to land, then the ground radar plotted an increase in altitude, suggesting a missed approach or, worse, the pilot’s loss of spatial orientation. In any event, no radio transmissions were received from the airplane about a climbing circle for a second landing attempt. The airplane dropped off radar coverage; three hours later, at approximately 4 a.m., the wreckage and the bodies were discovered by police and firefighters who were called to search the area.

The airport tower had closed at 10 p.m., but it is not unusual — although not necessarily safer — for airplanes to land at airports without trained air traffic controllers in the tower.

A short, one-hour, flight ended in disaster

A short, one-hour, flight ended in disaster

Coincidentally, on the same day as the crash, the National Transportation Safety Board (NTSB) issued a safety alert titled “Understanding Flight Experience.” The NTSB argued that “Pilots may have many hours of experience” and “Even if operating a specific type of aircraft is allowed by regulations, it does not mean the practice is safe.” The alert cited four general aviation accidents in which experienced pilots nonetheless crashed their aircraft.

The crash in Bloomington is part of the larger pattern of wrecked airplanes and lives cut short.

ISU issued a statement: “Words cannot fully express the grief that is felt in the wake of such a tragedy. We move between shock and profound sadness.”

After a period of grief, ISU may wish to examine Oklahoma State University’s (OSU) grim experience in January 2001. A Jet Express Services aircraft, a Beechcraft Super King Air 200 with twin power plants, was returning from Colorado to Stillwater Regional Airport in Oklahoma. It was one of three airplanes chartered to fly the school’s basketball team home after a game with the University of Colorado at Boulder.

The airplane crashed shortly after reaching cruising altitude. The sole pilot and the nine passengers were killed.

Similar to the crash in Illinois, the event was at night, with a lone pilot flying past his usual bed time in wintry overcast weather. In this case, the pilot was preoccupied with an electrical failure and probably did not sense the airplane’s right descending turn.

The airplane did not have, and was not required to be equipped with, a standby attitude indicator powered from a separate source.

As a source close to the investigation recalled, “The King Air was designed and certificated for single pilot operation and also to a lower certification standard — although the FAA [Federal Aviation Administration] would say ‘different’ — than air carriers. Therefore, it does not have some of the equipment found on an air carrier, such as standby instruments.”

“Of course, the issue is that passengers are unaware of the difference in the certification of a King Air versus, say, a B737 [airliner]. They assume it’s all the same,” the source added. That is, if they even think about FAA approval of an aircraft design.

The NTSB investigated the crash of the King Air, as it is now investigating the crash in Illinois of the Cessna light twin.

Many of the findings from the earlier investigation can no doubt be included verbatim in the 2015 crash:

– The pilot was properly certificated and qualified under Federal regulations.

– The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any pre-existing structural, engine, or system failures.

– The accident was not survivable for any of the airplane occupants because they were subjected to impact forces that exceeded the limits of human tolerance.

– Oklahoma State University did not provide any significant oversight for the accident flight.

Fifteen months after the accident, in April 2002, OSU published an eight-page policy regarding athletic team travel, which included athletes, coaches, mascots, managers, etc.

Extracts of this policy may be instructive:

“All air travel, except the use of commercial air carriers, shall be subject to the review of the institution’s aviation consultant.”

“The University will, through competitive proposals, retain an aviation consultant. Such individual or firm must have expertise in operations, safety and certification for the purpose of evaluating the certification and safety records, of charter air carriers, time-share and other aircraft and assure pilot certifications are in keeping with this policy….”

“The institutional aviation consultant shall have final approving authority for approving a firm/aircraft for purposes of this policy.”

“Two pilots will be required …”

“Charter aircraft used according to this policy must be maintained under the appropriate FAA operations specifications….”

“…weight and balance computations using average passenger weights are prohibited. A weight and balance form must be completed for each flight using actual weight figures for passengers…”

The policy goes on in this vein, being very specific. The table immediately below summarizes the impact of the policy:


The Difference an Accident Makes

OSU Athletic Team Travel Policies


Before the Accident Crash occurred the night of 27 Jan. 2001

After the Accident Policies in effect after 22 April 2002

Number of pilots

Copilot optional, depending on weather and/or length of trip. Accident pilot often flew as a single pilot because
OSU athletic staff wanted to use all the seats.

Two pilots required; no exceptions.

Pilot qualifications

OSU pilots required or qualified hired part-time pilots, instrument rated, commercial pilot’s license, minimum of
2,500 hours as pilot-in-command, and 500 hours in multi-engine airplane.

Must be full time pilot with 1st class medical certificate, type rated in airplane to be used, minimum of 200 hours flying in past 90 days, and three instrument approaches and
three night landings in the past 90 days. Copilot must have multi-engine and instrument ratings, including 100 hours in type, 10 hours in past 90 days, and three instrument approaches and three night landings in past 90 days.

Flight conditions

Day or night in visual or IFR (instrument flight rules) conditions. Pilot judgment regarding whether conditions were safe for the trip.

All flights operated on IFR flight plan; aircraft may not depart into forecast hazardous weather conditions, including
severe icing, thunderstorms, severe turbulence or wind shear. Passengers cannot enter the cockpit or distract pilots when aircraft is below 10,000

Use of donated aircraft

Permitted. Accident aircraft was donated.

Donated aircraft permitted for coaches and staff but not flights carrying student athletes. Donated aircraft must be
powered by two or more turbine engines — which would rule out piston

Outside, independent advice


Aviation consultant retained to evaluate certification and safety records of charter air carriers, time-share and other aircraft, with final authority for approval.

Aircraft maintenance

No specific provisions

An FAA-certified repair station or the manufacturer must perform inspections and maintenance. Maintenance personnel
must be appropriately rated and must have trained within the previous five years
on the aircraft type they are maintaining.

Following the recent crash in Bloomington, chances are that Illinois State University opts for similarly strict policies regarding aviation. Hope is no substitute for prudent oversight.

Deadly Cessna 414 Crash: Looking Beyond Pilot Error

On Tuesday morning, April 7, 2015, a twin-engine Cessna 414 was recovered after crashing near the Central Illinois Regional Airport in Bloomington Illinois. Seven victims of the crash were recovered including Scott Bittner (42), Bittner’s Meat Co.; Terry Stralow (64), a partner in Pub II; Aaron Leetch, (37), ISU deputy director of athletics for external operations; Torrey Ward, (36), associate head coach of the Redbirds men’s basketball team; Thomas Hileman, (51), the pilot; Andy Butler, 40, a regional representative for Sprint; and Woodrow “Jason” Jones, (45), a senior vice president and certified financial adviser at Wells Fargo Advisors.

First responders on the scene

First responders on the scene

The plane was registered to “Make It Happen Aviation” of Towanda, Illinois. The plane was being piloted by Thomas Hileman, who held a valid flying certificate, had over 12,000 hours of flight time, and had undergone a medical check-up in early February.

At the time of the accident conditions at Central Illinois Regional Airport showed declining visibility and light wind. According to reports, the plane had been in contact with air traffic control in Peoria, which typically handles communication with airplanes after the Central Illinois Regional Airport radio tower closes at 10:00 p.m.

According to Carl Olson, director of the airport, Peoria air traffic control lost contact with the plane just after midnight. Olson also said the pilot did not indicate any trouble and had not made any alterations to the registered flight plan.

While the airport control tower normally closes at night, it is common for planes to land after hours with runway lights illuminated. Pilots also have the ability to remotely indicate they need the runway lights turned on. In a Chicago Tribune report, Todd Fox, an air safety investigator for the National Transportation Safety Board, said the pilot had been cleared for an instrument landing on Runway 20 at the airport and that the plane began to climb out of its descent into Central Illinois Regional Airport as if it had missed its approach. According to Fox, if that is what happened, the plane should have climbed and turned west. Instead, according to Fox, it turned east. “The aircraft was seen (on radar) to climb and then descend well on this easterly heading before crashing in a farm field just east of the airport,” Fox said. The final radio communications from pilot Thomas Hileman, as the plane neared the airport, included no sign of distress.

Reports state that the plane went down in a bean field north of Illinois Route 9 off a paved county road. Emergency crews located the plane around 3:15 a.m. The wreckage was found “within one wingspan” of the main fuselage, according to Fox, which should help investigators inspect the aircraft. All seven passengers were found dead still strapped into their seats. All had died from blunt force trauma resulting from the crash, said Coroner Kathleen Davis.

