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Airline Downloads Flight Recorder Before Passing It To Safety Board

Imagine a classroom of students taking a quiz. One student has been designated to collect the completed work and deliver it a distance of several blocks distant to the teacher. The student courier is highly tempted to take a peek at the students’ work. This is an approximation of the procedure by which flight recorders are removed and shipped from aircraft involved in incidents. In this case, the recorder was downloaded in whole or in part at the airline’s maintenance facility instead of being shipped unmolested to the Washington DC headquarters of the National Transportation Safety Board (NTSB).

On 28 December an American Airlines B757 overran the snowy runway at Jackson Hole, WY by some 350 feet. None of the 181 persons aboard was injured; neither spoilers nor thrust reversers deployed promptly.

An American B757 of the type involved in the overrun

An American B757 of the type involved in the overrun

The immediate problem in the Wyoming incident is that neither NTSB nor Federal Aviation Administration (FAA) officials were present to supervise removal of the flight recorders. This task was left to the airline, which then flew the recorders to its maintenance base at Tulsa, OK. While there, a portion of the flight recorder data (FDR) or the entire 2-hours was downloaded for company use. The recorder was then shipped to the NTSB laboratory in Washington.

According to knowledgeable sources, this is not the first time that the carrier has downloaded recorder information while entrusted to ship them – without interference – directly to the NTSB.

As a result of its ill-advised actions, American Airlines has been removed from party status, which basically means it has been barred from participating in the investigation.

The penalty seems to be the equivalent of a hand-slap.

NTSB Chairman Deborah Hersman said in a statement that the download was “a breach of protocol” that violates standards for any organization that is allowed to participate in a Board investigation.

Adherence to standards is “vital to the integrity of our investigative processes,” she said.

American Airlines spokeswoman Mary Fagan said in a statement that the airline downloaded information from the FDR “as part of its normal safety investigation of the incident.” There was no attempt to circumvent the collaborative process with the NTSB, she added. These glib excuses suggest that American Airlines sees nothing wrong with its actions and, indeed, may have engaged in similar downloading previously.

Information from the cockpit voice recorder (CVR) was not downloaded, raising questions about the carrier’s motives for accessing only the FDR.

"Do not open" implies to the airline "do not download"

"Do not open" implies to the airline "do not download"

Given the history of airline and manufacturer denial of key information, obfuscation of facts, and selective memory, one could question the NTSB assertion that the process has worked jut fine for 40 years.

In the Wyoming overrun case, a number of questions were posed to the NTSB; some of the answers point to numerous holes in their investigative process:

Question: Who removed the recorders from the overrun airplane and when?

Answer: The NTSB asked American Airlines to have their personnel remove the recorders from the aircraft and transport them to the NTSB recorder lab in Washington, DC, in accordance with normal party procedures. The recorders were removed from the aircraft the same day as the incident.

Q: Why were these recorders not transported via the NTSB chain of command instead of by American Airlines?

A: The NTSB investigates most accidents using the party system. In this case, the NTSB initiated a formal incident investigation and designated American Airlines as a party to the investigation and requested that they ship the recorders to NTSB HQ in the most expeditious manner. As the operator, American is required to preserve all data surrounding the incident until the Board takes custody in accordance 49 CFR 830.10 [Title 49, Transportation, Code of Federal Regulations, paragraphs dealing with Preservation of aircraft wreckage, mail, cargo, and records].

For major accidents on which an NTSB Go Team launches, the NTSB or our designee takes custody of the recorders at the site and the recorders are flown to Washington, usually via the FAA airplane that transported the NTSB investigative team to the site. For incidents, where there is no FAA or NTSB employee on scene and there is not likely to be for several hours, we may have the carrier remove the recorders and send them to us by the most expeditious means possible.

Q: Were these recorders in a locked steel container for shipment? If so, how did American Airlines access the recorder?

A: The recorders were shipped in appropriate shipping containers specifically designed for each recorder.

Q: In civil jurisprudence, evidence tampering is a crime. What do your lawyers and administrative law judges propose in the way of sanctions – for this or future cases – that have more bite than removal of party status?

A: The sole objective of an NTSB investigation of an accident or incident is for the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability (§ 831.4 Nature of Investigation). The “party system” utilized by the NTSB to investigate accidents has been in use for decades, primarily because it is the most effective investigatory process for major transportation accidents and incidents.

Guidance provided to parties for their participation in an NTSB investigation notes that parties and party participants must be responsive to the direction of NTSB personnel and may lose party status if they conduct themselves in a manner prejudicial to the investigation or do not comply with NTSB instructions.

In this situation, we have determined that the revocation of American’s party status was the appropriate course of action. We also believe that this will send a clear message to the aviation community that such breaches of protocol are not acceptable. There are certain circumstances in which actions by an individual or entity, including a party, that interfere with or impede the Board’s investigation can rise to the level of a criminal offense. The Board may turn those matters over to federal prosecutorial authorities as the Board deems appropriate.

Q: If the NTSB does not have a regulation that says, in effect, “NO REPRESENTATIVE OTHER THAN THE NTSB WILL BE ALLOWED TO HANDLE, STORE AND/OR TRANSPORT FLIGHT RECORDERS” is such a proviso now contemplated?

A: In accordance with 49 CFR 830.10, the operator of an aircraft involved in an accident or incident must preserve “all recording mediums of flight, maintenance, and voice recorders pertaining to the operation and maintenance of the aircraft” until the Board “takes custody thereof or a release is granted ….” The NTSB took custody of the recorders when they arrived at DCA and, until that point, the party was responsible for preserving them in the condition they were upon removal.

