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Obscuring Safety Hazards

Since 1970, more than 240 incidents involving jet engine malfunctions — some of them catastrophic — have been recorded. The event search was based on the key words, “shutdown, vibrate/vibration, bangs, loud, seized, contained, uncontained” or “bearings.” Oil and fuel systems issues, as well as bird strikes to engines, were discarded. In other words, only the most serious reports involving internal mechanical failure were considered. Suffice to say, problems run from the inlet to the hot section to the exhaust ducting.

The actual total is probably higher, but the Federal Aviation Administration (FAA) does not enforce any discipline regarding reporting. What reports do trickle in are the heart of “identified safety risks.” The risks, such as represented in the FAA’s incomplete data base, are well short of the actual frequency of incidents.

And this is just for engines.

The term “identified safety risks” is part and parcel of the FAA’s bureaucratic language used to transmit corrective actions — in the form of airworthiness directives — to the airlines. These directives mandate corrective action, usually on a very generous timeline so as not to inconvenience flight schedules.

From various and sundry airworthiness directives, “identified safety risks” encompass virtually every aspect of the airplane:

— Uncontained engine explosions that compromise continued safe flight. Not only loss of thrust, but shrapnel damage to hydraulic and electrical systems, leading to a cascading series of failures and cockpit crew confusion and overload.

— In-flight fires in inaccessible areas unprotected by fire suppression. Every square inch of public buildings is required to have fire detection and suppression; not so for the most crowded of public spaces, a modern jetliner.

— Electrical wire insulation that exceeded smoke, toxicity and flammability standards. The running of low-power circuits in the same bundles as high-power circuits aggravated the problem, as high-power arcing has led to overload of low power circuits, with resulting fire and explosions. The lack of separation and segregation standards for electrical circuits continues to this day; when electrical arcing occurs, the result is usually a sequence of cascading failures.

— Flammable thermal/acoustic insulation blankets installed throughout the fuselage for fire burn-through “protection.” The use of flammable insulation for burn-through protection remains a sick irony. Yet insulating material that resists the hottest fire is available, but continues to be unrecognized by the FAA and not used by the industry, either on newly-manufactured aircraft or retrofitted onto older aircraft during periodic overhauls.

— Electrical equipment cabinets that allow faulty arcing components therein to spew molten metal, thus enabling an otherwise contained electrical fire to transition to an uncontained fuselage insulation fire.

— Electrical heater tapes, used throughout all airframes for freeze protection, with faults that led to an uncontainable fuselage insulation fire, raging just a few feet below the passenger cabin floor. Following two Air Canada fire investigations by the Transportation Safety Board (TSB) of Canada, Boeing said, “Between June 1985 and June 2002, operators of Boeing aircraft made a total of 67 reports to Boeing of heater ribbon failures where thermal degradation was evident.” Note the wording: “reports to Boeing.” The FAA was clueless regarding the extent of heater-tape induced conflagrations.

Damage to a B767 airliner from a faulty heater tape and the resultant damage to insulation blankets

Damage to a B767 airliner from a faulty heater tape and
the resultant damage to insulation blankets

— Uncommanded rudder movements, or dangerous rudder deflections from one side to another, which contributed to at least three fatal crashes and an unknown number of incidents in flight from which a startled crew was able to retrieve the situation.

— Continued incidents of flight into freezing rain/freezing drizzle that aircraft are not certified to cope with, and for which the FAA has been egregiously lax in setting a standard. In-flight upsets from what is known as “supercooled liquid droplets” (SLD) continue to occur. In SLD, the water slaps onto the airfoil and instantly freezes. Unlike the larger Boeing and Airbus jets, with their much larger engines to supply hot air for anti-icing, the smaller regional jets have a lesser ability to resist icing conditions.

— Cockpit smoke impairing the pilots’ view of the instruments and of the outside world. The FAA and the National Transportation Safety Board own up to one such event, but a search of various databases yields at least six events.

These and other hazards persist because of “firewalls” that hinder recognition of safety hazards. There are many such firewalls, many of them self-imposed by regulatory bureaucrats, but here are five indicating the magnitude of the problem:

1. The Accident/Incident database maintained by the National Transportation Safety Board (NTSB) contains only 20% (or thereabouts) of these hazards, which are seen in such incident reports as the FAA’s Service Difficulty Report (SDR) database or counterpart agency reports.

2. The FAA’s Incident database is even more abysmally incomplete than the one maintained by the NTSB. For example, of some 67 uncontained engine explosions involving GE engines, the FAA Incident database captured just one. The gaping gaps in the FAA’s database makes one wonder: what is the purpose of “maintaining” such a record; to use a Swiss cheese metaphor, the holes are greater than the amount of cheese. For analytical purposes, the Incident database is utterly useless.

3. The SDR data itself is woefully incomplete. Although required by FAA regulations, some airlines comply, reporting gaps at other airlines range from 70% compliance to as little as 30%. The FAA does not enforce reporting compliance, so the SDR database is incomplete, and many reports that are submitted have missing data or “apparent causes”. Moreover, SDR’s are only required on incidents that occur in the air. Ground events are not part of the reporting mandate. The industry successfully lobbied to force the FAA to withdraw a proposal to include SDR-reportable events that occur while the airplane is on the tarmac. The SDR system is in need of a complete overhaul and stiff penalties for not reporting. Moreover, the reports must be systematically analyzed for trends by aircraft type and among airlines; the SDR database in its present form is scandalously incomplete and gathering dust as a “data morgue”, not rigorously analyzed to identify emerging trends.

4. Identified safety hazards remain hidden from public view with the manufacturers’ use of Service Bulletins (SB’s) and All Operator Alerts (AOL’s). FAA-issued airworthiness directives — available to the public — often refer to AOL’s and SB’s. In fact, AOL’s and SB’s often contain gritty details, which are referred to in only the vaguest terms in the airworthiness directives. The situation is analogous to reading about the efficacy, or lack thereof, of a medicine by reading the label on the bottle. The protocols, clinical trials and scientific studies remain behind lock and key. Suffice to say, published airworthiness directives, which reference these proprietary documents, make their associations to prior events and to safety trends simply impossible for members of the general public.

5. Certain FAA studies (on fuselage flaws, on uncontained engine explosions, on electrical wiring) also are not available to the public, thus obscuring trends and/or non-safety associations. The disclaimer on a study of the flammability of in-service materials is typical: “In general, data are proprietary to the applicant, and we cannot disclose those data to the public.” Here’s another regarding rotating engine parts: “The FAA proposes to designate the … data submitted to them to create the Rotor Manufacturing Induced Database (known as the ‘ROMAN database’) as protected from disclosure … under the Freedom of Information Act (5 USC552) and other laws. The FAA wants to encourage … suppliers that manufacture high energy rotating gas turbine engine components to voluntarily submit information into the ROMAN database.” Of course, voluntary reporting is likely to lead to as porous and incomplete information in ROMAN as in the “required” SDR database.

The question is why this state of affairs exists.

For one thing, costs to the industry are lower because AOLs and SBs, unless mentioned in FAA-issued airworthiness directives, require no mandatory action. Similarly, by not requiring reporting of all SDR data — occurrences both in the air and on the ground –the FAA lowers the cost to the industry of submitting reports.

To be sure, making available incomplete and selective data for public consumption gives a false impression of safety. The average John Q. Public is probably not aware of the appalling database incompleteness. Certainly the association between incidents involving injury and accidents involving deaths is obscured. Thorough SDR and Incident databases might reveal plenty of precursor problems leading to a fatal accident. Defining a fatal loss as an unfortunate “one time” occurrence lessens the role of industry in these losses, as it also lessens the role of the FAA’s sloppy certification system in such losses.

In sum, costs to the industry are minimized and facilitated by the use of partial, incomplete and limited public access to identified risks and related events.