While weather conditions have been sighted as a possible cause of the accident a preliminary report is expected sometime next week. The FAA and the National Transportation Safety Board are investigating the accident and a final report will most likely take a year to 18 months to complete.

There have been other unexplained crashes of Cessna 414A aircraft. Back in 2000, a Cessna 414A crashed near Hyannis, MA.  Immediately before the crash the pilot had told air traffic control that he lost the artificial horizon on his instrument panel. While a survey conducted by Aviation Consumer says the Cessna 414 twin-engine has a fairly low fatal accident rate (boasting 0.8 fatal accidents for each 100,000 hours of flight time), questions are sure to be asked during the investigation regarding why the plane tuned east instead of west, were the flight control instruments working properly, how many hours of flight time Pilot Hileman had in this particular model and type of multi-engine aircraft and when was his last proficiency check?


Compliance with Airworthiness Directives and Service Bulletins

In an article titled: “Cessna 414 Used Aircraft Report: Buying Before Extinction,” written by Peter A. Bedell, AOPA Pilot, Bedell states that the Cessna’s 414 is among a large group of aircraft headed for extinction. However, he notes, the market for these airplanes remains active.

Bedell states that early 414s can be recognized by their tip tanks and stubbier nose. In 1976 Cessna redesigned the 400 series beginning with the 421. The changes eventually made their way to the 414 in 1978 and it was renamed the 414A Chancellor.

The redesigned airplane had a wingspan that was 4.5 feet longer and a nose extending nearly 3 feet. The fuel capacity reached 206 usable gallons, and the fuel system was made simpler with an On/Off/Crossfeed valve for each engine. Previous 414s had as many as six tanks and made for difficult fuel management. Continental’s TSIO-520-J powered the original 414s, while the TSIO-520-Ns pulled the 414A. Both models were rated at 310 hp at 2,700 rpm. Since most of these airplanes are operated in the unpredictable environment of the flight levels, the 414’s engines have had their share of problems. The engines are sensitive and don’t respond well to abrupt throttle movements or casually monitored engine operations.

The engines began life with a TBO of 1,400 hours, which was later extended to 1,600 hours; but, according to many owners, Bedell says, the 1,400-hour figure is a more accurate estimate of the engine’s lifespan.

Given the airplane’s average of logging 200 or more flight hours per year, one could ask if the aircraft owner had complied with most of the engine ADs or service bulletins, such as those requiring replacement of crankshafts made via the airmelt process. Exhaust manifold clamps and elbows have a 100-hour inspection requirement. Finally, a recent AD regarding recurrent inspections of McCauley three-blade propellers covers the 414 line as well.


Limited Load-Carrying Capacity

Although the 414s have a huge cabin-class interior, they have never been a large load hauler. A typically equipped 414A has a full-fuel load of about 500 to 700 pounds, depending on equipment. Although you could fly for about 1,100 miles, you would be able to bring only two friends and a few bags. In a well- equipped airplane weighing in at 5,100 pounds, you could fill the cabin with six people and a little baggage and fly for about 2 hours with IFR reserves. It’s because of this limited load-carrying ability that many operators opt for modifications. Among the questions Nolan Law Group is asking are: how old is the plane? What modifications have been made and how recently? What baggage was on board in addition to the seven occupants?

The Cessna 414A is a large cabin class, piston twin. Flying high with its comfortable pressurized cabin, the 414 can carry up to 7 passengers.

The Cessna 414A has a large comfortable pressurized cabin. The 414 can carry up to 7 passengers.

As part of its’ own preliminary independent investigation Nolan Law Group has reviewed accident reports compiled by the AOPA Air Safety Foundation. Reports state there were 46 accidents involving 414s between 1983 and 1993. The pilot has been cited as being responsible for almost every 414 accident, and weather was a common link in the accident chain. However, many accidents that occurred after engine failures involved airplanes loaded far beyond the maximum gross weight and flown improperly with a failed engine (for example, with the gear and/or flaps down). Single-engine rate of climb is listed as 240 feet per minute for the 414 and 290 fpm for the 414A with the gear and flaps up.

The 414’s have a spacious cabin. Unfortunately, the stock 414s have more room than the useful load allows.

The 414 can fly six people on a 2-hour trip in a comfortable pressurized cabin or it can fly two people some 1,200 miles. On the other hand, the big cabin results in an equally big speed penalty.

While many facts and circumstances of the accident remain unknown and the NTSB investigation is expected to take more than a year, attorneys at Nolan Law Group continue to question factors beyond “pilot error” as causal or contributing to this crash. Ultimately, those causes and contributing factors must be analyzed to determine who bears liability for the crash, an analysis that the NTSB is prohibited from making.  As a firm concentrating in aviation accident claims, Nolan Law Group routinely monitors accident investigations such as the Bloomington tragedy for similarities, differences and safety trends. The firm handles claims and litigation on behalf of victims and families of victims of aviation accidents ranging from small, general aviation aircraft to large commercial airliners.

Flight into the Valley of Depression

A statement appeared in a New York Times article about the crash of Germanwings Flight 4U9525 that passengers will not see reprinted in the in-flight magazine stuffed into their seat pocket: “Having a mental illness does not necessarily mean one cannot successfully fly a plane.” Given that depression can often lead to unpredictable behavior, piloting a passenger airliner seems decidedly more risky than, perhaps, driving a car.

This statement was in the same paragraph discussing a certificate issued by the Federal Aviation Office of Germany that allowed First Officer Andreas Lubitz to fly. Lubitz was seen at a clinic in Germany on March 10th, for unspecified reasons. This date was just 14 days before Lubitz locked the captain on a lavatory break out of the cockpit. With the captain frantically banging on the door to be let back in (“For God’s sake, open the door!” the captain pleaded), the isolated first officer programmed the autopilot to fly the airplane so low that a collision with the Alpine mountainside was inevitable. The fact that the captain could not regain access to the cockpit will doubtless be a topic covered by the investigation. In the U.S., pilots have a secret code that they can enter if locked out of the cockpit, a feature evidently absent on the Germanwings A320.

The A320 jet slammed into the rocky slope at a speed in excess of 400 mph. At that speed, the tip of the nose and the tailcone impacted a quarter second less from one another in a violent telescoping collision with unyielding terra firma. Pieces of metal and pieces of the bodies of the 150 persons aboard were strewn over the mountainside. Death was blessedly instantaneous, although some in the passenger cabin were aware of the mortal danger entailed in flying low in the French Alps. Looking out the windows on that clear, sunny day, they would have been horrified to see peaks ascending hundreds of feet above their flight path.

The descent to death was probably deliberate, as Lubitz would have received ample notice of the mortal danger from aircraft systems, particularly the Terrain Avoidance Warning System (TAWS). This system looks out ahead and compares the airplane’s flight path to a digital terrain map stored in the computer. When flying 1,000 ft above any mountains, the terrain map shows the high terrain in green — the airplane is comfortably above any terrain ahead. If the airplane’s flight path takes it below the 1,000 ft clearance, the terrain will change color to yellow, the universal color denoting caution.

If the flight path takes the aircraft to within or below the highest points of terrain ahead, the terrain will be color-coded red on the digital map display in the cockpit. Within approximately 40 seconds of projected ground impact, a computerized voice will sound, “Terrain. Pull up!”

Lubitz sat there, doing nothing. Those on the ground reported that they did not hear the sounds of engines spooling up, which would indicate a last-second attempt to add power and climb as the rocky hillside loomed ever larger in the windscreen. Lubitz rode the airplane right into the boulder-strewn slope.

The terrain warning system was ignored

The terrain warning system was ignored

Now, scores of European airlines belatedly have instituted a “two persons in the cockpit at all times” rule. If one of the pilots has to leave the cockpit for a bathroom break, a flight attendant must come to the cockpit and be present while one pilot is aft in the cabin. This procedure has been standard, as mandated by the Federal Aviation Administration (FAA), ever since two-pilot aircrews and locked cockpit doors have prevented the unique threat of a one-pilot failure — medical or mental — on the flight deck. It took the deaths of 150 people for European airworthiness authorities and airlines to wake up to prohibit solo cockpit occupancy. One is prompted to ask, were you people willfully ignoring the hazard?

Also, pointed questions apply to carrier Germanwings and its parent, Lufthansa. First Officer Lubitz was a flight attendant before becoming a very junior pilot. Did depression or any mental condition manifest itself in his prior employment as a member of the cabin staff? Was he seeking mental health care during this earlier time and, if so, was this known by his employer?