As referenced above, there are provisions already in place that address interference with an NTSB aircraft accident investigation. We provide clear and unambiguous instructions to the carrier on the protocols for handling the recorders and transporting them to us. As noted in response to the previous question, all parties are instructed that they may lose party status for failure to comply with NTSB instructions.

Based on these responses, a number of thoughts occur:

The airplane could have been parked, unmolested, until an NTSB official arrived on-scene to supervise/witness recorder removal. It makes absolutely no sense that an FAA employee from Casper, WY, or elsewhere could not be at the incident site sooner than it took to assemble a group of American Airlines mechanics and fly them in a chartered corporate jet from Tulsa to Jackson Hole.

And having this team retrieve, unsupervised, the flight recorder, was more expedient for the NTSB? Safety and sanctity of the FDR data should take precedence over expedience any day.

In its answers, the NTSB included this sentence: “The airline is instructed to transport the recorders without delay and without accessing the information contained within them by any means.” Where or when was this instruction given to American Airlines? §49 CFR 830.10 is silent on the matter.

The recorders should have been placed in a steel tamper-proof lockbox at the scene for shipment to Washington DC. If necessary, the steel box can be shipped via overnight, registered express. One doubts that shipment by the concerned airline is appropriate or faster.

The NTSB says “most accidents” are investigated by the party system, suggesting that not all inquiries involve parties. The question is why ANY investigation should involve parties and their resultant privileged position. Some other accident investigation bodies internationally do not utilize the party system, and their accident reports do not seem to be hampered in the least.

The Board should “take custody” of recorders at the incident site, not when the recorders are received in Washington DC. Different procedures for incidents and accidents are nonsensical; the difference between an accident and an incident is a few feet or a few seconds timing.

Custody by “our designee” suggests that said designee could be the airline involved – which compromises the NTSB’s role as an independent investigator.

What is the point of evidence collection through party members who may tamper with that evidence? The NTSB seems mighty trusting. Note the NTSB says the recorders were shipped in “appropriate” containers, sidestepping the issue of whether they were locked and bonded to deny access to all but the NTSB.

The claim that the party system in use for decades works well is belied by controversy. In the early 2000s, then-Chairman Jim Hall was extremely dismayed to find that Boeing had withheld from the Board key information about B747 fuel tank inerting. Filling the void space in the fuel tank with inert gas is the process of insuring that the tank is explosion-proof. Had this information been available, it certainly may have influenced the Safety Board’s recommendations coming out of the investigation into the fuel tank explosion that downed TWA flight 800 and involved a B747. The FAA, also a party to the TWA 800 investigation, failed to disclose to the NTSB that it had successfully test-flown a fuel tank inerting system at its technical center in the late 1970s.

Another point to be made is that 40 years ago the technology allowed for recording only minimal data about flight performance. Today, much more raw data is available through flight recorders, enabling precise reconstruction of an event. The volume of data available today means it is a more valuable resource, requiring enhanced procedures to secure and transport the recorders to the NTSB.

The NTSB says it “may” turn over to Federal prosecutors cases involving blatant abuse of the party system. There is no record in recent years of the NTSB ever having done so. One thinks this would have a marvelously clarifying effect on any party to an NTSB investigation.

While 49 CFR 830.10 requires operators to turn over all recording mediums to the NTSB, the regulation is silent on the matter of unauthorized downloading of the data.

In the NTSB’s convoluted and self-justifying responses, the whole issue of when custody should be assumed is given short shrift. The NTSB, not the party, should supervise removal of flight recorders (or retrieval from the wreckage, as the case may be), ensure that recorders are placed in an NTSB-locked tamper-proof container, and shipped to the NTSB laboratory in such a manner as chain of custody is maintained by the NTSB and not by a party to the investigation.

It seems the NTSB should adopt protocols by which a recorder may not be removed from any aircraft involved in an accident or incident while engaged in a Part 121 (scheduled) or Part 135 (air taxi) operation without an NTSB and/or FAA representative with authority present. The only exception would be if the recorder is in imminent danger of being further damaged if not removed promptly.

If the NTSB does not have the resources to guarantee this process, it should request them from Congress. Nothing less than the NTSB’s independence is at stake.

For the first offense of party malfeasance, no less than a fine in the six figure range is appropriate, with a second offense within five years increasing the penalty to the seven-figure rage. For the third offense, losing of the operator’s license should be considered. Similarly, any party that opens and/or downloads information from the flight recorders should face a heavy fine and possible operating license suspension.

In this case, the NTSB was not even at the scene when American Airliners had a team of technicians and maintainers from that charter flight going over every possible procedural, mechanical and electronic component that may have contributed to the overrun. The circuit breaker was pulled to ensure that the recorder information was not corrupted, but the airplane itself should have remained where it was until an NTSB official arrived to take charge.

One does not take custody of critical evidence a few miles from NTSB headquarters, and from the airline involved, while insisting the loosey-goosey collaboration has “worked” for 40 years.

Improved Safety by Dribbles

Think about this: safety deficiencies have already been identified, but the Federal Aviation Administration (FAA) is dribbling out corrections in penny-packets. Not only does the practice put aircraft occupants at risk, it creates a nightmare for maintenance personnel.

Recall that after the fuel tank explosion that downed TWA flight 800 in 1996, the aviation industry was challenged to go back and look at its design practices for fuel systems and associated electrical components thereof, and come up with recommended fixes.

Since aircraft fuel systems already met the certification regulations, one would think there would be maybe a couple dozen items across all transport category aircraft that would need retroactive correction. Not so. Based on the FAA’s 2001 order, known as Special Federal Aviation Regulation (SFAR) 88, titled “Fuel Tank System Fault Tolerance Evaluation Requirements,” aircraft manufacturers were told to review their fuel system designs and recommend correction, by aircraft model, by component, to reduce the possibility of an ignition source igniting an explosion of fuel-air vapors.