By allowing this system of data truancy and industry-friendly policies, one has to ask: who is the FAA’s customer — the favored airlines and manufacturers, or the flying public, which falsely believes the feds really practice the doctrine of safety first.

Passengers Frightened; Safety Board Not Interested

About 25 minutes into JetBlue Flight 1416 from Long Beach, CA, to Austin, TX, the underwing engine on the right side of the Airbus A320 began to overheat. Within moments of the September 19 event, the crew decided to activate the fire extinguishing bottles mounted on the engine and banked for an immediate return to Long Beach.

Afterward, passenger Michelle Settergren shared her experience with the Long Beach Post newspaper:

“I had a window seat, so I was looking out the window. We were flying over downtown and then all of a sudden I started to smell something rank, just awful. The plane started to fill with smoke. Before you knew it, it was just gray and you couldn’t see anything. People were screaming and panicking. All of a sudden you just hear this ‘whoosh’ sound and whatever [jet] motor was running just stopped. I thought, hands down, I was going to die. The pilot got on the intercom and said we had engine failure and we were headed back to Long Beach. That’s it. There was no reassurance that we would be okay. The plane had a lot of turbulence, and people were praying, crying and screaming.”

Passenger Dean Delbaugh recalled, “The fumes were ridiculous. I can still kind of taste them in my mouth.”

Passenger Cynthia Manley said the engine failure was accompanied by a loud ‘boom’ and almost immediately smoke began filling the cabin. The smoke was thick and acidic. “I was breathing through my pillow,” she recounted.

The scene in the cabin of JetBlue Flight 1460

The scene in the cabin of JetBlue Flight 1460

Actor Jackson Rathbone, travelling with his wife and infant son, said, “The oxygen masks did not deploy, but the brave stewardesses came around and manually deployed them.”

The flight attendants had the presence of mind to don portable emergency oxygen masks before working their way down the aisle to manually deploy the “little yellow cups” for the passengers from the overhead service compartments.

The airplane was rocking, Rathbone said, and before touchdown the order came over the public address system to “Brace!” This order was repeated by the flight attendants.

After the airplane came to a halt, the exits were thrown open, and the 147 occupants jumped down the slides.

A few passengers were treated for bumps and bruises. All were bussed to a room at the Long Beach airport where they filled out forms. They were given freebie snacks. Rathbone described the gesture as ” ‘Sorry the engine blew up in mid-flight’ bag of chips.”

While there were no serious injuries, questions abound:

Had the engine demonstrated temperature fluctuations in earlier flights? That day? That week?

What did the engine monitoring system record? Were temperature anomalies being watched by JetBlue maintenance personnel? If so, were they just noting the deviations, or had they already decided to conduct a detailed maintenance inspection of the engine?

If JetBlue maintenance was in the dark about the impending engine failure, what good are state-of-the-art engine health and monitoring programs?

Was the engine shut down before the fire extinguishers were activated? Cabin air is provided by “bleed” air from the engine compressor. Most compressed air is sent straight to the “hot” section of the engine to be mixed with fuel and produce thrust, but some air is diverted before the “hot” section to provide cabin air. Was the foul odor smelled by passengers the telltale of an engine fire, or was part or all of the smell resulting from the fire extinguishing agent?

If the engine was shut down, how did contaminated bleed air get into the cabin? Is it because the engine is still free-wheeling even when shut off?

Most interesting of all, why did some or all of the passengers emergency oxygen masks fail to deploy, requiring flight attendants to work their way down the smoke-filled aisle to manually deploy them? These masks are normally deployed by an electrical switch in the cockpit. Had this switch been activated? If not, was there a breakdown of communication in the cockpit? If the switch had been triggered but the masks still didn’t deploy, this fact would point to an electrical failure. Is the electricity for mask deployment provided solely by the affected engine? If so, where is electrical redundancy.

Lots of issues. No answers likely to come from either JetBlue or Airbus. The National Transportation Safety Board should investigate. The Board is not doing so.

An opportunity to learn, and correct deficiencies, is being lost.

Inscrutable Technology

Cockpit automation is a source of suspicion, even mistrust, among many pilots. Cockpit systems tend to be overly complicated and their functioning inscrutable. A technical memorandum on “Cognitive Engineering … of the Vertical Navigation (VNAV) Function”, a central component of the drive toward increasing automation, by a team of researchers found:

“The typical VNAV function automatically chooses the active altitude target from a possible list of sixteen, and chooses the active speed target from a possible list of twenty-six … [and] Pilots are ‘surprised’ by the behavior of the VNAV function when the aircraft trajectory or the thrust indicators do not match their expectations.”

The researchers concluded: “VNAV function behavior is not intuitive in the descent and approach phase of the flight plan.”

This problem was amply demonstrated in the July 2013 crash of Asiana Airlines Flight 214 at San Francisco. The National Transportation Safety Board (NTSB) concluded, “The crew over-relied on automated systems without fully understanding how they interacted.”

Thousands of hours of flying experience, hundreds of hours in classrooms and simulators, yet the crew was unaware that the engines were in idle thrust during the critical landing phase. Automation did not help to prevent this accident — rather, it contributed to the catastrophe.

During the course of its exhaustive investigation into the crash, then-NTSB Chairman Deborah Hersman observed that “mode confusion or mode awareness is an issue … Because it’s not just in this accident … It’s over and over again.”

She asked Stephen Boyd, of the FAA’s transport aircraft directorate, a basic question, “What’s the purpose of automation?”

Boyd: “Are you asking from a regulatory perspective?”

Hersman: “I’m asking for a one-sentence answer.”

Boyd: “Madam Chairman, it’s very difficult to answer because there is such a wide range of what automation means … it’s hard to say what the purpose is, and I would have to say it depends on what you’re automating.”

Hersman: “Okay. So what’s the purpose of autothrottles? Is it to reduce workload? Is it to increase safety? I mean, I’m just looking for a really big picture understanding of why you would implement that rather than manually fly all the time, be responsible for throttles all the time?”

Boyd: “Well, I would say that’s fundamentally a question for the designers to answer.”

Captain John Cashman, formerly Boeing’s chief pilot for the B777 program, did little better, saying the customer wanted automation to “improve the efficiency of aircraft.”

Unsaid in these unsatisfying exchanges is that automation has been increased because of the gains in calculating capability and the reduced size and power demands of computers. Automation has increased because the technology enabled it.


Cockpit automation has increased because technology enabled it, not because it met the pilots' needs

Cockpit automation has increased because technology enabled it,
not because it met the pilots’ needs

Hersman never did get an answer to her basic question.

Let us try a basic definition:

“Automation is applied to relieve the pilots’ routine workload while increasing their control of the airplane and their awareness of the airplane’s safe and unsafe location and path in three-dimensional airspace; automation calls to the crew’s attention any deviation from normal operating parameters with plain and compelling language, all while facilitating the pilots’ ‘heads-up’ view out the windscreen.”

Or, the short version:

“To increase pilots’ control of the aircraft and their awareness of systems functioning.”

In other words, attending to the task of entering values on a key pad, to the detriment of looking through the windscreen, would be a negative according to this definition. So would engines at idle thrust in the moments before touchdown during landing. So would attempted takeoff without deployment of trailing edge flaps. So would all fuel dribbling out through a leaky pipeline, leading to an unusually low fuel state too soon in the flight. There is a long list of problems where existing automation has failed — either designers did not account for a seemingly improbable failure (technological hubris), or explicit alerts to the crew were not provided (design complacency).

Under the definition above, sixteen altitude targets, twenty-six speed targets, and the computer selecting between this array — to the frequent mystification of pilots — would be impermissible. The automatic selection of target altitudes and speed is not in accordance with strengthening the crew’s control of the airplane.

Increasing the automation because it was possible to do so has only served to increase pilot surprise. According to the technical memorandum referred to at the outset of this discussion, more than half of the pilots surveyed reported being surprised by VNAV behavior (e.g., unexplained altitude errors, unpredictable speed targets during approach). One group of pilots reported the VNAV function as “the most disliked feature of automated cockpit systems.”