If strict privacy rules pertain in Europe regarding the doctor-patient relationship, does public safety enter into the equation? If a pilot with a serious heart condition is not allowed to fly, surely mental depression should qualify for grounding. News reports indicate that Lubitz was worried about his eyesight; vision problems would have been revealed during company-mandated physicals.

In searching his apartment, authorities found doctors’ notes in a trash can. The torn and rumpled notes said Lubitz was unfit for work. Prescription medicines were found showing that he was being treated for psychological problems. A girlfriend indicated that he had nightmares about flying and that he had complained about not being treated properly by the airline and co-workers.

Lubitz was an avid jogger, but running was no antidote to mental turmoil

Lubitz was an avid jogger, but running was no antidote to mental turmoil

There is mounting evidence suggesting that Lubitz was in a deeply depressed state of mind.

If he was mentally disturbed to the point of being suicidal, his case mirrors others:


Possible Pilot Suicides In Airliner Crashes
Date Airline Location Deaths
March 24, 2014 Germanwings Flight 4U9525 French Alps 150
March 8, 2014 Malaysia Airlines Flight 370 Indian Ocean 239 Note: investigators are still trying to determine if the crash was caused by a deliberate pilot act
Nov. 29, 2013 Mozambique Airlines Flight 470 Namibia 33
Oct. 31, 1999 EgyptAir Flight 990 Atlantic Ocean 217
Dec. 19, 1997 Silk Air Flight 185 Indonesia 104
Aug. 21, 1994 Royal Air Maroc Flight 630 Morocco 44
Feb. 9, 1982 Japan Airlines Flight 350 Tokyo Bay 24

There is a need for periodic testing of the psychological health of pilots, according to Canadian psychiatrist Dr. Daniel Cappon. After the apparent actions of relief pilot Gamil el Batouti in the crash of EgyptAir Flight 990, Cappon declared in Toronto’s Globe and Mail newspaper, “[T]he mental problems of some pilots may be more widespread than what has been reported.”

For this reason, he argued, “The public must insist on new legislation to enable medical authorities to detect early mental dysfunction in flying personnel and in air traffic controllers.”

He believes psychological testing can identify at-risk pilots. Cappon disagrees with the view of some pilots that psychological screening would not catch problem pilots. “That’s like saying x-rays won’t identify a cancer,” he said in a 2000 telephone interview with this writer. The test he has in mind involves some 300 items of background information, plus 120 additional items of what he calls the “foreground” aspects of a pilot’s mental health. He believes the focus of the periodic checkup ought to be changes, from the focus on finding the absence of health to one of the presence of physical fitness, to include the presence of mental and social fitness.

These vital signs of the “whole person”, Cappon maintains, are too often left to “casual verbal inquiry by physicians”. He believes the depth of psychiatric inquiry should equal the rigor of the physical examination.

The pilot’s lifestyle certainly argues in favor of periodic mental evaluations. There are the demands of the flying schedule, the family separation, the commute to and from work, the nights in a hotel, the disruption of sleep, the enervating routine of checklists and procedures, the stress added by bad flying weather, unruly passengers, and the list goes on…

The flying profession is one of boredom, rote, and routine — hardly the glamorous one often presented in motion pictures.

In his newspaper article, Cappon wrote:

“The vast majority of pilots and aircrews are extremely brave and resourceful people … Their heroism has saved countless lives … But, having dealt with many of these problems, I think that when pilots’ ailments threaten flying safety, better control must be exercised.”

When the captain of Germanwings Flight 4U9525 left the cockpit, he told First Officer Lubitz, “You’re in control.” Implicit in that statement was the assumption that the first officer would maintain the safety of the flight, not mortally endanger it.


In the middle of an intense snowstorm, with the wind blowing from the rear of the airplane and across the runway, Delta Air Lines Flight 1086 touched down on La Guardia’s Runway 13. Moving at 153 mph, the jet almost instantly began skidding.

Passenger Steve Blazejewski occupied a left-side window seat. The airplane felt “out of control”, he recalled. “We were skidding forward but veering off to the left. I said to myself that we were going to go into the water.” He was referring to Flushing and Bowery Bays right alongside the runway.

The airplane veered left and departed the runway about 3,000 ft. from the approach end. The runway is 7,000 ft. long.

At 4,100 ft., as measured from the approach end, the left wing struck the perimeter fence, which is located on top of an earthen berm designed to keep water out of the airport during flooding. The airplane tore along the top of the berm, wrecking perimeter chain-link fencing as it went. With its nose teetering over the water, the damaged airplane finally slid to a stop.

“Two seconds more and we would have been in the water”, recounted passenger Jared Faellaci.

The 125 passengers and five crew members evacuated through available exits, many without coats and shivering in the cold. Contrary to flight attendant instructions, some passengers exited with their carry-on bags.

The earthen berm beside the runway stopped the airplane from sliding into the water

The earthen berm beside the runway stopped the airplane
from sliding into the water


The wrecked airplane was towed to a nearby hangar, where it will doubtless undergo intense scrutiny by members of the National Transportation Safety Board (NTSB).

While a few passengers suffered bumps and bruises, no one was seriously hurt. Nevertheless, the NTSB has a number of issues here that bear scrutiny as the lengthy investigation proceeds.

► First, why was the airport even open for takeoffs and landings? After the crash, the airport was closed for a few hours; however, by late afternoon, it was open as if the crash never occurred.

On March 5, 2015, the day Delta Flight 1086 left Atlanta for the trip to New York, the northeastern United States was in the midst of a heavy snowstorm. Amtrak trains were delayed or stalled due to power outages. Highways were a slick mess, with multiple accidents as trucks and cars slipped and careened into one another on the icy roads. Semitrailer trucks and cars in ditches were all-too-typical. Many airports were closed. More than 21% of all commercial flights (4,892 to be exact) were cancelled that day due to the stormy weather. Add in the delays and about 40% of the day’s airline flights were either late or scrubbed altogether.


The snowstorm of March 5; Washington DC is pointed out, but New York City was definitely affected, right smack under the blue cloud mass

At New York City’s other two airports, JFK and Newark, inbound landing delays of more than three hours were attributed to snow and ice.

La Guardia received a total of 8 inches of snow on March 5th. Blowing snow reduced visibility. The captain of the Delta jet told the NTSB that Runway 13 appeared “all white” when the aircraft broke out of low overcast moments before landing.

How severe must the bad weather be before airport authorities decide that the risks of further operations outweighs the flying schedule, and close the airport to further arrivals and departures? The practice of flying in any weather to maintain schedule is too dangerous.

► Second, when the airplane touched down, the spoilers did not deploy automatically. The first officer quickly deployed them manually.

Spoilers are panels on the upper wing surface which open after landing. Essentially, they dump lift and put weight on the main landing gear so that the brakes will have maximum effect.

Quick deployment of spoilers is especially important at La Guardia’s Runway 13. The runway is relatively short, only 7,000 feet long. Moreover, this length is achieved through a pier built out over the water, thereby lengthening the runway beyond the land. This feature meant that the runway on the pier would tend to freeze over before the landward tarmac. Recall the sign posted on highway bridges: Caution, bridge freezes before highway pavement.

Path of DAL Flight 1089 Note that Runway 13 is built on pylons to extend its length, but the surface atop the pylons was subject to freezing before the landward portion of the runway

Path of DAL Flight 1089
Note that Runway 13 is built on pylons to extend its length,
but the surface atop the pylons was subject to freezing before the
landward portion of the runway

The wind blowing from the right rear did not help. It tended to push the airplane down the runway and to the left. It was critically important to kill lift and get on the brakes.

The failure of spoilers to activate automatically occurred before. It was in the fatal overrun during an intense thunderstorm at Little Rock, Arkansas, in June 1999. The same kind of airplane, an MD-80, this time with American Airlines livery, skidded down the drenched, slick runway and rocketed off the far end, finally coming to a stop amongst the rip-rap rocks just short of the Arkansas River. The captain and 10 passengers were killed. Only 24 of the 139 passengers escaped uninjured.

The first officer was in the habit of noting to himself that the spoilers were armed before touchdown. The NTSB concluded the spoilers were not armed. Nor did American Airlines have a procedure for pilots to call out after touchdown should the spoilers fail to deploy.