Hundreds of potential safety hazards were identified. The FAA has been issuing airworthiness directives (ADs) ever since, ordering operators to correct problems. The most recent as the 1 October proposed AD addressing Airbus A330 and A340 passenger jets:

“Failure of the auxiliary power unit bleed leak detection system could result in overheat of the fuel tank located in the horizontal stabilizer and ignition of the fuel vapors in that tank, which could result in a fuel tank explosion and consequent loss of the airplane. The proposed AD would require actions that are intended to address the unsafe conditions …”

The FAA says this is one of 11 proposed ADs and 233 final ADs issued since the SFAR 88 design reviews were completed. They have been issued singly, or in small batches of three or four ADs. In addition, 26 additional fuel tank safety ADs have been issued addressing potential ignition sources discovered after the completion of the SFAR 88 reviews.

That’s 270 ADs all told. They’ve been published quietly from 2003 forward. How an airline maintenance operation is to keep track of and coordinate the necessary work is not the FAA’s problem. Meeting the varying compliance times, assuring parts and labor, is not the FAA’s concern. To the agency, issuance of the ADs “solves” the safety problem.

The total cost to the industry of the various fixes remains unknown. To appreciate the overall price in terms of labor, materials, aircraft down time, lost revenue, etc., would entail going through each and every AD.

Since the overwhelming majority of risks were identified through the SFAR 88 process, it would seem better, from a safety and scheduling standpoint, to issue as many ADs as possible at one time, together. Airline maintenance personnel would then see the scope of work involved and could incorporate the activity at the next overhaul period.

With more than 200 deficiencies corrected at one time, the safety of passengers and aircrews would be materially enhanced sooner.

Nor have the last of the ADs been published. The FAA expects to issue 40 more SFAR 88 related ADs. In other words, hazards already identified on airplanes carrying thousands of passengers a day. That’ a total of 310 fuel system safety corrective actions.

The last AD will be published in 2011. Why wait? If the deficiency is known, publish the AD now.

Thus, the ADs will have been promulgated over an eight year period, 2003-2011. The last AD will be issued some 15 years after TWA 800 blew up. Given the time allowed to correct each condition identified by AD, it will be at least 2016 before the final fixes are implemented.

If all corrections known in 2003 were implemented over the same five or six year deadline, safety would have been immeasurably increased by now, not by 2011 or by 2016.

Why Airplanes Are Vulnerable: The FAA Allows It

Reports of smoke filling the cabin of Boeing’s new B787 Dreamliner on a test flight, forcing an emergency landing and deployment of the inflatable slides to speed evacuation, raise a pertinent question: is the flying public going to be as vulnerable in the next 40 years as it has been in the past to smoke and fire? (See Aviation Safety Journal, “Boeing’s New B787 Suffers Electrical Fire in Flight”)

The B787 incident has parallels to an electrically induced fire that occurred on a United Airlines B777 at London’s Heathrow airport in February 2007. Good thing British investigators were on the case. United filed a service difficulty report (SDR) that indicated only “smoke,” not “fire,” so there was no reason for the Federal Aviation Administration (FAA) to press further. As for the U.S. National Transportation Safety Board (NTSB), its accident/incident database characterized the event as “fire” but no further information was given.

The case was duly and glibly passed to the U.K.’s Air Accidents Investigation Branch (AAIB). The AAIB, fortunately, was on the scene and produced a thorough and juicily detailed investigation in February 2009. The AAIB noted, “The electrical power system is designed to isolate a fault or failed device selectively while minimizing power interruption to a functioning system.” Then it went on to describe how the protections utterly failed to prevent a fierce and fiery conflagration:

— An internal failure of the Right Generator Circuit Breaker or Right Bus Tie Breaker contactor on the P200 power panel inside the Main Equipment Center resulted in severe internal arcing and short-circuits which melted the contactor casings.

— The open base of the P200 power panel allowed molten droplets from the failed contactors to drop down onto the insulation blankets and ignite them.

— The aircraft’s electrical protection system was not designed to detect and rapidly remove power from a contactor suffering from severe internal arcing and short-circuits.

— The contactors had internal design features that probably contributed to the uncontained failures.

The passengers were debarked by a mobile step way, as the airplane was taxiing to its takeoff position at the time of the electrical fire. The B787 incident was obviously more serious, as the occupants got off the plane via the evacuation slides. This recourse suggests that there wasn’t time to haul a mobile stairway up to the plane for a more deliberate debarkation.

In the B777 incident, the AAIB concluded:

“The RGCB [right generator circuit breaker] and Right Bus Tie Breaker (RBTB) suffered from severe internal arcing and short circuits which generated temperatures in excess of 1,000º C [1,800º F], and resulted in uncontained failures.”

Fire damage to the P200 power panel.

Fire damage to the P200 power panel.

“Molten copper and silver droplets from the failed contactors dropped down through the open base of the P200 panel and ignited the insulation blankets below.”

“The insulation blanket fire spread underneath a floor panel to the opposite P205 power panel, causing heat and fire damage to structure, cooling ducts and wiring.”

Burned aircraft structure and insulation blankets below the P200 power panel.

Burned aircraft structure and insulation blankets below the P200 power panel.

As in this B777 event, the B787 reportedly suffered from a spreading insulation blanket fire.

Now consider the three requirements for a fire: oxygen, an ignition source and fuel.

In the B777 emergency at Heathrow, and the B787 emergency landing at Laredo, TX, electrical arcing provided the ignition source and the insulation blankets provided the FUEL for the fire.