Hersman asked the salient question — one that neither the FAA nor designers of modern jetliners have asked themselves. Yet inscrutable technology, its secrets buried in lines of computer code, is piled on top of existing protocols that are, at best, only partially understood by pilots.

“A Cognitive Engineering Analysis of the Vertical Naviation (VNAV) Function” by Lance Sherry et. al., National Aeronautics and Space Administration, Ames Research Center, TM-2001-210915

A Programmed ‘Pilot Trap’

Landing a modern jetliner requires the full attention and coordination of the pilots. The speed of cruise flight — approximately 550 miles per hour — must be bled off for landing. The airplane must be guided down an invisible glide slope so the tires skim the end of the runway. While descending, the airplane must be configured for landing; trailing edge flaps and leading edge slats deployed, engine power throttled back for a stable descent, communications must be maintained with the airport tower and with the flight attendants in the cabin, and a lookout must be maintained for other aircraft in the vicinity.

While the pilot handling the flight controls is seeking to maintain the airplane on the descending glide path, any automation that maintains the airplane’s reduced speed certainly frees his mind for the task of keeping the airplane along the -3° path to the runway.

If the pilot mistakenly believes the automated system is maintaining the correct speed for descent, when it is not, the lack of thrust can mean premature contact with the ground — and usually disaster.

The subtle failure of speed protection during descent is a classic “pilot trap”, one that caught the captain of Asiana Airlines Flight 214 on July 6, 2013. During a daylight landing in clear weather at San Francisco, with 291 passengers aboard the B777, the airplane lost speed, struck the seawall at the end of runway 28L, and cart wheeled to a spot about 2,000 feet further down, completing a 330° turn before skidding to a stop. Three passengers died and 199 were transported to hospitals with injuries.

The airplane was destroyed, broken apart and charred in a goo of firefighting foam.

The wreckage of Asiana Flight 214

The wreckage of Asiana Flight 214

A fiery, deadly fiasco resulting from decreasing airspeed that was not sensed by any of the supposedly professional pilots in the cockpit (three captains and one first officer, some training and evaluation being conducted on the flight from South Korea).

The National Transportation Safety Board (NTSB) investigated. A year after the crash, acting NTSB Chairman Christopher Hart glumly observed, “In this accident, the flight crew over-relied on automated systems without fully understanding how they interacted.”

Whether the automatic speed control was “On” or “Off” was not clear to the crew. The handling pilot presumably thought it was “On” when in fact the equivalent of speed control in an automobile had quietly, without announcing this fact, snapped “Off”.

The NTSB recommended that the Federal Aviation Administration (FAA) review the design of the speed protection systems on the B777:

“Convene a special certification design review of how the Boeing 777 automatic flight control system controls airspeed and use the results of that evaluation to develop guidance that will help manufacturers to improve the intuitiveness of existing and future interfaces between flight crews and autoflight systems.”

Classic toothless bureaucratese. Preferable wording might be:

“Redesign B777 and all other aircraft model autoflight systems to ensure that their controls of airspeed and altitude are obvious and that their ‘On’ and ‘Off’ status is unambiguous to the crew, and that changes in status are both aurally and visually apparent in the cockpit such that acknowledgement or rejection is required by crew action. Require all autoflight systems not meeting this standard to be upgraded in aircraft within 24 months of this recommendation, with associated documentation and recommended flight training to be issued to the airlines. Ensure FAA approval of all such changes and issue of FAA-compliance directives to ensure mandatory implementation by airplane manufacturers and the airlines.”

Let us not be wishy-washy about the flight crew’s real-time knowledge about whether speed is automatically being maintained, or not.

The problem predates the Asiana crash at San Francisco. At least one other crash and one incident involving other Boeing aircraft models can be attributed to mode confusion — or ignorance — according to the NTSB.

Captain Kim Je Youl, a B777 instructor pilot at Asiana Airlines, remarked in an interview with NTSB investigators that if the Flight Level Change (“FLCH”) mode is selected during descent, the autothrottle will move to the HOLD mode, which does not support airspeed protection. Rather, the engines will spool down to idle power. From an English translation of his statement:

“During an approach to Seattle … the airspeed was falling close to the target airspeed but the autothrottle was in an idle state and did not respond … when the airspeed was 10 knots below the target airspeed, I turned off the autothrottle and manually pushed the throttle and had an uneventful landing. However, I was surprised that the autothrottle did not maintain the selected target airspeed.

“After the flight, I examined the ‘Flight Control’ section of the Boeing Flight Crew Operations Manual (‘FCOM’) and was eventually able to find, with some difficulty, a single sentence ‘note’ item on circumstances in which the autothrottle may not respond. I still felt this ‘note’ was insufficient to explain what I had just experienced. Therefore, I did a further study of the ‘Autopilot’ section of the Boeing FCOM and realized that in the circumstances I described above the autothrottle can be in a dormant state and the autothrottle will not function even if the target airspeed is reached. In my personal opinion, this is very important information that should be highlighted to pilots as a ‘warning’ item and not merely a ‘note’ item in the Boeing FCOM.

“In light of my personal experience, I made it a point to teach this aspect of the Boeing 777’s authrottle logic in ground school.”

No aural alarm. Just a green “Hold” light on the instrument panel (not yellow or red) — green signifying everything is normal. The term “Hold” is a misnomer; not holding thrust to maintain the target airspeed, but holding at idle power. Unless this condition is caught, the airplane will descent below the glidepath.

Captain Jung Tai Soo, a B777 pilot for Asiana, recalled his ground school session:

“I attended [a] course on ‘Performance’ that was taught by Captain Kwon Young Sik, a Boeing 777 captain and flight instructor at Asiana. Captain Kwon stressed that during approach … he strongly cautioned against using FLCH in a situation where a fast descent was required, using the visual approach to runway 28L at [San Francisco] as an example.”

One would think that for an airplane in flight, any automatic command to reduce thrust to idle power would be signified by a yellow light on the instrument panel illuminating the word ‘IDLE’.

Note the illuminated green letters, with HOLD supposed to indicate idle power; for the unwary, a 'pilot trap' of the first order

Note the illuminated green letters, with HOLD supposed to indicate idle power;
for the unwary, a ‘pilot trap’ of the first order

A pilot who does not remember his ground school instruction, or who is otherwise distracted or busy during the descent to the runway, might not recognize that the airplane’s computer has reduced the two engines’ power to idle. Basically, nil power when more power is needed.

This deadly quirk was discussed at a December 2013 NTSB hearing on the Asiana crash. Indeed, mode confusion, the design of the authrottle system, and how the crew is supposed to know “HOLD” means idle power consumed a good portion of the discussion between the five Presidentially-appointed board members, FAA, Boeing and Asiana witnesses called to testify.

This particular autothrottle system is found on hundreds of Boeing aircraft; not just on the B777. The same arrangement is a feature of the B747, the B757 and the B767. The exact same autothrottle system is found on Boeing’s brand new B787. In other words, the system is widely used in the existing fleet and will be in use for the nest 50 years as the B787 enters widespread service.

The FAA’s Stephen Boyd testified about the absence of a “wake-up” function on the autothrottle, revealed during the course of certification flight testing, done as part of the process to gain FAA approval of the B787 for use by the airlines:

“We were conducting a flight test and there was a flight level change initiated and [it] was interrupted by another event … Our pilot … was monitoring airspeed and noticed airspeed was decaying, and then as part of his test pilot functions, allowed the airspeed to decay further to see what would happen

“And our test pilot was expecting … the autothrottle would wake up … not realizing that the autothrottle was on, the autothrottle would not wake up.

“In the process of doing the evaluation [of the autothrottle design software], working with Boeing in this one, our FAA pilot determined that the fact that the autothrottle did not wake up was not a safety issue, nor was it a regulatory compliance [issue] …he worked with Boeing to include additional information in the flight manual to explain that the autothrottle on the 787 would not wake up from an autothrottle hold.”