In December 2001, the NTSB recommended to the Federal Aviation Administration that all airlines must require dual crew member confirmation before landing that spoilers are armed. The FAA subsequently modified its Advisory Circular (AC 120-71), “Standard Operating Procedures for Flightdeck Crew Members”, to include dual crew member confirmation that the spoilers are armed before landing.

It is important to note that an advisory circular does not require compliance by the airlines. The NTSB urged that dual crew member confirmation of arming spoilers be a required procedure.

Whether Delta Air Lines learned anything from the 1999 overrun at Little Rock is hard to say at this point. It seems certain that NTSB investigators will probe into Delta’s pre-landing checklists and captain/first officer dual confirmation of spoilers armed in preparation for landing.

Precious seconds of braking opportunity were lost as the crew had to identify the lack of spoilers and then manually activate them. Without spoilers, 90% of the airplane’s weight is borne by the wings. Only 3% of the weight is on the nose gear. Without spoilers, only 7% of the airplane’s weight is on the main landing gear, which severely compromises landing distance.

► Third, where was the instrumented truck that is normally used to assess runways for braking efficiency? The tower controller said pilots who landed immediately ahead of Flight 1086 reported braking was “good”. Did they touch down at the same point on the runway? Did the spoilers on their airplanes activate automatically?

Reports of 'good' braking action were, in this case, highly optimistic

Reports of ‘good’ braking action were, in this case, highly optimistic

The fact is that “good” braking action is judgmental. A more reproducible measure is needed. That is the purpose of an instrumented truck, to render a precise report of the runway and braking effectiveness thereon.

Did La Guardia have an instrumented truck, as is the case at many airports with icing conditions? Was it in the garage at the time?

► Lastly, this case illustrates the folly of selective application of safety protocols. Specifically, the FAA has ordered airlines to implement a risk-based Safety Management System (SMS), whereby latent hazards in operations are supposed to be identified and corrected. The January 2015 SMS mandate was not applied to airports, only airlines (see “A Tardy & Myopic Approach to Air Safety”).

Let us consider some of the problems at airports that have occurred: takeoffs and landings on taxiways; airplane-to-airplane collisions on taxiways; service truck and baggage tow tractor collisions with each other and with airplanes; passenger buses and baggage trains colliding on the route from airplane parking to the terminal; confusion and incidents/accidents regarding airport construction and “works in progress” signage; and, not least, decisions to remain open during severe weather.

These are just a few of the noteworthy risks that are independent of the airlines and are unique to the operation of the airport. Yet, as reported in this space, the FAA will not require SMS of airports when its order takes effect in 2018 (years late, it should be added). An entire and grim record of airport mayhem was ignored by the FAA.

Here’s betting that if La Guardia had SMS in place, a so-called “latent hazard”, such as eight inches of snow, would have been sufficient to close the airport. In that case, Delta Flight 1086 would have numbered among the hundreds of flights cancelled on March 5th. As the torn-up chain link fence and damaged airplane (not to mention frightened passengers) demonstrated, a decision to close the airport would have been fully justified. Without a requirement for airport managers to implement SMS, there is no structured, proven methodology for mitigating risks at airports.

Risk avoidance should be the overarching ethic, not risk-taking.

After Banging Up the Airplane and Runway Lights, Corrective Action

Human error can never be reduced to a zero-probability event; therefore, the notion of an accident-free airline transportation system is nothing more than a feel-good myth, especially if corrective action follows rather than precedes a mishap.

The August 5, 2013, nighttime landing of Korean Air Lines flight KAL763 at Niigata Airport on the west coast of Japan is an excellent case in point. After the accident, KAL instituted additional procedures and pilot training to forestall a repeat — the word “prevent” is not used here because the human mind can foul up in an infinite number of ways.

The serious incident investigation report of January 29, 2015, by the Japan Transport Safety Board (JTSB), will serve as documentation of the event.

The KAL aircraft was a B737-900 with 106 passengers aboard, seven flight attendants and a cockpit crew of two pilots. The captain was the pilot flying; the first officer was the pilot monitoring.

It was an uneventful one-hour and 45-minute flight from Inchon, South Korea.

The Niigata tower controller cleared the airplane to land on runway 10, which the KAL 763 crew acknowledged. From the opposite direction, the tarmac is designated runway 28.

The autopilot and autothrottle were disconnected at an altitude of 1,000 feet.

The flight crew made all the necessary call-outs, acknowledgments and read backs. The landing was stabilized; touchdown was at a normal and nominal 143 knots (165 mph).

Thrust reversers were deployed. Brakes were applied at 69 knots (79 mph).

Niigata tower radioed the aircraft: “Korean Air seven-six-three, turn right end of runway Bravo One (B1) and taxi to spot cross runway two-four/two-two (04/22).” This was the instruction to exit the runway and make another right turn and cross 04/22 again while taxiing. Runway 04/22 crosses runway 10/28.

The first officer radioed acknowledgment to the tower: “Cross runway 04/22, end of runway right turn.”

The captain noted, “Cross runway 04/22.”

The first officer wondered, “Cross runway?”

Events rapidly started to go downhill.

Neither pilot had been to Niigata in some months, and it was the first officer’s first night landing at the airport.

The airplane roared through the intersection of runway 10/28 and runway 04/22. Braking was insufficient to stop the airplane from running through the runway 10/28 threshold lights. The airplane tore up a bunch of lights and screeched to a stop with its nose wheel dug into the grass and the main landing gear right at the paved edge.

Not according to plan; it could have been worse

Not according to plan; it could have been worse

No one was hurt, but no doubt there was much embarrassment in the cockpit.

The first officer later said he was confused about whether the red lights looming ahead were the stop bar lights for runway 04/22 or the threshold lights at the far end of runway 10/28.

The captain said he assumed the lights signified the stop bar for runway 04/22; not realizing the lights marked the threshold for runway 10/28, he tried unsuccessfully to brake before running out of pavement.

The air traffic controller had radioed “turn right end of runway Bravo one …” indicating the B737 was to exit runway 10 after crossing runway 04/22, as that exit was right at the end of runway 10 and past the intersection of the two runways.

The first officer had read back the clearance in inverted sequence, indicating the intersecting runway first and then the taxiway exit. The tower controller did not catch that the flight crew might have misinterpreted his instruction to turn off runway 10 at the B1 exit and then cross runway 04/22 on the way to the terminal.

Schematic of runways 10/28 and 04/22, with tire skid marks exceeding 500 ft as the crew tried to stop

Schematic of runways 10/28 and 04/22, with tire skid marks exceeding 500 ft
as the crew tried to stop

As the investigation report theorized, “It is highly probable that the Captain and the F/O did not have enough time to confirm with the Niigata Tower or discuss among them [sic] about the meaning of the instruction of ‘cross runway 04/22’ at this point.” However, the crew had been cleared to use the entire length of runway 10 before landing. In telling the crew that they were cleared to cross runway 04/22 after landing, the tower controller was being doubly assiduous.

There was no illuminated sign indicating the juncture of runways 10/28 and 04/22, nor was there a requirement to have such a sign in place.

The investigation report concluded that the tower instruction had been misinterpreted and that the flight crew was short of the intersecting runway during the landing roll out, at too high a speed to stop before the end of pavement.

For Niigata airport, procedures were subsequently changed to have the tower controller radio “Affirm” upon receipt of a correct read back. For example:

            Upon vacating runway 10

            Controller: (Call Sign), turn right end of runway Bravo One (B1).

            Pilot: (Call Sign), roger, turn right end of runway Bravo One (B1).

            Controller: (Call Sign), affirm.

KAL changed its procedures. Among them, “The aircraft must be decelerated to an appropriate safe taxi speed (maximum 30 kt) before 1,000 ft from the planned runway exit point.”

A few observations are in order.

The wrong comforting assumption or a moment’s unvoiced doubt can have dire consequences.

Intersecting runways are common to many airports. An illuminated sign marking the intersection should be required.

The controller’s confirmation of “Affirm” (or not affirmed) should be the standard procedure at ALL airports worldwide, not just at Niigata.

Decelerating to a minimum safe speed 1,000 feet from the planned runway exit point should, likewise, be a prudent procedure at all airports around the globe.

Here are three latent hazards that combined to produce an overrun (the JTSB report has more). There is no indication that they will be shared among airports or airlines for their universal applicability.

One fears that each airport and each airline must experience similar events to correct after the fact.