From 2000 to 2008, the FAA issued more than 20 airworthiness directives (ADs) directing the removal of insulation blankets that burn. From 1988 to 2010, at least eight FAA Technical Center reports and two FAA Safety Conference Papers were issued that addressed electrically induced fires or the insulation blankets that give fuel to the fire.

In 2002 an FAA Aging Transport Systems Rulemaking Advisory Committee (ATSRAC) presentation in Atlanta concluded:

— In-flight fires in hidden areas are a risk to aviation safety.

— Most hidden fires are caused by electrical problems.

— Non-compliance with safety regulations has been uncovered.

— Fire safety problems and improvements are in various stages of correction and study.

— It is impossible to predict the relative risk of serious fires occurring in hidden areas or locations.

The expression “various stages of correction” can mean anything, and the term “study” reveals the lack of a sense of urgency. Thus, the B787 crew had an urgent reason to land, and an urgent reason to evacuate the airplane as rapidly as possible, but the issues of electrical fire and flammable insulation blankets remain under “study” by the FAA – with no deadline for resolution.

After its investigation of the 1998 in-flight fire that downed Swissair flight 111, the Canadian Transportation Safety Board (TSB) said airliners ought not be designed and built with flammable components. If there is nothing to burn, the danger of electrical arcing igniting anything is hugely reduced. This TSB recommendation has obviously not been taken to heart. The B787 Dreamliner is a post-Swissair flight 111 design, yet flammable materials are still used in building new airliners.

Instead of this “strategic” approach, which implies a tightening of the certification standards for airplanes like the B787, the FAA remains stuck in the “tactical” mode, which is to say not much has changed. ADs are issued with overly generous compliance times in years. One of the latest ADs illustrates the FAA’s “slackadaisical” approach. AD 2008-23-09 requires flammable AN-26 insulation blankets to be replaced on a raft of Boeing designs, from the B727 to the B747. The rationale for the AD is given as:

“This AD results from reports of in-flight and ground fires on certain airplanes manufactured with insulation blankets covered with AN-26, which may contribute to the spread of a fire when ignition occurs from sources such as electrical arcing or sparking.”

The AD was issued in November 2008 and operators have 96 months to comply.

Actually, the AD is more accommodating to the industry than hinted at by this summary. The industry had ample notice that the AD was coming. From the time the Notice of Proposed Rulemaking (NPRM) was published in April of 2004, to the “comply-by date” of December 2014, the industry had fully 19 years and 8 months to work with, and nibble at the requirements to reduce the airplanes affected. This is seen in the “Cost of Compliance” section of the AD:

“The number of airplanes is reduced from those in the NPRM because of airplane retirements or changes from U.S. to foreign operation. A substantial decrease in estimated cost results from the net change of increasing parts and labor cost, but reduced number of airplanes, and a changed assumption of service for the entire fleet.

“All passenger airplanes in the AD fleet will reach 25 years of passenger service at most three years prior to the end of the compliance period, at which time we assume they will be converted into cargo service [which is 40% cheaper].”

If an airplane is sold into foreign operation, the provisions of the AD can be ignored. In other words, let foreigners be exposed to risks passengers will (belatedly) not be exposed to here in the U.S. Allowing eight years for the work on U.S. registered airplanes allows for much less cost than, say, a four year deadline.

The AD is typical. A model-by-model approach, over years to minimize the cost, while the root problem cited by the TSB of Canada goes unaddressed: the very materials used across many manufacturers and model applications.

A strict ban on flammable materials, as recommended by the TSB, should have been applied starting with the new B787. It wasn’t, and the emergency evacuation resulted.

This airplane is going to be in service for the next 40 years. Instead of future item-by-item corrective ADs, the vulnerability of the aircraft to in-flight fire should be designed out now.

Time to Reverse the FAA’s Priorities

Congressman John Mica (R-FL) is a master at avoiding obvious issues. Mica stands poised to inherit the chairmanship of the Transportation and Infrastructure Committee. He’s been the ranking member under Chairman James Oberstar (D-MN), who failed re-election.

Mica was quick to issue a press release regarding the next, 112th Congress, which said in part:

“If selected by my peers to chair the Transportation and Infrastructure Committee in the next Congress … Among my top legislative priorities will be passing … a long-overdue Federal Aviation Administration reauthorization (and) better management and utilization of federal assets.”

Rep. John Mica (R-FL)

Rep. John Mica (R-FL)

Of course, adequately funding the FAA is essential – it has to be kept open to conduct business, and “better management” is always a laudable goal.

Now let’s get down to particulars –

The Government Accountability Office (GAO) released a report in late October on aircraft certification within the FAA whose title reveals how substantially deficient the GAO review was substantively: “Aviation Safety: Certification and Approval Processes Are Generally Viewed as Working Well …”

In a 29 October press release, Mica said:

“The FAA must address the inconsistencies and eliminate the costly confusion and delays in its certification process. I am concerned FAA bureaucrats are making U.S. aviation less competitive, and that if the problems are not quickly resolved, NextGen [the Next Generation air traffic control system] will be negatively impacted.”

Let’s see how “FAA bureaucrats” are gumming up the works on certification. The Eclipse EA-500 twinjet is an excellent example. Based on revelations that unfolded at an Aviation Subcommittee hearing in September 2008, the FAA clearly accommodated the wishes of an upstart manufacturer by granting all that it asked for and by ignoring shortcomings in design and by shelving critical safety issues to be solved at a later date. The FAA accepted “IOUs” from Eclipse that avionics software would meet the accepted industry standard – after certification.