So, buried deep in the B787 flight manual is the same quiet but revealing caveat — “additional information” according to the FAA’s obviously satisfied Boyd — that Captain Kim found hard-to-find and woefully deficient in the B777 manual.

Captain Kim was present at the NTSB hearing, representing Asiana Airlines. He noted that the European Aviation Safety Agency (EASA) wrote during B787 certification that the wake-up function was not operative and did not protect the aircraft.

“EASA noted the inconsistency in automation behavior has been in the past a strong contributor to aviation accidents and concluded that Boeing would enhance the safety of the aircraft by avoiding exceptions in the autothrottle wake-up mode,” he point out.

“Why didn’t Boeing devise its automation design to address this recommendation?” he asked Robert Myers, Boeing’s chief engineer for flight decks.

Myers reply was revealing:

“This EASA recommendation came up during the 787 certification in a similar manner as the FAA response item that we discussed earlier. This [EASA concern] came out as a recommendation, which means that Boeing is not required to respond to it and it is not a certification issue.”

Thus, the FAA determined the autothrottle’s lack of wake-up was not a safety issue, and the European concern about the same issue did not “require” a response. By such careful parsing of words, the very same autothrottle deficiencies contributing to the crash of Asiana Flight 214 were embedded in the new B787.

Board member Robert Sumwalt asked Boeing’s Darren Gulbranson, head of the company’s simulators, “Where does it caution that if you’re in a flight level change mode and the autothrust is in hold, that they (sic) will not wake up as we’ve just described here?”

Gulbranson: “I believe it’s in Chapter 4 of the Flight Crew Operations Manual, a note that says in flight level changes, the mode — that the throttle’s in hold, it will not wake up.”

Sumwalt was not impressed that this key behavior of the system was buried in the fine print. “See? If you know all of those nuances, it’s pretty clear, but here we are training people and we’re instilling in them that the autothrottle is going to wake up.”

Needless to say, the NTSB hearing was a startling revelation that when the authrottle is in HOLD mode it will not wake up and provide speed protection. One is left wondering what other foibles and quirks lurk in the highly automated cockpits of today’s, and tomorrow’s, jets, covered by notes in the manuals but not fixed?

In its listing of safety concerns emanating from the Asiana Flight 214 crash, The NTSB listed “reduced design complexity” to “help reduce the type of error made by the PF [pilot flying].”

The NTSB concluded:

“If the autothrottle engagement function (wake-up), or a system with similar functionality, had been available during the final approach, it likely would have activated and increased power about 20 seconds before impact, which may have prevented the accident.”

The chaotic cabin of the Asiana B777 following the crash

The chaotic cabin of the Asiana B777 following the crash

Twenty seconds of added thrust — time that probably would have spelled the difference between a routine landing and fearful passengers scrambling to evacuate a wrecked airliner.

Recliner Rage

Passenger arguments over reclining seat backs have resulted in at least three unplanned landings recently. Tempers were flaring, and the pilots deemed it prudent to follow the admonition of one aggravated passenger cramped behind a reclined seat back: “Put this airplane down, NOW!”

The number of reclining seat back disputes resolved by diplomatic flight attendants remains unknown but is probably a lot.

Economy class seats have been cramped for years. Anyone sitting in the middle seat knows the subtle disputes over the arm rests, which must be shared with passengers in the adjoining window and aisle seats. In the case of seat width, the passengers in the window and aisle seats have the option of scootching slightly outwards, either toward the cabin wall or into the aisle, giving the hapless middle seat passenger use of at least one arm rest.

This flexibility does not pertain to the space measured from the hinge point of the seat in front to the hinge point of the seat in back — what is known as seat pitch. When the forward seat is reclined fully, the passenger behind is wedged in; the feeling can be positively claustrophobic. It should not surprise that occupants crammed like sardines are turning on each other.

As a passenger commented:

“In most economy class seats, if the person in front of me reclines, I cannot use my fold down tray, cannot use my computer, cannot read a book or newspaper. The reclined seat takes up all the room in front of my. This is intolerable for more than an hour or so.”

On one of the three flights that landed prematurely, a passenger had locked the seat in front of him in the fully upright position, using a device known as a Knee Defender. The irate passenger whose seat was blocked from reclining threw a cup of water in the face of the passenger using the Knee Defender when he refused to remove the device.

The Knee Defender prevents the seat back in front from being reclined into the space ahead of one when the tray table is deployed

The Knee Defender prevents the seat back in front
from being reclined into the space ahead of one
when the tray table is deployed

The $22 Knee Defender consists of two plastic wedges that, when affixed at the base of the seat back in front, prevents it from reclining. According to the website where Knee Defender can be ordered:

“It helps you defend the space you need when confronted by a faceless, determined seat recliner who doesn’t care how long your legs are or about anything else that might be ‘back there’.

“For those of use who have to squeeze ourselves into the limited airplane legroom space of a coach seat offered by many airlines, a seat in front us that is poised to recline is a collision waiting to happen — with our knees serving as bumpers.

“Knee Defender™ to the rescue.”

Of course, passengers can always upgrade to Economy Plus (or variants of this moniker), in which they are afforded a greater distance between seat rows — but the seat itself remains the same.

In many cases, the Economy Plus seats are in the exit rows for emergency evacuation out the removable window panel. The extra space between seats is required by the Federal Aviation Administration (FAA) so that all passengers — not just those in that row — can speedily evacuate the airplane.

On these rows, the seat backs in front do not recline, to prevent any inhibition to quick evacuation.

The obvious solution to recliner rage is to make all rows the equivalent of exit rows — more distance between rows of seats and locked recliners. This stratagem would doubtless be unacceptable to the airlines, which would lose revenue-generating seats, and to passengers who want to recline, albeit courteously.

But this recourse does not address the overall problem of seat size. Airline seats are designed for the 95th percentile of men. However, people are getting bigger, and it is estimated that about 1 in 10 passengers today find the seats too small for them. With many economy class seats measuring a scant 17 to 18 inches across, many passengers find them too snug. The widest part of the body is in the shoulders, which is why many passengers wind up shoving for arm rest space.

The FAA should initiate a study of population size to resize, as it were, the minimum seat size and spacing, both fore-and-aft and left-to-right. FlyersRights, a passenger advocacy group, argues that there is a safety dimension not being addressed in the current mania to cram more seats into airliners and fill them completely for each flight:

“We sounded the alarm on substandard seat pitch due to airlines being allowed to insert extra rows to increase profits, resulting in passengers unable to brace themselves according to the aircraft safety card. Passengers also cannot exit a plane in 90 seconds during an emergency as required by the FAA, due to lack of egress in seat rows.

“What is needed is the FAA stepping in and setting a minimum distance between airline seats…”

Assuming such an FAA study resulted in larger seats and increased pitch, the result might not be increased comfort for the passengers. The new standard would have to be embedded in regulation. Any proposed regulation would have to be published for public comment. Airline opposition to any reduction in seats would doubtless be fiercely opposed.

The sad case of child safety seats on airlines is instructive. The FAA proposed mandating them — which would have ended the unsafe practice of infants in parents’ laps. The public response was overwhelmingly favorable. Parents, medical and safety experts all weighed in favorably. Airlines were opposed. The FAA proposal died.

Until the FAA is no longer subject to the dictates of the airline industry, expect no relief on cramped seating.

How might relief be accomplished? Have Congress enact a law requiring the FAA to study seat size and pitch from a safety and comfort standpoint, and to require its findings to be implemented by the airlines within ten years. Nothing less will relieve the present cramped and disputatious economy class seating conditions.

The Absence of Caution — The Tragedy of Malaysia Airlines Flight MH 17

Following the downing of Malaysian Airlines flight MH 17 over the Ukraine on July 17, the airline’s website featured senior officials with hang-dog looks offering condolences to the families of the 298 passengers and crew blasted to oblivion, likely by a surface-to-air missile fired by Ukrainian separatists.