Neither the airline industry nor government regulatory bodies take a pro-active approach — that is, before incidents or accidents occur — to safety.

Safety Board Recommends Action to Prevent Another Jetliner From Disappearing

Ten passenger planes have gone missing without a trace since 2000, according to Harper’s magazine Index in the March 2015 issue of the magazine. The Aviation Safety Network, based in the Netherlands, shows 85 aircraft — including passenger airliners, corporate jets, cargo and military — have utterly disappeared since 1948.

Hundreds of lives have vanished. Officials have some idea of the location (ocean, country), but beyond that, no specifics.

The most recent disappearance was Malaysian Airlines Flight 370, with 239 aboard. The airplane is believed to have plummeted into the sea off the west coast of Australia after exhausting its fuel on March 8, 2014. Authorities mounted a great search — patrol planes in the air, ships on the water’s surface, and submersibles deep in the depths — and they have not found a thing. The critical flight data and cockpit voice recorder (FDR/CVR), mounted in the tail of the aircraft, remain hidden in their watery grave. Without these recorders, details of the B777’s disappearance remain an abiding mystery.

A visual search, hoping to find floating debris from MH370

A visual search, hoping to find floating debris from MH370


Below the waves, the search area off the coast of Australia; 3,000 foot depressions and summits that make the European Alps look like foothills complicate the search for the wreckage of MH370

Below the waves, the search area off the coast of Australia; 3,000 foot depressions and summits that make the European Alps look like foothills complicate the search for the wreckage of MH370

Even though it was a foreign airliner lost far beyond the borders of the United States, the U.S. National Transportation Safety Board (NTSB) has recently urged the Federal Aviation Administration (FAA) to undertake technical improvements that would make a disappearance of Malaysian Flight 370 a thing of the past. The January 22, 2015, letter also urges the FAA to mandate additional flight recorder improvements, to include a closed-circuit television recorder to capture the scene in the cockpit during the last moments of crisis.

“Technology has reached a point where we shouldn’t have to search hundreds of miles of ocean floor in a frantic race to find these valuable boxes,” declared NTSB Acting Chairman Chris Hart, referring to the FDR/CVR. “In this day and age, lost aircraft should be a thing of the past.”

Indeed, technology to preclude utterly losing the whereabouts of a crashed plane has been available since at least 2000 but has not been ordered installed on airliners by that sleepy backwater of aviation safety, the FAA.

Maybe the NTSB’s recent letter will goad the FAA to rise from its regulatory torpor and take action, although the record of the FAA’s dilatory and partial response to such letters from the NTSB is, frankly, discouraging.

Nevertheless, details of the NTSB’s letter warrant scrutiny.

All scheduled and charter airliners operating over water and more than two hours from a diversionary airfield should be equipped with the capability to transmit to a ground station “sufficient information to establish the location where an aircraft terminates flight as the result of an accident within 6 nautical miles of the point of impact,” the NTSB recommended.

Restricting the recommendation to extended flights over water leaves out flights over trackless areas on land that are not covered by ground based radars. The Amazon River basin in South America, for example, has vast areas not covered by radar. An airplane traversing this huge wilderness could crash and be swallowed up by the watery muck and jungle; the remnants could be extremely difficult to locate.

It would have been better to word the applicability of the recommendation to all transport-category aircraft operating over regions not covered by ground surveillance radar.

Transmitting the location of the crash site within six miles of the point of impact was taken from the French investigation into the June 1, 2009, Air France Flight 447 crash into the Atlantic Ocean on a flight from Rio de Janeiro to Paris. It took almost two years of searching to recover the flight recorders. The French accident analysis authorities (Bureau d’Enquêtes et d’Analyses, or BEA) determined that it is feasible with current technology to broadcast an aircraft’s location to within a six miles circle of the point of impact. The NTSB sensibly piggy-backed on the French finding.

Significantly, the NTSB recommendation does not include a timeline for accomplishment. Without a deadline, the FAA will dilly-dally and stretch out any action for years. The absence of a deadline is unfortunate, as the technology for broadcasting the location of crash and key recorder information already exists, and in a form that is commercially applicable to the airlines.

A small company in Canada, FLYHT Aerospace Solutions, has been selling a system that beams flight recorder information to orbiting satellites when trouble with the aircraft is sensed. The airplane’s location, its flight attitude, and other essential parameters captured on the flight recorders would then be beamed to a ground station; the information would be available almost instantly to those on the ground searching for answers. Known as the Automated Flight Information Reporting System, or AFIRS, a Canadian operator of B737s and DHC-8s has already bought and installed the system, as the carrier operates in the northern reaches of Canada. The wilderness is frequently beyond the coverage of ground-based radars.

With a requirement to equip their jetliners with an AFIRS-like technology, FLYHT could license its system for production by major avionics companies and installation could proceed on an accelerated basis. An NTSB deadline would spur this activity.

The NTSB letter reprises an earlier sensible recommendation already rejected by the FAA. The January 22 NTSB letter offers additional information; if unlucky in its recommendations, the safety board is nevertheless persistent. The subject: cockpit videos. The camera would record crew actions in the moments before a crash, key instrument displays, switches and flight control positions. The Safety Board was careful to note that the faces of pilots would not be recorded. Rather, the camera would be mounted above and to the rear of pilots, capturing only their arm and hand positions and the instrument panel.

The cockpit of the B777, essentially showing the view to be captured by the cockpit image recorder. Pilots' faces would not be seen, but their manipulation of knobs and flight controls would be captured, as well as displays  on the instrument panel (or displays obscured by smoke).

The cockpit of the B777, essentially showing the view to be captured by
the cockpit image recorder. Pilots’ faces would not be seen, but their manipulation of knobs and flight controls would be captured, as well as displays on the instrument panel (or displays obscured by smoke).

The FAA had opposed this recommendation in January 2000, largely due to pilots’ concerns that the videos would find their way onto the Internet as voyeuristic “snuff films”. Although the FAA rejection of that date did not specifically mention pilot union opposition, that was part of the overall criticism at the time of the NTSB proposal. The FAA simply said, “The FAA has no rulemaking underway at this time to mandate the installation of cockpit image systems as described in this safety recommendation.”

The NTSB offered new arguments in favor of cockpit videos:

“In its final report on the Air France Flight 447 accident, the BEA cited difficulties in reconstructing critical instrument panel indications that were available to the flight crew. Consequently, the BEA recommended that ICAO [International Civil Aviation Organization] require public transport flights with passengers be equipped with a cockpit image recorders that can record the instrument panel and also that guidelines be established to guarantee the confidentiality of the recordings.”


“On September 3, 2010, a Boeing 747-44AF, operated by United Parcel Service (UPS), crashed while attempting to return to Dubai International Airport following an in-flight cargo fire. Some critical information, such as flight instrument indications, switch positions, and aircraft system conditions, could not be confirmed by the available evidence. The final report, prepared by the United Arab Emirates General Civil Aviation Authority … specifically cited the lack of cockpit imagery as a detriment to the timeliness of the investigation and delivery of critical safety recommendations …

“Further, in the Air France and UPS crashes, the accident aircraft were equipped with FDR’s that greatly exceeded the minimum parameter requirements. However, in these accidents, critical information related to the cockpit environments conditions (for example, crew actions and visibility [e.g., smoke from the cargo fire]), instrument indications available to crewmembers, and the degradation of aircraft systems was not available to investigators. The NTSB concludes that image recordings would provide critical information about flight crew actions and the cockpit environment [e.g., smoke filled] that has not been provided by CVRs and FDRs.”

And, the NTSB glumly noted:

“(A)fter 15 years the FAA still has not mandated installing cockpit image recorders … Therefore, Safety Recommendations A-00-30 and -31 are classified ‘Closed — Unacceptable Action/Superseded.’ “

The NTSB’s recommendation letter of January 2015 supersedes all previous frustrating correspondence with the FAA on this issue.

The dismal history of cockpit image recorders does not bode well for prompt and sustained action on broadcasting the airplane’s location and key FDR parameters in the moments before impact.

To gauge the FAA ‘s willingness and commitment, the NTSB should have recommended the broadcast capability be installed within three years. Absent a mind-focusing deadline, the FAA is quite likely to dawdle, taking 10 or more years to solve the problem (if at all), when the capability already exists.