Mid-level FAA witnesses from offices in Ft. Worth and San Antonio at the hearing testified that this type of certification was rushed and that the production certificate was issued before Eclipse could demonstrate an ability to replicate the design in mass production.

These local FAA officials were followed at the hearing by a table full of senior Washington-based FAA officials. They defended their actions overruling the local FAA offices by stating, basically, that the locals just were not thinking “outside the box” to approve the EA-500 design and its manufacturing. (See Aviation Safety Journal, September 2008, “Airplane Certified by FAA Despite Concerns”)

As Chairman Oberstar opined at the time:

“There is a disturbing suggestion that there was another ‘cozy relationship’ and reduced level of vigilance on the FAA’s part.”

Eclipse has since gone bankrupt; however, this a very inefficient way to protect the flying public, and there is no question top FAA officials, instead of supporting their subordinates’ legitimate objections, went out of their way to roughshod the regulations and accommodate Eclipse.

We see the same action taken in airliner certification. The FAA issues “special conditions” when no regulations, or outmoded rules, exist to approve new designs, such as Boeing’s all-composite B787. The FAA would do better keeping its regulations current with the march of technology, and holding manufacturers accountable.

We see the FAA accommodating the industry with a move to have its inspectors look more at paperwork than actual airplanes.

We see this accommodating attitude in the FAA allowing critical safety programs to be optional, like Flight Operations Quality Assurance (FOQA) to analyze deviations from accepted norms.

We see the FAA accommodating the airline industry by issuing a proposed rule on pilot fatigue which ignores the problem of aircrews commuting hundreds of miles to their base stations. (See Aviation Safety Journal, “Rules Proposed on Pilot Rest Requirements”)

We see the FAA accommodating the helicopter ambulance industry with proposed regulations that ignore the incentive to pursue “golden trout” patients in bad weather. (See Aviation Safety Journal, “Medical Helicopter Standards Proposed”)

 The problem isn’t the need for “better management” in the FAA, as Mica suggests, but management that holds the industry accountable for safety on behalf of the flying public.

The passengers, not the industry, are the FAA’s “customers.” The FAA needs to reverse its priorities. It would have been refreshing to hear such a statement from Mica.

Deadline Looms for Arrestor Beds

With such a bona fide success record, you would think deployment would be accelerated.

I am referring to the Engineered Materials Arresting System (EMAS), which employs specially configured concrete that slows aircraft that have overrun the runway. EMAS has been credited with seven “saves” since 1999, the most recent of which occurred 1 October 2010 at Teterboro, NJ. A Gulfstream G-IV business jet ran off the end of the runway and into the arrestor bed. The EMAS, as designed, crushed under the weight of the aircraft, providing a predictable, controlled deceleration. The Gulfstream was stopped before it could break though the airport perimeter and hurdle across Route 46, a busy highway.

Runaway corporate G-IV halted by an arrestor bed.

Runaway corporate G-IV halted by an arrestor bed.

In this fortuitous case, no one was hurt and the aircraft suffered only minor damage – mainly needing a new set of tires.

In February 2005, an overrun at Teterboro had a less happy outcome. A Canadair CL-600 corporate jet attempted take off with its center of gravity well forward of allowable limits. The airplane did not get off the ground. It crashed through the perimeter fence, crossed Highway 46 and plowed into a warehouse. No one was killed. The 11 occupants of the aircraft all survived, but the badly damaged aircraft was written off. Two people in automobiles hit as the Canadair roared across the highway were injured.

Canadair jet lodged in a warehouse after overrunning the same runway in 2005.

Canadair jet lodged in a warehouse after overrunning the same runway in 2005.

After that accident, EMAS was installed in 2006 to prevent future overruns from bursting through the fence.

The light-colored area shows the installed EMAS at Teterboro. Note close proximity of the highway.

The light-colored area shows the installed EMAS at Teterboro. Note close proximity of the highway.

A witness said of the latest incident, “Just drove by and thankfully they installed those arrestors or it would have gone straight across Route 46 again.”

EMAS is produced by NJ-based ESCO-Zodiac Aerospace. The company’s Kevin Quan said:

“Both the airport and ESCO [Engineered Arresting Systems Corp.] – Zodiac Aerospace are thrilled about the aircraft arrestment from last Friday afternoon … This is our 7th successful save with the product. Both loss of lives and millions of dollars of aircraft damage have been avoided with the use of EMAS arrestor beds. Airports that have been proactive in installing arrestor beds such as Teterboro are now seeing the benefits of this technology.”

Six previous "saves" attributed to EMAS.

Six previous "saves" attributed to EMAS.

One could quibble with Quan’s enthusiastic use of the word “proactive.” The terrible 2005 accident spurred the 2006 installation that saved the plane and lives in 2010.

There is a disturbing pattern of the Federal Aviation Administration (FAA) freeing up money for airports to install EMAS after, not before, an accident. Following the fatal overrun of an American Airlines MD-82 twinjet at Little Rock, AR, EMAS was installed.

EMAS works by increasing the resistance of the aircraft tires to rolling. A concrete surface normally decreases rolling resistance through its hard surface. But EMAS consists of aerated cement blocks. Those blocks are designed to have the same effect on the airplane’s tires as gradually deepening snow would to a moving automobile. EMAS is configured for each runway, and is intended to stop a jet moving up to 70 knots (80 mph).

Close up of the crushable concrete.

Close up of the crushable concrete.

In the latest incident at Teterboro, the jet did not show obvious signs of structural damage, although its tires and landing gear struts were buried in the fractured concrete.

According to ESCO-Zodiac, “[A] Proprietary computer model predicts aircraft performance and design for the most effective solution for each runway end.” The company is the only one that presently produces an aircraft arresting system certified by the FAA for airport runway safety areas (RSAs).