Captain Izham Ismail, the airline’s Director of Operations, vowed a week later, “Safety has always and always will be our utmost priority.”

If so, one has to ask what the airline was doing flying at 33,000 feet over an active war zone where the antagonists were equipped with SA-11 missiles capable of striking jets flying as high as 49,000 feet. At least ten aircraft and helicopters had been shot down in the three months leading to the missile hit that destroyed the airliner. A Ukrainian military jet was shot down just the day before.

Other airlines had chosen to re-route their flights, accepting the slight increase in fuel consumption for the assurance of a flight outside the missile-striking envelopes of the combatants.

Before the missile attack, the Ukrainian government had closed airspace below 32,000 feet because of security concerns — note that flight MH 17 was cruising just 1,000 feet above. Eurocontrol, the air traffic controller for Europe, had banned flights below 26,000 feet since July 1, after rebels shot down a Ukrainian military aircraft. Some other airlines had already elected to avoid Ukrainian airspace, at any altitude, and were routing their airplanes to skirt any possible threat from the fighting below.

Belatedly, Malaysian Airlines now touts its avoidance policy, declaring it flies around Ukrainian airspace altogether. The once-popular aerial east-west highway is now empty.

Malaysian Airlines now faces liability estimated in excess of $1 billion. The lives lost are incalculable. Captain Ismail’s fervent commitment to safety is not only belated, it lies in tatters.

His words are not the only ones bereft of real meaning.

The International Civil Aviation Organization (“ICAO”) proclaims safety first and efficiency third in its priorities:

“ICAO sets international standards necessary for the safety, security and efficiency of air transport…”

Consider the Articles of Association listed by the International Air Transport Association (‘IATA”), of which Malaysian Airlines is a member:

“The mission of IATA is to represent, lead and serve the airline industry. In carrying out this mission IATA shall: 1. Promote safe, reliable and secure air services for the benefit of the peoples of the world; 2. Provide means of collaboration among Airlines in compliance with applicable law; 3. Cooperate with the International Civil Aviation Organization and other relevant international organizations.”

Each — Malaysia Airlines, IATA, and ICAO — failed to fulfill its of safety role, as the burned, twisted remains of flight MH 17 mutely attest.

The distancing from accountability was noteworthy for its brazenness. On July 18, Malaysia Airlines asserted on its website and on Twitter that MH 17’s flight plan was approved by Eurocontrol, which is solely responsible for determining flight paths over Europe, and further asserted that MH 17’s route was approved by ICAO. Contemporaneously, IATA issued a statement that “it is important we are very clear: safety is the top priority” and “[a]irlines depend on governments and air traffic control authorities to advise which air space is available for flight, and they plan within those limits.” ICAO President, Dr. Olumuyiwa Benard Aliu, was blessedly more circumspect, stating only that “ICAO strongly condemns the use of weapons against international civil aviation.”

At a fundamental level, the international community appears to be in agreement that whoever launched the missile bears responsibility for the crime of slaughtering the innocents 33,000 feet above. Who, though, bears responsibility for the conditions that allowed this civilian airplane to enter an area of active conflict? Further, how does this accident get prevented in the future?

1. Malaysia Airlines and IATA Knew Or Should Have Known

On July 14, three days prior to the MH 17 missile strike, an Antonov An-26 belonging to the Ukrainian government similar to the one pictured below was shot down by a missile at a reported altitude of approximately 21,325 feet.


An Antonov An-26 in Ukrainian military colors similar to the one shot down on July 14, 2014 near the village of Davido-Nikolsk, in the Luhansk region

An Antonov An-26 in Ukrainian military colors similar to the one shot down on July 14, 2014 near the village of Davido-Nikolsk, in the Luhansk region

An Antonov An-26 in Ukrainian military colors similar to the one shot down on July 14, 2014 near the village of Davido-Nikolsk, in the Luhansk region

The news of this event was widely reported in the media, including the altitude at which the airplane was struck. However, the significance of such an event escaped appreciation by officials at Malaysia Airlines, KLM (which stuck to the preferred fuel-saving route) and IATA. Lost was the understanding of the weaponry be used to bring down an aircraft from such an altitude. Lost was the understanding of the of the escalation of hostilities in the area, and lost was the understanding that the flight plan for MH17 “threaded the needle” between the restricted air space over and near Crimea to the south, and that of the Luhansk region to the north where the An-26 was shot down earlier that week.

However, the hostilities in the region were appreciated by several other IATA member airlines. Take for example, Korean Air which experienced the shoot down of KAL Flight 007 in 1983 at the hands of the Russian military. Korean Air, an IATA member airline, ceased flights over Ukrainian air space on March 3, 2014, or more than four months prior “due to the political unrest in the region.” Reportedly, Asiana Airlines, Qantas Airlines and China Airlines, all IATA members, had diverted flights around Ukraine well prior to July as well.

2. IATA and ICAO Lacked Redundant Security Intelligence

Counter-intuitive to its mission of promoting secure air services for the peoples of the world, it appears IATA never set up a system of intelligence sharing between its members relating to route-of-flight safety and security, including threat assessments. Instead, IATA rejected responsibility for any such thing on its part or its member airlines in a position paper submitted to ICAO which included the statement:

“IATA believes that governments have direct responsibility for aviation security and its funding. This responsibility includes protection of its citizens in the air and on the ground…”

Under such a position, safety and security would only be as good as the worst government upon whose information the flying public is expected to rely. Ukraine is a signatory to the Chicago Convention and should have followed its provisions and those in its annexes. Annex 17 to the Convention contains a provision that “[e]ach contracting state should constantly review the level of threat to aviation in their territory and establish any new procedures accordingly, as well as notify ICAO of the changes.”

So, did the Ukrainian government appreciate the threat that existed to civil aviation over its air space? Apparently not. Ukrainian controllers approved MH 17 to travel along the route and at the altitude it did. Again, only as good as the worst, and precisely why ICAO cannot solely rely on the provisions of Annex 17.

Certainly, ICAO has the personnel and expertise to have appreciated the threats that existed over Ukraine prior to the downing of MH 17. However, there was no system in place to independently gather and assess such available information. It seems that even with the report run by the CBC television in Montreal on July 14, where ICAO’s headquarters are located, no one at ICAO believed they were expected or empowered to do anything with the information published on the downing of the An-26 or the escalating violence in the region.

Nevertheless, the flying public was led to believe that the MH 17 route-of-flight was safe because, as Malaysia Airlines stated, it was an ICAO approved route. The reality is the ICAO approval of the route was not an endorsement of its safety on July 17, 2014 or at any other time.

The evasiveness and rationalizations are astounding.

Contrary to its mission, ICAO eschewed the duties of its self-proclaimed role as coordinator for international cooperation in all areas of civil aviation

3. Safety of International Civil Aviation is a Mutual Responsibility

The courts will eventually sort out the legal responsibility for the tragic downing of MH 17, but the airlines, industry and governments around the world know now where the systemic vulnerabilities to safety and security exist. Empty words in mission statements and vague declarations that safety is the highest priority are not enough when airliners are routed over active conflict zone.

Regulatory bodies, Eurocontrol, and airlines might take a page from the procedures used to avoid volcanic ash.

When Iceland’s Eyjafallokull erupted in 2010, ejecting huge amounts of ash into the upper atmosphere — and right into the path of international flights — jetliners were either grounded outright until the hazard had passed, or they were re-routed into safer climes by air traffic controllers.


The 2010 eruption of Iceland's Eyjafallokull volcano  disrupted international flights

The 2010 eruption of Iceland’s Eyjafallokull volcano
disrupted international flights

In just three days the volcano spewed 100 million tons of fine particulate matter into the atmosphere. The fine ash, not detectable by radar, scours windshields and gums up engines, causing them to wind down to a stop as the ash collects like glass on turbine blades and other components (See “The Hazard of Flying Through an Ash Cloud”, Aviation Safety Journal, May 17, 2010; see http://asj.nolan-law.com/2010/05/the-hazard-of-flying-through-an-ash-cloud/.