The Trivial Cost of Certainty

Doing nothing, despite a clear need and available technology, is always an option if it can be demonstrated that the costs are prohibitive. This seems to be the emerging case regarding “streaming” of flight recorder to a ground station, as has been suggested in the wake of the mysterious disappearance of Malaysian Airlines Flight 370.

The wreckage of the airplane has not been pinpointed; whatever caused the crash is doubtless encoded in the recorders — both flight data and cockpit voice recordings — which are housed in the tail section of the airplane. They are ensconced there in the belief that the aft section is the most likely to be least damaged, as the forward sections of the airplane will impact first and absorb most of the destructive forces.

Flight data sitting at the bottom of the ocean is of no use

Flight data sitting at the bottom of the ocean is of no use

However, if as is widely believed, the airplane crashed into the Indian Ocean off the west coast of Australia, no wreckage has been found. The batteries powering the recorders’ locator beacon have long exceeded their 30-day time for providing essential power.

The frustration with the utter disappearance of the airliner has renewed interest in “streaming” the recorders’ information before the crash. In the event of an unexpected scenario, the recorders’ vital information would be transmitted from the stricken airplane to orbiting satellites overhead, for subsequent beaming back down to a ground station. The airplane’s location, its flight attitude, and other essential parameters captured on the flight recorders would be available almost instantly to those on the ground searching for answers.

The technology exists. Known as the Automated Flight Reporting System, or AFIRS, it beams flight recorder information to orbiting satellites when trouble with the aircraft is sensed. AFIRS was developed and is marketed by a small Canadian company, FLYHT Aerospace Solutions, Inc.; since the disappearance of Malaysia Airlines Flight MH370, the company has been busy marketing AFIRS.

FLYHT Chief Executive Bill Tempany told the Washington Post newspaper that AFIRS installation costs about $120,000 per airplane.

The cost for multiple installations adds up. Delta Air Lines operates a fleet of 764 airliners; equipping all airplanes with  AFIRS totals about $90 million.

For the whole U.S. fleet of approximately 4,000 airliners, the installation cost would be approximately $480,000,000.

The cost appears prohibitive. But let’s look closer. According to its website, Delta Air Lines reports it has $2.8 billion in “free cash flow” that it is using, in part, to reduce net debt levels by $2 billion. If 5% of this $2 billion — $90 million — were invested in the safety of all the company’s aircraft, that sum puts the investment into replacing 20-year old crash resistant recorder technology in perspective.

Actually, the price per year could be significantly lower. Let’s continue with the example of Delta. Assume the airline retires its aircraft after 20 years of service. In a steady state illustration, for simplicity of argument, the airline would have to buy 38 new replacement aircraft annually. At $120,000 per installation, adding 38 AFIRS would impose an annual added cost of $4.5 million to the annual purchase price (big jetliners now selling for $100 million to $150 million apiece, or more). $4.5 million is practically lost in the rounding when a company is spending approximately $3.8 billion a year on new airplanes.

And, surely, Delta can get a good deal from the manufacturer if it commits to buying many airplanes over the course of years, all built to a standard configuration. It is not unusual for Airbus or Boeing to offer discounts of 20% or more on bulk orders. As cost of a package deal, the price of AFIRS is trivial.

If a small operator like Canada’s First Air, which operates a half-dozen airliners in the Canadian Arctic, can afford AFIRS, large operators are better positioned to absorb costs. Qatar Airways, which operates a fleet of more than 130 airliners, recently announced its intention to “stream” flight data information. At $120,000 per installation, Qatar announced a commitment of $15.6 million, over multiple years.

Here is another way to put the $120,000 cost per AFIRS installation in perspective: seat-back entertainment systems. The video displays are expensive, because the electronics must be separated completely from the airplane’s avionics, and they must be fireproofed. One estimate places the cost if in-flight entertainment system displays at an astonishing $10,000 per seatback. Let us halve this price to $5,000 per seat. This means the cost of equipping a 200-seat jetliner with seat-back entertainment displays approximates $1 million, or roughly ten times the cost of AFIRS.

One would bet that equipping the fleet, deliberately over years, to an AFIRS-like configuration would play well with airline insurers. There are cost savings to the technology that go well beyond $120,000 per system.

It is estimated that the search for the missing Malaysian B777 has totaled some $240 million for the various governments that have committed ships and aircraft to the ongoing search. That sum is roughly 2,000 times the cost of a single AFIRS installation. The cost of AFIRS equipage would surely meet the most demanding government-imposed cost-benefit calculation. Again, given a U.S. airline fleet of about 4,000 jetliners, assuming a 20-year installation period, the annual installation cost would amount to $24 million. Given the cost, thus far, of the international search for the missing jetliner, the $24 million price of AFIRS data-certainty is one-tenth that of the we’ve-got-nothing search for the wreckage.

To say nothing of the next of kin, the airline, the regulators, the manufacturers, and the investigators — they are left with maximum uncertainty. For the next of kin, there is the incalculable sense of loss. For the regulators, manufacturers and airlines, the lack of data hobbles any corrective action to make sure another airplane isn’t lost under the same or similar circumstances.

The U.S. Federal Aviation Agency preaches the ethic of “data driven safety”. But when there is no data, safety cannot be assured. In the grand scheme of costs and benefit, the price of AFIRS, or a similarly capable system, seems worth more than a few rows of in-flight entertainment system screens. Seat-back television fills the bored mind with vacuous “entertainment”. AFIRS promises to fill enquiring and responsible minds with hard facts.

Blowing Up The Status Quo

How might the aviation accident investigation process be improved? That is the question the National Transportation Safety Board (NTSB) asked for public comments in an August 24 announcement posted in the Federal Register. Comments must be submitted not later than October 14; that is not much time, given the importance of the subject.

But, then, from the NTSB’s 18-page notice, it is obvious that substantive changes to the current process are not envisioned. The NTSB proposes sundry technical edits to existing regulations. Left intact is the direct affront to the NTSB’s charter as an independent investigative body, the so-called “party” system. Under this existing arrangement, airlines, manufacturers, air traffic controllers, pilots and mechanics unions and, not least, the regulator — the Federal Aviation Administration (FAA) — are accorded an official role in the investigation. A representative for the killed or injured passengers is not included. However, those involved in the deaths or injuries of passengers are official members of the investigation.

The official definition of a party is “a person, government agency, or association whose employees … or products were involved in the accident or incident and who can provide suitable qualified technical personnel to assist in the investigation (49 Code of Federal Regulations, paragraph 831.111(a)(1)).

This arrangement has come about partly because the NTSB is a small agency, without enough investigators to do the job. The agency has about the same number of aviation investigators as the equivalent strength of a Marine Corps rifle company. That is 130 Marines which, in NTSB “uniform”, are charged with airline accident and incident investigations, which includes air charter operations, plus investigating the same for the nation’s private, general aviation, fleet of aircraft. All told, the Safety Board has to investigate about 2,500 aviation accidents and incidents yearly with an extremely limited staff.

The party system supposedly has evolved to allow the Safety Board to leverage resources to meet its broad and complex mission.

This may be so, but the parties are hardly impartial. Airplane manufacturers have an interest in minimizing any design flaws in their aircraft that either caused or contributed to the accident. Airlines have in interest in downplaying pilot training or maintenance deficiencies. Pilots’ unions have an interested in demonstrating that the pilots in the accident were not at fault and, indeed, were let down by inadequacies in airplane design or airline practices. The FAA has a vested interest in obfuscating any shortages in its oversight of the airline or shortcomings in its certified approval of the airplane’s design.

Richard Kessler, who lost his wife in an airline crash, takes a dim view of the party system. “As one who has experienced accident investigations first-hand … it is my view that the current process is shot through with conflicts of interest.”

“We can do better,” he maintained.

While parties are not involved in analysis and the determination of probable cause, their intimate involvements is spelled out in the NTSB’s Aviation Investigation Manual. A few extracts from this seminal document serve to highlight the parties’ deep involvement in the warp and woof of the supposedly “independent” investigative process:

“The IIC [NTSB Investigator in Charge] will … meet daily with the party coordinators ….These meetings should be used as a way of determining the parties level of satisfaction with the investigations and their ability to cooperate with each other and with the Safety Board … Guidance and input should be provided to them, as needed, to prevent potential problems from escalating.” The parties’ level of satisfaction is a sure give away that the NTSB will accommodate party wishes.