Normally, an RSA consists of a grassy area, free of obstacles, extending 1,000 feet beyond the end of each runway and about 500 feet in width. But many airports were built before the 1,000-foot RSA length was promulgated by the FAA about 20 years ago. And airport locations are constrained by highways, railroads, severe drop-off of terrain – as at Little Rock – bodies of water, and populated areas (residential, office, industrial).

Where there is insufficient area for the 1,000 x 500 foot RSA, the EMAS arrestor bed can be installed. It normally extends up to 600 feet past the end of the runway, but the design is tailored for each location and for the heaviest types of aircraft anticipated to operate at the particular airport.

Under the FAA program of airport safety improvements, all runways must feature either the full 1,000-foot RSA or the EMAS arrestor bed by 2015. For some deficient runway RSAs, grading and planting will suffice if land is available and not too costly. Where this is not possible, EMAS is employed.

According to ESCO, as of October 2010, 55 EMAS configurations have been applied to runways at 37 airports worldwide (35 U.S. airports) since 1996. This works out to an average of about four installations yearly in the U.S. According to the FAA, about 80 EMAS installations remain to be completed during 2011-2014 to meet the deadline of projects completed by 1 January 2015.

emas installed

That works out to an installation rate of about 20 EMAS per year, or four times the annual rate of installations thus far.

It is doubtful the FAA will meet its goal.

The pity here is that the EMAS installation can easily be justified on cost-benefit grounds. Assume an EMAS installation price at Teterboro of $8 million. Now assume the statistical value of a life is approximately $3 million, and there were 9 passengers and crew aboard the G-IV that was stopped by EMAS. Assume $25 million for a used G-IV. Add together the cost of airplane and lives and compare to the price of an EMAS installation:

Benefit: $27 million lives saved + $25 million aircraft saved = $52 million

Cost: $8 million EMAS

Ratio of benefits to cost: 6.5 to 1

That’s one runway, one incident. The benefits nationwide clearly are in the hundreds of millions of costs avoided.

The FAA’s support of EMAS is laudable; at the same time, the agency’s definition of a “high priority” program does not square with the 2015 deadline. An accelerated limit of 2013 would be more in keeping with the FAA’s definition of the program’s importance.

Draft Guidance on Fatigue Evades Accountability

Fatigue is the one area where minimizing it is the joint responsibility of the pilot and the airline, claims the Federal Aviation Administration (FAA). This is a curious arrangement, because this is the only area where the airline is absolved of ultimate responsibility. In every other aspect of operations, such as safety, maintenance, and compliance with regulations, the airline has final responsibility for operation of the airplane in “airworthy” condition.

But sleep deprivation is somehow different than, say, fuel deprivation – taking off with insufficient fuel reserves.

The issue of pilot/airline joint responsibility for being fit for duty has been relegated to the hazy, non-regulatory, non-requirement area of an Advisory Circular (AC). More specifically, a draft AC issued attendant with the proposed rule on pilot duty and rest requirements. (See Air Safety Journal, “Rule Proposed on Pilot Rest Requirements”)

When joint responsibility is propounded by the FAA, it is fair to say that neither party is accountable. To state the matter bluntly, the situation is a cop-out.

In every other aspect of an “airworthy” operation, the airline has the final obligation, and failure can result in millions of dollars in proposed fines or loss of operating certificate. Failure to inspect the airplane structure for metal fatigue or corrosion is not a joint responsibility of the airline and its outsourced maintainers. To ensure that engines and flight controls will work as designed is the airline’s final responsibility. To repair an item on the Minimum Equipment List (MEL) in a timely fashion is the airline’s duty, not that of a third party maintainer. Passengers certainly expect, and assume, that the pilots on the other side of the locked cockpit door have had sufficient rest before assuming duty, otherwise the airline would not permit them to fly.

Yet in the area of human factors, in which fatigue has a pernicious effect on flight safety more dangerous than an unrepaired MEL item, the airline has been given a regulatory free pass by the FAA. This free pass is not by accident. More important, this loophole needs to be closed.

The proposed regulation on pilot duty and rest requirements, placed in the Federal Register 14 September, relegates the issue of pilots commuting to work to a draft AC. This 18-page document, AC 120-FIT, titled “Fitness for Duty,” leaves open a loophole that allowed the two pilots of Colgan Air flight 3407, which crashed 12 February 2009, to commute from Florida and the West Coast, respectively, the night before, and to assume duty in Newark with no more than catnaps on a couch.

Here is what the AC says (partial but salient extracts, with comments in parentheses):

“Managing rest is the means for managing the risk of being unfit for duty because of fatigue. This is the joint responsibility of the air carrier and the crewmember.” (Emphasis added)

“Unlike the vast majority of U.S. workers spanning other industries, crewmembers have the unique opportunity to live in another city or region than the one they are based. The general public does not fully understand the concept principally because they are unfamiliar with airline industry practices.” (The public also puts its trust in the FAA to ensure that airlines only allow rested pilots to fly.)

A pilot commuting to work; hardly inspires confidence.

A pilot commuting to work; hardly inspires confidence.

“[The] commuting crewmember is solely responsible for determining and using the mode of transportation to commute to and from their domicile.” (There is no maximum time outlined for the commute, again placing sole responsibility for fatigue management on the crewmember, with zilch consequences for the airline.)