For volcanic ash clouds, the international aviation policy is strict avoidance with a 100 mile buffer for uncertainty.

Such a standard would make eminent sense as well for flying jetliners over the world’s conflict zones. The standard could be a part of an airline’s standard operating procedure (SOP), utilized by both dispatchers and pilots. It could be written into air traffic control procedures. The policy could be codified by ICAO and IATA. Certainly the policy should be enforced by government regulatory bodies.

As in the case of volcanic eruptions, flying trusting passengers over a conflict zones just begs the question: Why wasn’t the airspace banned (at all altitudes), and what was the airline thinking? The absence of caution invited disaster.

Questionable Accountability

The Federal Aviation Administration (FAA) proposed a $12 million fine July 28 against Southwest Airlines for sloppy repairs to fuselages on its B737 jets. What appears as significant regulatory action appears distinctly as another tardy and weak effort to assure the safety of the flying public.

“The FAA views maintenance very seriously, and it will not hesitate to take action against companies that fail to follow regulations,” vowed FAA Administrator Michael Huerta.

Tough talk and a proposed fine that are both years late, when timely FAA oversight might well have made a difference. The whole announcement of this “civil penalty” against the airline appears scripted for public consumption.

The FAA says it seeks financial disciplinary action based on Southwest’s maintenance lapses from 2006 to 2009. Note that it is now 2014, five years after the closing window of alleged shortcomings. Financial penalties and mandated procedural and personnel changes would have made eminent sense in 2010; now, years after the fact, the FAA’s belated action is too late to impact procedures, or to make a meaningful imprint on the minds of those responsible.

Not to mention that had the FAA acted in a timely manner, the sudden 60-inch tear in the upper fuselage of a Southwest jet cruising at 34,000 feet in April 2011, forcing an emergency landing of the planeload of terrified passengers, might not have occurred.


<a href=”https://nolan-law.com/wp-content/uploads/2014/08/hole.jpg”><img class=”size-medium wp-image-2869 ” alt=”Hole blown in the aluminum structure of a Southwest jet when the lap joint failed ” src=”https://nolan-law.com/wp-content/uploads/2014/08/hole-300×169.jpg” width=”300″ height=”169″ /></a> Hole blown in the aluminum structure of a Southwest jet when the lap joint failed

The FAA says that proper procedures were not taken when fuselage skins were repaired on Southwest’s jets. Specifically, that the airplanes were not placed on jacks to stabilize them for the repair work; sealant was applied between overlapping skin panels, but not all rivet holes were affixed with fasteners within the time allowed to assure a good bond and corrosion-free service.

The repairs, according to the FAA, were not performed in accordance with airworthiness directives (ADs). However, the FAA adds that it approved the repairs after the airline provided proper documentation. So, did the FAA subsequently okay the repairs even though they were made on airplanes that had not been first placed on jacks, and rivets were applied in the time allowed after sealant was applied? And it took five years for the FAA to determine that the paperwork was sloppy and to issue a proposed fine? Where were the FAA’s on-site inspectors when the repairs were first made?

Lots of questions. No answers.


<a href=”https://nolan-law.com/wp-content/uploads/2014/08/faa.jpg”><img class=”size-full wp-image-2870 ” alt=”Looks official, but the globe should be a pillow until the agency acts like a rigorous regulator ” src=”https://nolan-law.com/wp-content/uploads/2014/08/faa.jpg” width=”261″ height=”192″ /></a> Looks official, but the globe should be a pillow<br />until the agency acts like a rigorous regulator

Now begins a period of negotiation between the FAA and Southwest Airlines, in which the likely outcome is a dramatic reduction in the fine.

A fine against American Airlines for $162 million was subsequently whittled down to $25 million — an 85% reduction.

For Southwest’s lawyers, this 2013 precedent will surely provide a stimulus for vigorous argument.

Previous maintenance lapses do not seem to result in increased fines. From 2005 to 2013 the FAA levied $1,155,000 in proposed penalties against various airlines for maintenance lapses. Three forfeitures were announced against Southwest, the largest being $45,000. Eight penalties were proposed against Alaska Airlines, one of which was a measly $5,500. You would think that with eight proposed penalties from 2006-2007 there would be a special inspection of the Alaska’s maintenance practices across-the-board, especially when the airline came within a hairsbreadth of losing its FAA-issued operating certificate after the fatal crash in 2000, a direct result of maintenance deficiencies.

Each proposed penalty is viewed in isolation, not as part of a pattern warranting scrutiny as to the root causes of the maintenance violations. The flying public is unaware of these penalties; that is, unless the FAA decides to make a show of toughness.

The penalties would put a crimp in a household budget. For a corporation, they are not even as irritating as a minor hangnail.

Southwest earned a net profit in 2013 of $804 million. The proposed penalty of $12 million represents a mere 1.5% of 2013 profits. Negotiated down by 85% — as in the American Airlines case — will result in a penalty of just $1.8 million, or about two-tenths of one percent of Southwest’s 2013 profits.

These thoughts occur:

1. FAA action regarding AD noncompliance should occur within 12 months of discovery.

2. A forfeiture should be meaningful. Say, 5% of annual profits for each instance, times the number of airplanes affected.

3. The FAA should not be in the business of negotiating with the airlines what they will actually pay. The FAA is the regulator; if irregularities have been documented by the FAA’s principal maintenance inspector, the airline should be fighting to retain its operating certificate, not the amount of a reduced fine.

4. If the FAA were serious about safety and accountability, it would annually publish for the flying public each airline’s ranking using a star system similar to that used for automobile crashworthiness. For aviation, a three-star rating system would apply:

One star (¶): the airline meets FAA standards. If the airline is not meeting these admittedly minimum regulations, it should not be operating.

Two stars (¶¶): the airline more than meets FAA standards and has in place some voluntary safety programs.

Three stars (¶¶¶): all of the above, plus the airline has a pro-active safety culture with a non-punitive program to encourage employee reporting of deficiencies.

A civil penalty of less than $1 million would knock down an airline’s star rating by one star for six months. If already at the minimum one-star level, the airline would have its rating reduced to just a half-star. For penalties equal or greater than $1 million, the airline would be penalized by one star for a full year,

In pretty short order, we would see airlines scrambling to achieve a three-star rating and to make this ranking a feature of advertising, annual reports, and even on the corporate letterhead. Imagine a little logo on a proud airline’s web site and in its advertising: the great seal of the FAA emblazoned with three gold stars and a motto like, “Top ranking for safety, for five years and still improving.”

The flying public would have a ready measure; the airlines would have a meaningful incentive to avoid fines.

Carbon Trading Hits Airline Industry

The aviation industry is now facing direct actions to abate the growing effects of climate change. The implications for the industry are profound: fewer flights with more passengers, higher ticket prices to offset the costs of environmental pollution, and perhaps even a reduction in the size of the industry as a draconian step to limit air pollution.

With weaker carriers driven out of operations, the result could be a smaller but safer airline industry.

The latest environmental impact on aviation comes from the European Union (EU). Starting in January 2012, the EU is demanding all carriers that land or take off in the 27 nation block would emit no more than a set amount of carbon dioxide (CO2). Under the cap-and-trade concept, carriers can buy extra credits from each other if they exceed the limit, or they can sell credits if they emit less.

Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share

Transport contributes about 13% to global CO2 emissions, of which aviation involves a 13% share

The cap for 2012 is set at 212.9 million tons of CO2 – about 3% less than the average emitted by the airlines between 2004 and 2006. In 2013, the cap will drop another 2% — to around 208 million tons of CO2 – remaining at this level until 2020.