“The [Safety] Board’s administrative practice regarding the conduct of public hearings is to ensure that before opening the accident file to the public, all parties to the investigation are given the opportunity to record in writing whether or not they want a public hearing to be conducted on the accident.”

“[The] IIC should also e-mail a ‘warning memo’ to the parties notifying them that the docket will likely be opened on the date selected by … the Office of Public Inquiries.”

“The IIC/hearing officer should inform all parties of the details of the hearing and the prehearing conference well before both are held … The IIC/hearing officer should allow sufficient time (at least 2 weeks) for the parties to receive and review the items critical to the hearing before the prehearing conference. These include exhibits, issue list, areas of questioning, and relevant exhibits for each witness.” The public is not accorded this generous courtesy.

“The witnesses may be from the parties to the investigation or can be suggested by one or more of the parties.” If ever there was a set up for friendly testimony, this section of the manual is a dead give away.

“The prehearing conference allows the parties to review plans for the hearing and provides them with a final opportunity to make suggestions on its conduct.” To “make suggestions” and the party’s “self interest” are evident.

“The IIC will write each party … informing him or her of the opportunity to present party submissions. It should be explained that the submissions should contain their proposed conclusions, probable cause, and recommendations relating to the accident … The party submissions will be considered during the development of the final report.” Note the term “will be” taken into account as the final NTSB report is written.


Parties (foreground) participate in an NTSB accident investigation. Why?

In 2005, the RAND corporation submitted a report to the NTSB on its investigative process, a report requested by the NTSB, and observed: “The party process presents inherent conflicts of interest for entities that are both parties in an investigation and ‘parties defendant’ in related litigation.”

This incestuous arrangement can be dispensed with. The party system ought to be expunged entirely. If the NTSB does not have enough staff to handle the workload and the often arcane technical issues involved, there are two remedies, both of which should be adopted:

First, the NTSB should not be involved in the great majority of general aviation accidents. Most of these involve pilot error and/or poor judgment (e.g., taking off with inadequate fuel or persisting in a flight where the weather is worsening). This one step would reduce the NTSB’s workload from 2,500 investigations to about 500 yearly.

Second, it should be noted that the NTSB has frequently gone past the parties, hiring small, expert companies, consultants and university professors to fulfill needs for specific technology and knowledge beyond the ken of the NTSB’s professional staff.

The parties no more would be involved in negotiating the issues to be investigated or not to be explored, as is the case at present. The parties now submit a statement of probable cause or suggested recommendations. This astonishing practice would end.

Unfortunately, in its August 12 announcement, the NTSB takes the opposite course, actually liberalizing the role of parties, allowing them to “release information within party organizations as needed to implement prevention [or] remedial action” as a result of disclosure during an accident investigation. Note, this activity is proposed even before the NTSB has concluded its investigation. To be sure, it is useful to accelerate the pace of remedial action, but the real problem is the glacial pace of FAA correctives when in receipt of the final investigation and its many recommendations.

The NTSB proposal abets the status quo, when that arrangement itself is deeply suspect. The status quo needs to be blown up. The often devious and manipulative parties can be dispensed with entirely. If the present parties have a comment, they can submit a letter to the Safety Board, just like any other member of the public. And if the NTSB wants them to testify, a subpoena will serve.

NTSB independence and impartiality as an aviation accident investigation body finally would be assured.

A Regrettable Declaration

Nothing can be more dangerously arrogant than an airline publicly declaring a fatal accident involving one of its planes is inconceivable. Yet an article in an AirAsia in-flight magazine that went to press before the disappearance of Malaysian Airlines Flight MH370 in March 2014 boasted that AirAsia pilots would never lose an airplane because of their “continuous and very thorough” training”.

“Rest assured that your captain is well prepared to ensure your plane will never get lost,” the article declared.

Now AirAsia Flight QZ8501 is missing, presumed at the bottom of the Java Sea. Ground radar contact was lost with the Airbus A320 with 162 aboard early on the morning of December 28. The airplane was about a third along its flight from Surabaya, Indonesia, to Singapore. The airplane was lost right at a line of severe thunderstorms. The cockpit crew apparently did not have time to radio a distress call; whatever happened, it was quick. Three days later, Indonesian rescuers were pulling bodies and wreckage from the sea.

The lost airplane

The lost airplane

The in-flight magazine was pulled in April 2014 — a month after the disappearance of the Malaysia Airlines B777 — as a result of criticism in social media, with profuse apologies from management and the airline’s CEO, Tony Fernandes.

It is one thing to generally declare a commitment to safety, but quite another to assert that a crash is never going to happen. At worst, this sort of hyperbole can breed an attitude of complacency, which can take various forms:

• Highly scripted simulator training sessions that are predictable and/or not reflective of real-world emergencies.

• Pro-forma cockpit checks of pilots by management pilots.

• An increase in deferred maintenance.

• A shortage or even absence of contingency funds to address a loss, specifically:

– Money to support passengers next of kin, to include necessary transportation, lodging, meals and incidental expenses.

– Funds to support the inevitably costly investigation

– Monies to support safety adjustments deemed necessary even before the investigation is completed.

• A paucity of training, if any, for airline employees who are appointed to deal with the passengers next of kin, and for airline officials tasked with representing the carrier in various public forums.

• A deterioration in a “just culture”, where employees are encouraged to speak out — and are rewarded — for calling management’s attention to safety deficiencies.

• A ho-hum attitude regarding Safety Management Systems, which can be useful for teasing out latent hazards and correcting them.

In airline operations, complacency may be a huge threat to air safety. The abortive in-flight magazine article would have been far better focusing on pilots’ prudence, as in: if there’s any doubt, don’t. Proven, standardized procedures will reign. Good cockpit discipline and focus will be established for every flight. Sound airmanship and effective crew resource management will be practiced continually.

These sorts of assurances, if backed up with effective programs to ensure that they are practiced, are appropriate.

Indeed, the pilots of Flight QZ8501 may have reflected the natural caution of pilots facing severe convective weather. Shortly before the airplane disappeared, they requested to ground controllers that their assigned altitude of 32,000 feet be changed to 38,000 feet. They may have seen a safe opening in thunderstorms raging to 50,000 feet. Because of other “traffic” in the area, controllers denied their request.

One wonders about how much “traffic” potentially conflicted with the AirAsia pilots’ request. There were reportedly seven other aircraft on that route, which is hundreds of miles long. No doubt, “conflicting traffic” will be a subject of the inevitable investigative inquiry.

In the meantime, the AirAsia magazine article serves as an object lesson: an attitude of “it can’t happen to us” is bound to breed complacency and cruel events may undercut passengers’ confidence in safety.

With a fatal crash on his hands, Tony Fernandes is now using appropriate words. “My heart is filled with sadness for all the families involved in QZ8501,” he wrote in a Twitter message after the wreckage was found. “On behalf of AirAsia, my condolences to all.”

Words may not suffice. The issues presented above — regarding a “just culture”, realistic pilot training, maintenance that is up to snuff, etc. — bear thorough audit and corrective action. They apply not just to AirAsia, but any airline bent on avoiding condolences.

A Deadly Disappearance That Should Be The Last

When we plop into our airliner seat and buckle the seat belt, we expect a rather boring journey to the destination, not a terrifying journey to mortal oblivion. Yet that is exactly what occurred on March 7, 2014, as 227 passengers boarded Malaysia Airlines flight MH 370 for a nighttime flight from Kuala Lumpur to Beijing.

Approximately 40 minutes after the 12:41 a.m. takeoff, the B777’s electronic transponders broadcasting the plane’s altitude and identity fell silent. Flying over water, beyond the range of ground-based radar, the airplane simply disappeared.

A massive international search was mounted. An impact crater on land was never found. Not a shred or scrap of debris floating was ever found along the track of ocean sites where fuel exhaustion would have marked the end of the plane’s flight.

Investigators surmised the airplane turned from its path toward Beijing and headed southwest, out into the Indian Ocean. Patrol planes with observers searched the wave tops for pieces of floating aluminum, maybe a bobbing seat cushion, bodies, or some other evidence of the plane’s catastrophic plummet into the water. Nothing.

The airplane’s aft-mounted black box featured a water-activated, battery-power pinger that broadcast a signal for about 30 days. Sensitive hydrophones would have picked up the telltale “pings” from the submerged wreckage. Nothing.