“If a crewmember’s first day of their trip is scheduled for 10 hours of duty and their commute requires another 4 hours, and assuming they arrive at their domicile 3 hours prior to their report time, the crewmember’s first day could exceed 17 hours without a rest period. Since air carrier schedules are designed to account for the scheduled flight duty time, the additional time associated with a commute may add to the crewmember’s fatigue for that day as well as aggravating the cumulative fatigue for the duration of the crew’s schedule that the carrier had planned.” (The scheduled flight duty time does not include commuting time before duty. Note the use of the weasel word may when commuting is known to contribute to fatigue. Cumulative fatigue is a recognized problem everywhere except in the FAA’s regulations and in the airline’s obligations for the highest level of safety in flight operations.)

Imagine a fatigued pilot managing a complex landing and taxi here, at Midway, after 17 hours on duty.

Imagine a fatigued pilot managing a complex landing and taxi here, at Midway, after 17 hours on duty.

“The FAA defines ‘local area’ to mean any location more than 2 hours transportation, regardless of the mode, to the physical location of the crewmember’s domicile or the location where the flight duty period starts … Travel from outside the local area is commuting … In essence, the 2-hour limit starts from the time the crewmember leaves their home and terminates when they arrive at the physical location of their domicile or the location where their flight duty begins.” (The 2-hour limit is not enshrined in regulations as a hard ceiling on commuting; the expression limit is a misnomer.)

“Air carriers should have a commuting policy to address their expectations from crewmembers commuting to work. Some air carriers currently have such a policy and are aware of those crewmembers who commute, thus these carriers design schedules to mitigate potential risk of fatigue for those commuters. Air carriers should also provide crewmembers with a quiet area at the domicile where they can take advantage of rest before or between flights….” (Note use of non-specific words. Will should be substituted for should; all should replace some, and the word potential must be deleted.)

A pilot rest and sleeping room; spartan, but it provides needed restorative conditions for being alert on duty.

A pilot rest and sleeping room; spartan, but it provides needed restorative conditions for being alert on duty.

 “(Crewmembers) should take advantage of quiet areas … as provided by the air carrier, to reduce fatigue …” (Should the air carrier be so progressive as to have a quiet area with bunks, there is no requirement that crewmembers use them.)

The FAA approves airplane flight manuals, the carrier’s maintenance program and manuals, and specifies which items must be independently inspected, but the issue of commuting and fatigue is left to a non-required advisory circular full of toothless verbiage.

One can readily envision policies to reduce fatigue:

First – limit travel from a domicile to place of duty to two hours, and account for this time in the duty schedule. To be sure, this policy will limit the airlines’ freedom to open or close stations from which flights are dispatched. At a minimum, such a policy would force the airlines to pay for crewmembers’ relocation costs. As a cost of doing business, such payment does not seem unreasonable given that it’s done by many other companies imposing onerous moves on their employees and by the government for its military and public service members.

Second – require airlines to provide a quiet area with bunks for fatigued crewmembers to rest before duty and in between flights. The expense of such a facility is minimal. Having such a tangible recognition of the fatigue problem is overdue. Since some airlines have such facilities, the expense evidently has been cost-justified.

Third – require all airlines to maintain a Flight Operations Quality Assurance Program (FOGA) for all airplanes. Under such a program, any flight deviations from approved procedures are identified from data captured by quick access recorders. Deviations outside of prescribed limits are examined by a committee comprised of airline officers, pilot union representatives, and FAA officials. Pilots involved in the incident are questioned as to why it occurred. Excessive time on task, insufficient rest, schedule, equipment or procedural anomalies are identified by this process, and corrective action is taken.

The absence of a FOQA program allows fatigue-related performance deficiencies to go unexamined and uncorrected. For an airline to receive an FAA operating certificate, one would think a safety-critical item like FOQA would be an essential precondition.

Fourth – drop the draft AC because it is an exercise in evasive – if not entirely absent – accountability. Pilots are airline employees. The airline is ultimately responsible for their performance. As is done for operations and maintenance, these facts also need to be stated by the FAA.

Designs for the Future Don’t Address Today’s Safety Problems

Two workhorse airplanes of today could be replaced by radical new designs in 35 years, although there is an alternative scenario where the airline industry is a fraction of its current size. Beware of glitzy projections that the future will feature extensions of current technology and even more passenger-miles.

If in three decades oil costs $150 a barrel (or more) air travel will be a pricey commodity available only to governments and the very rich. As transport for the masses, air travel will be a memory.

This stark vision of the future has not discouraged the National Air and Space Administration (NASA) from sponsoring teams at MIT, Boeing, GE, and Northrup Grumman to come up with aircraft designs that burn 70% less fuel and create less noise than existing planes. Two designs resulted, both of which pack passengers into high-density seating in order to rationalize fuel costs of $5-$10 a gallon. Today’s jet airline industry is based on fuel costs of $1-$2 a gallon – which has led to a misery of discomfort, from cramped seating to fees for baggage and just about everything else.

The U.S. airline fleet, presently numbering about 4,000 planes, could well be 1,000 planes or fewer in 35 years – not big enough to justify investments in radical new designs. And safety might be improved more by investing in pedestrian research into improved electronics, a better interface between pilots and their increasingly automated airplanes, a more maintenance friendly aircraft (less avionics hidden behind sidewall panels), and a real advance in on-board fire detection and suppression (vast areas of current airliners are unprotected, to include the passenger cabin and main deck cargo compartments). Today’s jet, redesigned to yield a much safer airplane, might have been a more fruitful effort than for NASA to engage in a radical rethinking for a mass transportation industry that won’t be around in 35 years. The number of passengers turned off by the hassle of air travel has already declined by a couple percentage points; the economic meltdown has further depressed air travel. A tripling of ticket prices and serious limitations on stocks of jet fuel may well be enough to change air travel as it is known – from a convenience enjoyed by millions annually to a select mode for a few hundred thousand.