According to the EU, aircraft CO2 emissions account for only 3% of the global total but they have increased by 87% since 1990. Moreover, the real impact on global warming is amplified 2 to 4 times because airliners flying at high altitude leave condensation trails which add to the greenhouse effect.

Contrails contribute to the greenhouse effect

Contrails contribute to the greenhouse effect

The EU estimates the cost of the program at $10 to $15 per ticket. The European airline industry warned earlier this year that it would have to spend over $65 billion between 2011 and 2022 buying up credits from more fuel-efficient industries to meet the aviation quotas.

The EU’s carbon trading plan will only exempt airplanes with CO2 emissions that add up to 10,000 tons annually. Thus, a B777 airliner flying from Shanghai to London, a distance of approximately 5,500 miles, will emit 222 tons of CO2. If the airliner has three flights to Europe each week, the exemption quota will be used up in three weeks.

International flights represent approximately 62% of global aviation's fuel consumption

International flights represent approximately 62% of global aviation's fuel consumption

Airlines from non-EU member states flying to or from Europe will be affected by the law.

“This is already adopted legislation and we are not backing down,” declared Isaac Valero-Ladron, an EU spokesman. “We knew what we were doing in 2008 when we adopted this and we are not changing our legislation.”

The EU has banned some carriers deemed unsafe from landing in Europe; now the same is to be applied to airliners that emit too much greenhouse gases.

London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour

London's Heathrow Airport is the biggest single source of air pollution in Western Europe, aggravated by an average of more than 50 take off's and landings each hour

The EU mandate reflects frustration with the International Civil Aviation Organization (ICAO), which has studied the environmental effects for years but has not come up with a mandatory program. Rather, ICAO has developed voluntary goals for leveling aviation’s total emissions by 2020 and halving them by 2050. The ICAO plan artfully side steps the voluntary nature of its intentions:

“The ICAO Program of Action on International Aviation and Climate Change, agreed in 2009 … is the first and only globally-harmonized agreement from a sector on a goal and on measures to address CO2 emissions. ICAO continues to pursue even more ambitious goals for aviation’s contribution to climate change.”

Noble and toothless rhetoric.

In Europe, other energy-hungry industries have been under a cap-and-trade system since 2005; the exemption for aviation stood out.

Even though the EU program could be seen as an eventuality five years ago, only now are airlines and industry representatives outside the EU really making their complaints noted. The Chinese government has threatened to review its contracts for the purchase of Airbus airliners if the emissions caps are applied to Chinese airlines flying to EU states.

The U.S. Government has not yet weighed in, but the U.S. Air Transport Association (ATA), representing the vast majority of U.S. airlines flying to Europe, asserts the emissions cap-and-trade is illegal.

“Our position is that the EU ETS [Emissions Trading System] as applied to U.S. airlines is contrary to international law and bad policy,” claimed ATA’s Nancy Young.

ATA, American Airlines, United and Continental Airlines have taken their case to the European Court of Justice. Hearings were held this week and the judges are expected to issue a ruling by winter.

EU airlines insist that if they have to join the carbon trading market, their U.S. competitors should be forced to jump in as well. The European carriers say if they must spend $65 billion buying carbon credits over the next 15 years, and non-EU airlines are not forced to do the same, it would amount to a massive tax on European aviation.

On the safety side, if airlines are forced to retire their old fuel guzzlers, the new airplanes that replace them are safer. There could be a net safety benefit.

On the other hand, if peak oil has been passed or is about to be, the cost of travelling by air is likely to go up far more than it may under the emissions limiting scheme. A radar plot of airplanes flying to/from North America-Europe shows over 600 airplane symbols crowded over the Atlantic in a 24-hour period. That number could shrink by 200 or more if fuel prices air travel out of the reach of casual tourists.

The controversy over the EU cap-and-trade policy has spawned numerous comments on the Internet. Herewith, some of that commentary:


“I fail to see how carbon trading decreases emissions. I’m not a big fan of this system, as it still allows for people to continue to belch out as much pollution as before; they just have to buy credits from someone else.”



“It is well known that the impact of CO2 by airlines is greater than the same amount of CO2 by other means of transport because the airline exhaust is in the upper atmosphere whereas car exhaust is easily absorbed by the vegetation.

“It is environmentally illogical to exclude air transport. It will make flight more competitive compared to car or train and the CO2/passenger km is worse than for any other type of transport. Hence, excluding air transport will result in a negative effect in the end. Including air transport in the system is only a step to bring the different means of transport on the same level.”



“In the 1960s and 1970s some cars got maybe 7 mpg. With little government laws and many other big factors today for Chevrolet 7 out of 17 models get 30+ mpg. No model (other than trucks) gets lower than 20 highway mpg. Now imagine if Europe and the U.S. required Airbus, Boeing and others to have a similar increase in efficiency and maybe also somehow helping the airlines change to these newer, hopefully better planes. This would affect the entire market, reducing prices for customers and increasing business for the air industry.”



“To work any such system has to include any flight in and out of the EU. Otherwise you might get a situation where a plane starts in Greece and does not fly directly to Spain, but makes a short landing in North Africa and then continues to Spain just to declare the flight as ‘not within the UE’ and avoid the carbon tax. That way, you would have made the flight even worse than before … If the flight to Africa and from Africa are treated as flights in the EU, there is no incentive to ‘cheat’.”


“A general CO2 tax would be the first transnational tax in history.”


“You want a better way than a cap-and-trade system? How about a carbon tax on jet fuel and all other fossil fuels? Surely a carbon tax is more efficient and equitable than a cap-and-trade, and a lot easier to manage as well. And you don’t even have to get in an [argument] with head-in-the-sand Americans to make it work. That is, unless they don’t plan on refueling in Europe once they land.”



“As some have observed, yes, the cost of carbon credits will be passed on to the passenger. That’s the whole point!

“People will travel less, or rather shorter distances, when price goes up. More CO2 efficient means of travel can better compete with less efficient ones. Train may be preferred over plane or car. All this will cut emissions, which is the central objective.

“Europeans will go less to the U.S. as Americans go less to Europe; tourism will change to the home market. As a whole, I don’t think tourism on either continent will suffer …

“The carbon trade system is brilliant in that it allows countries to earn credits by investing in CO2 efficient tech [which] will be employed where the effect is greatest.”



“The so-called market approach will not, and cannot, solve airline emissions for a very simple reason: operating an airliner imposes a cost on the environment that the airline doesn’t have to pay! Since the airline can stick the rest of society/the world with the cost of its operation, there is no market incentive for it to curb emissions. Claiming that regular market incentives to reduce fuel consumption (to lower costs the airline DOES have to bear) amount to ‘dealing with’ the emissions problem is disingenuous because, again, the cost of the fuel paid by the airline does not include the cost its use imposes on everyone else in the form of environmental damage. The best way to factor in that cost is with a carbon tax. Cap and trade is just a way to spread the pain equally among participants in the industry being regulated.”


“Operating those B767s and B757s on transatlantic routes is about to become more expensive.”


“It is hardly a development that is hostile to the aircraft design and construction industries.”


“It’s pretty simple: no EU airline can avoid this tax. It will apply, without exception. on 100% of heir flights as, obviously, 100% of their flights come to, from or through the EU …

“The same won’t be true of, say, a U.S. airline, which may only have 3-4% of their flights coming in our out of the EU and thus will only be subject to this tax on a tiny portion of their network …

“3-4%. 100%. The difference is huge.”



“Microsoft took the view that the EU would back down. It looks like costing them $690 million in fines. It’s a high risk strategy unless you can play Brussels politics really well.”



“When the U.S. introduced anti-terrorism regulations, they forced the entire industry to comply or else lose the ability to land in the States. Why wouldn’t the EU do the same for global warming?”

2011 ‘Most Wanted’ List Still a Pig in Lipstick

The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.



The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

NTSB Chairman Deborah Hersman

NTSB Chairman Deborah Hersman

Regarding the new format, Deborah Hersman, NTSB chairman, said:

“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”

If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:

1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).