High-tech sonars were deployed from ships on the surface to probe the ocean depths. Robotic submersibles descended into the inky depths and bounced sound waves off the 14,700-ft deep ocean bottom, in the hopes that some of the return signals would reveal the location of the wreckage. The robotic submersibles went back and forth, probing with sonar in a pattern that covered a great deal of submerged acreage without duplicating the effort. Again, nothing.

Despite an effort involving 39 airplanes, 42 ships, technical support on land, and consuming an estimated $44 million, the international search proved to be one of false hopes, spurious signals and nil, zero, zilch, no evidence whatsoever of the Malaysian airliner’s fate.

The wreckage could be at the bottom of the Indian Ocean, elsewhere at sea, in the jungle, in the mountains — nobody knows.


Possible crash locations of MH370 based on fuel exhaustion

Possible crash locations of MH370 based on fuel exhaustion

The difficulty, and the extraordinary lengths taken to narrow down where the wreckage might be, was outlined in an October 8th PBS ‘NOVA’ television documentary titled “Why Planes Vanish”. The documentary focused on the frustrating search for the remnants of Malaysian flight MH370:

“Twenty-six minutes after takeoff, at 1:07 AM local time, the airplane transmitted a text message via satellite to its operations center — that appeared to confirm MH370 was bound for Beijing — just like it always had before this night.”

“Three minutes after that call [a voice radio communication between the cockpit crew and Malaysian air traffic controllers], at 1:22 in the morning, both transponders on the Boeing 777 went silent. And so did the crew.”

“Air traffic controllers monitoring the frequency they were assigned in Ho Chi Minh City never heard from MH370” ….

“In the handoff between control centers, MH 370 became nothing more than a silent primary radar blip. And when controllers finally tried to connect the dots, they couldn’t find the plane anywhere on their screens.”

“The plane had vanished.”

“As day broke, rescue crews immediately began searching for wreckage of a crash — in what seemed like a logical place: the South China Sea … where the plane was last seen by air traffic controllers on secondary radar. But there was nothing there.” ….

“The Inmarsat satellite transmissions to and from MH370 were relayed through a ground station in Perth, Australia, until 1:06 AM, when the plane send its last text message ty satellite to the airline’s operations center.” …

“The Inmarsat transceiver answers the call with a simple electronic ping, saying, ‘Yes, I am here.’ ”

“Even more surprising, the log documents SIX MORE handshakes or pings between the ground station and the airliner, about one an hour. All of them occurred after the airplane had vanished … the airplane had continued to fly for at least SEVEN MORE HOURS.” ….

“[Investigators] determined MH370 sent its final handshake somewhere on these two arcs — to the north, all the way to Kazakhstan — or in a place that is as close to nowhere as anyplace can be — the southern Indian Ocean. Two million square miles in all.” ….

“According to this new data [derived from analysis of the doppler shirt from Inmarsat], flight MH 370 ended in the southern Indian Ocean.”

“But where on the southern arc?”

“Investigators estimated various speeds and altitudes that the missing plane might have flown.”

“Those factors, along with the amount of fuel and the winds aloft, are crucial in determining where the plane might be along the last handshake arc — where it is presumed the [fuel] tanks ran dry.” ….

“David Gallo is Director of Special Projects at the Woods Hole Oceanographic Institution. In May of 2011 he co-led the team that found the wreckage of Air France flight 447.” [The airplane crashed in the South Atlantic in 2009.]

“Air France had paid for an ACARS subscription that provided investigators much greater detail about what had happened, including position reports right to the end.” [Malaysian airlines only subscribed to a bare bones service.]

“[David Gallo on camera] With Air France we knew there was a plane, so that was important. There was debris being picked up just about a week after the plane hit the water, so there was no question that there was a plane somewhere in that neck of the woods.”

“[Narrator] They were able to narrow the search area to a circle 80 miles in diameter. And yet it still took two years of searching with autonomous underwater vehicles to find the wreckage.”

“[Gallo] It’s not like putting scuba gear on and just going to the bottom. You’re talking about going miles into the deep, into the darkness … It’s incredibly difficult terrain, with mountains as steep as any mountains we have on earth.”


A huge and remote area to search

A huge and remote area to search

“[Narrator] The area that Inmarsat has defined and searchers are pursuing in the hunt for MH370 is about the size of the state of West Virginia — five times greater that the Air France 447 search zone. It would take an autonomous underwater vehicle nearly a thousand days to cover an area that size.”

This frustrating mystery is not necessary.

The location of every airliner flying beyond the range of ground-based radars is readily available. A new system called the Automated Flight Information Reporting System, or AFIRS, does this. It monitors what the flight data recorder is seeing. AFIRS starts transmitting key data automatically when it senses trouble, alternatively at the command of the flight crew or airline dispatches at the ground headquarters.

Some smaller operators, such as Canada’s First Air, have already equipped their airplanes with AFIRS. First Air operates a mixed fleet of Hercules cargo planes, B767, B737, ATR-42 and ATR-72s in northern Canada, where oftentimes ground-based radars do not provide coverage.

The Chinese have mandated satellite communications for all aircraft. AFIRS has been installed on 30 Chinese-registered airliners to date with another 20 planes awaiting components that have already been paid for.

AFIRS was developed and is sold by a small Canadian company, FLYHT Aerospace Solutions Ltd. The system takes advantage of communication and navigation satellite already orbiting Earth. The company claims its technology is installed in 400 aircraft and helicopters. A company press release advertizes:

“For the first time in history, FLYHT has developed a technology to stream data off an aircraft in real-time. If an airplane encounters an emergency, FLYHT’s proven technology can automatically stream vital data, normally secured in the back box, and provide position information to designated sites on the ground in real-time. This technology opens new doors for increased awareness and safety in the industry.”

Not only the airplane’s final location, but data that also goes to the airplane’s black box. A two-fer, as it were, rendering the costly search for the black box unnecessary (although other aircraft components and human remains might be desired for retrieval).

Additionally, the aircraft’s operation can be monitored in real time, allowing for more efficient navigation en route to avoid bad weather, take advantage of favorable winds, and generally maximize fuel economy. Components evidencing behavior problems — maybe in need of repair or replacement — are identified in flight and maintenance personnel are alerted. The routine monitoring in real time is done continuously; AFIRS begins transmitting flight recorder data when activated.


AFIRS installed in the belly of an airliner

AFIRS installed in the belly of an airliner

FLYHT President Matt Bradley maintains, “We have an internationally-recognized data streaming technology that is available to the industry now and are committed to advocating for its full implementation.”

Company representatives have been giving presentations to various aviation symposia around the globe.


AFIRS control panel in the cockpit

AFIRS control panel in the cockpit

When the system is activated, a message is sent to key ground personnel, with the subject line featuring the attention-getting “Aircraft XXX Emergency.” Additional information includes:

• Aircraft registration

• Aircraft latitude and longitude’

• Aircraft altitude, attitude, rate of descent, pitch and roll

• Engine parameters, flight control settings, smoke and fire detection, electrical system functioning, etc.

• A statement that the software has entered the data-streaming mode

• The time streaming mode was entered

• A description of the event that caused the streaming

The data streaming will continue for as long as the airline desires or until the airplane crashes.

AFIRS can be retrofitted onto existing aircraft for approximately $35,000 to $70,000, depending on aircraft type. The greater sum is for B777 wide body aircraft of the type that was operating as Malaysian Flight MH370. The system can also be installed during production of new aircraft.

The company claims that its technology realizes about $100,000 in cost savings per airplane annually. The savings accrue from reduced fuel consumption — benefitting from real-time reporting aloft rather than predicted winds and weather — and from reduced repair costs by having better information from in flight to preposition technicians and spare parts to minimize down time. Operators with AFIRS installed also benefit from reduced insurance rates.

The cost is cheap relative to, say, in-flight entertainment systems. These passenger entertainment systems can cost upwards of $1 million per airplane.

And AFIRS is a bargain compared to the $44 million spent in just the first month in the futile search for Malaysian Flight MH370.

Most importantly, a flight need not be a one-way journey to mortal oblivion. The less-than-emergency weather, maintenance and other information translates into more efficient and safer flights. When AFIRS is activated, authorities and family members at least will have critical flight data and a final location. In this respect, AFIRS promises to replace oblivion with certainty. This may be small comfort to the next-of-kin, but it is a great boon to investigators tasked with determining cause and recommending correctives — which imparts at least some meaning to the lives lost.

With AFIRS, the days of the flight recorder as a lost, unexamined “data morgue” could well be over.