The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

Addressing Human Fatigue

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety …


What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation … Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

ASJ comment: the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:

 “We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at lower costs.” [Emphasis added]

 In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.

 Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.

 The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:

 “The FAA … believes it is inappropriate to rely on existing requirements … to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”

 Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.

 In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)

General Aviation Safety

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.


What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders …

ASJ comment: The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence.

 It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.

 The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be used. (See Aviation Safety Journal, “Crash in Alaska & Lack of Probing About Key Safety System”)

Safety Management Systems

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries …

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs …

ASJ comment: The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been required by the FAA’s equivalent agency, Transport Canada.

Runway Safety

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight … In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.


What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers …

ASJ comment: the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.

Pilot and Air Traffic Controller Professionalism

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust …

most wanted 2011-4

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior … And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

ASJ comment: The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)


What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft … are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.

most wanted 2011-5

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

ASJ comment: the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”)

Beware The Icing Hazards Masked By Average Droplet Size, Scientists Warn

Expansion of the icing envelope for aircraft certification purposes, as proposed by the Federal Aviation Administration (FAA), will not cover all the icing conditions likely to be encountered by an airplane during its service life. The envelope needs to be expanded, claim a group of distinguished atmospheric scientists.

In 2010, the FAA proposed an Appendix O to cover supercooled liquid droplet (SLD) conditions. (See Aviation Safety Journal, July 2010, “Significant Regulatory & Related Activity”) This new appendix would theoretically cover icing conditions not defined in Appendix C of the regulations.

The icing conditions in the 1994 accident at Roselawn, IN, involving a twin-turboprop ATR-72, prompted the National Transportation Safety Board (NTSB) to recommend the FAA include much larger droplets than defined in certification regulations. This recommendation is the rationale for the belated publication of the Notice of Proposed Rulemaking with Appendix O in 2010, fully 16 years after the Roselawn crash.

Supposedly, Appendix C covered only 99% of the water and droplet sizes in so-called “cloud icing” conditions. Appendix O was intended to cover the conditions of freezing drizzle and freezing rain produced by other distinctly different processes of formation that are not part of the cloud icing conditions. Thus, an airplane certificated to both appendices should be able to cope successfully with any icing encounter while airborne.

Not so, claim the scientists. After examining the data used as a basis in the proposed Appendix O, and comparing these data to other data collected by instrumented research aircraft, they conclude in their submission:

“We therefore are concerned that adoption of these rules will lead to a false sense of security that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence this will not be the case.”

The essence of their argument is familiar to students of Statistics 101 and those gamblers who frequent craps tables at casinos. It is similar to the way two dice can land, showing a total count of seven on the top surface. There are six combinations: 1 & 6; 2 & 5; 3 & 4; 5 & 2; and 6 & 1. The average number of spots for all six combinations is 3½. The corollary in icing is what is referred to as the mean volumetric diameter (MVD), a hypothetical diameter characterizing all the sizes of droplets in the cloud for which half the mass of water is in droplets larger, and half is in droplets smaller. A dice has no face with 3½ dots and there need not be any droplets with the exact MVD.

The scientific evidence is that MVD, similar to the 3½, bears no relation to hazard. There are icing cases similar to rolling a 6 and a 1 that are the real hazards (and the other five combinations not so much). The way the icing envelopes are defined date back to the 1940s, but evidence now shows that other metrics are warranted. Scientific evidence supporting the need for reexamination has existed from multiple studies beginning in 1984 and revisited in the late 1990s.

Yet, as “nature abhors a vacuum’, the aviation industry abhors a change – and that is the seminal message in the scientists’ letter.

Extracts of the scientists’ submission to the docket follow:

June 21, 2011


Docket Operations, M-30

U.S. Department of Transportation

1200 New Jersey Avenue SE

Room W12-140, West Building Ground Floor

Washington, DC 20590-0001


Re: Supplemental Comments to Docket Number FAA-2010-0636

Dear Sir or Madam:

The following comprise our supplemental comments to the Docket with respect to the Notice of Proposed Rulemaking (NPRM) … published in the Federal Register June 29, 2010 … We recognize that the comment period has closed. However, the following has taken substantial time and effort to thoroughly review the data that the proposed Appendix O was based upon, compare it to our results, and prepare substantive comments.

On the basis of independent measurements of the icing hazard, obtained with a research aircraft while supporting research projects that studied icing environments, we argue that the proposed rules will not provide adequate protection against some of the most serious icing hazards. [Emphasis added] We explain the reasons for this assertion below …

Our main concern is that … the draft regulations implicitly assumes that the icing hazard is represented adequately by … liquid water content (LWC) and the droplet size distribution (DSD) selected from one of two average distributions on the basis of the median volume[tric] diameter (MVD). No justification has been offered to relate the plotted parameters to performance in icing. Incorporating these figures into the regulations will imply that the icing hazard is determined by these properties, so it is only necessary to demonstrate ability to encounter conditions characterized by these values. However, we suggest that for a given LWC and MVD there actually can be great variability in the icing hazard because real size distributions vary substantially from those shown in Fig. 2 for freezing drizzle and Fig. 5 for freezing rain. Those figures result from averaging many different size distributions, all of which can have different effects on performance, and that averaging can obscure the icing hazard …

We have experience and data to support these assertions. A summary of the effects of icing on performance of our Beechcraft Super King Air 200T (operated by the University of Wyoming and henceforth called WKA), first published in 1984 … concluded that there was no observed correlation between MVD and the impact of icing on performance. This same conclusion was arrived at and published in all the subsequent articles based on a much larger data set … The fundamental reason MVD is not correlated with performance is MVD represents cloud droplets rather than drizzle drops … Indeed, the most hazardous encounters in that data set and in subsequent studies in which we were involved had the same LWC and MVD as many other encounters that led to much smaller effect on performance. (We had the benefit of a continuous measure of the effect on performance of the aircraft to accompany our measurements, something that was not developed for the data set used as the basis for Appendix O, so we can defend the preceding statement with performance data.) We therefore are concerned that adoption of these rules will lead to a false sense that they will protect against the icing hazard of freezing drizzle and freezing rain, when we have evidence that this will not be the case.

The substance of our argument is that the proposed envelopes for LWC vs. temperature and average drop size distributions mask the most adverse conditions that have been measured by combining them with conditions that pose only a minor hazard. The envelopes in the draft Appendix O focus on average properties of the supercooled drop size distribution and do not represent the important effects of variations from that average distribution, but those variations often lead to variations in ice roughness and in the locations of accretion. Certain forms of icing with very adverse distributed ice roughness from freezing drizzle can accrete in a few minutes and can quickly create significant drag and associated controllability problems for airplanes, even in cases where the visual appearance of this ice accumulation is not remarkable …

In our measurements, performance (as measured either by potential rate of climb or by increased drag on the airframe) exhibited no correlation with MVD, further leading us to question the usefulness of this measure of icing severity …

Post-accident forensic weather analyses of icing-related accidents by scientists specializing in these phenomena support the occurrence of the icing conditions that we assert are not accounted for in the draft of Appendix O, and those analyses have pointed to the likely involvement of a particular type of freezing drizzle in the accident record of various airplanes. These conditions tend to produce ice features having distributed roughness that do not have significant thickness or mass …

We suggest that additional steps to address these problems and guard against the most serious icing hazards are needed before new envelopes are inserted into the regulations. The proposed new regulations could delay efforts to address the problems raised in these comments and would lead to unnecessary effort to meet inadequate requirements.


The crux of the matter now rests with the FAA in the rulemaking process. Does the FAA proceed with the proposed Appendix C and Appendix O envelopes or revisit them? Given the pre-eminent stature of the commentators above, the FAA will have some important decisions to make. Ignoring the comments above is one option, but that course does nothing for the safety of aircrews and passengers flying in icing conditions.