MIT won the NASA competition for new “green” subsonic airplane designs.

The objective was to develop concepts for quieter subsonic commercial airplanes that would burn 70% less fuel and emit 75% less nitrogen oxide (NOx) than today’s commercial jetliners. NASA also wanted aircraft that could take off from shorter runways. NASA expects air traffic to double in 35 years, necessitating rethinking the basic airplane design. There is an adage that just when you think present trends will continue into the future, they are about to change. That point may have been passed in the last couple years. The entire transportation system – air, rail, maritime, auto and truck – will be dramatically altered by the end of cheap oil.

This inexorable fact did not affect NASA, which blithely predicted a doubling of passengers in 35 years.

The MIT design team met NASA’s challenge by developing two designs: a 180-passenger “double bubble” airplane to replace B737 class aircraft, currently employed for domestic flights, and a 350-passenger “hybrid wing body” series to replace the B777 class aircraft now used for transcontinental and international flight.

According to MIT’s aeronautics professor Ed Greitzer, a “radical change” is needed. “Aircraft silhouettes have basically remained the same over the past 50 years,” he said, describing the traditional, easily recognizable “tube on a wing” arrangement of an aircraft’s wings and fuselage.

For the domestic B737 replacement, Greitzer’s team reconfigured the tube-and-wing structure. Instead of using a single passenger cylinder, two partial cylinders placed side-by-side were used to create a wider fuselage. Its cross-section resembles two soap bubbles joined together. The rear mounted engines take in slower moving air. Known as Boundary Layer Ingestion (BLI), this technique allows the engines to burn less fuel for the same amount of thrust (at a drawback of more stress on the engine).

The "double bubble" concept has an extra wide fuselage to provide some extra lift. The aircraft would carry 180 passengers, lightly more than the current B737-800.

The "double bubble" concept has an extra wide fuselage to provide some extra lift. The aircraft would carry 180 passengers, lightly more than the current B737-800.

The design mitigates some of the drawbacks of the BLI technique by travelling about 10% slower than a B737. To further reduce the drag and the amount of fuel burned, the concept airplane features longer, skinner wings and a smaller tail.

A version of the airplane built out of conventional aluminum (as opposed to weight saving composites), would burn 50% less fuel (as opposed to 70% less) and might be attractive as a lower risk, near-term alternative.

The “double bubble” concept of conjoined tubes evidently did not consider the demands of emergency evacuation. With two fuselages of passengers, and only half as many emergency exits (from the artist’s rendering), the problem of crowding and delayed evacuation at the exit doors could be a show stopper.

The “double bubble” design is particularly attractive from an airport perspective. The airplane could use the current boarding and jet bridge designs. From an airport rescue and fire fighting (ARFF) view, delayed evacuation may be a real problem.

For intercontinental travel, the MIT tam designed a triangular shaped hybrid winged body aircraft that blends a wider fuselage with the wings for improved aerodynamics. The large center body generates lift, thus overcoming a major limitation of the current tube-on-a-wing design – the conventional fuselage produces drag, not lift.

For longer range and more capacity, a blended wing body is envisioned that would carry about 350 passengers.

For longer range and more capacity, a blended wing body is envisioned that would carry about 350 passengers.

Both the domestic and the intercontinental designs feature one real safety benefit: the fuel in the wings is separated from the engines at the rear of the fuselage. The intercontinental design has the added advantage of wrapping most of its crash-absorbing structure around the passengers.

But survivability could be improved in present designs with 3-point restraints similar to that found in automobiles, and by facing the seats toward the aft end of the airplane. This would have the beneficial effect of spreading the force of a sudden deceleration across one’s entire backside, not just across the width of a 2-inch wide lap belt.

NASA might better spend its limited time and resources on a more modest but significantly better payoff research program. Specifically, NASA is the repository of the Aviation Safety Action Program (ASAP) database, the anonymous reports submitted by flight crews, mechanics and air traffic controllers. NASA is the repository to assure submitters of independence from the Federal Aviation Administration

NASA could cull through these reports, identify the 20 or so greatest threats to safety, and come up with mitigation strategies. Simple things, like radios that don’t lose a message when two persons broadcast on the same frequency. Or separating electrical power conduits from oxygen lines, so that arcing does not burn through the oxygen line, worsening the fire problem.

There is another axiom that has been forgotten in this 35-year look ahead: solve today’s problems today.

It’s Obvious – Offshore Drilling Practices Shockingly Behind Aviation Protocols

Listening to BP and Transocean executives testify about the Deepwater Horizon disaster is very much like hearing airline executives following an air crash testifying to the National Transportation Safety Board (NTSB). The selective memory, or non-memory, is breathtaking in its scope – until attentive NTSB members ask pertinent questions.

And it’s not credible. This writer remembers details of infantry combat in Vietnam 40 years ago as vividly as if the events happened yesterday, right down to the dirt in hastily pulled-on combat boots.

Similarly, anyone who has survived an air crash recalls details – the sights, smells, sounds that come from the “hypervigilance” associated with impending disaster.

Yet the vice presidents and other executives both ashore and on the Deepwater Horizon rig were full of “I don’t recall” and “I don’t know” and “I can’t comment” and “I’m not specifically aware” and other suchlike phrases reflecting muddled and completely absent memory. The occasion of this memory vacuum was the probe last week by the Coast Guard and the Bureau of Ocean Energy Management (BOEM) into the 20 April explosion of the rig, killing 11 of the 126 people aboard and leading to the largest oil spill ever in the Gulf of Mexico.

The USCG/BOEM hearings are not sounding credible. Said one commentator: "Our government is covering for BP in a blatant disregard for the people of this country they profess to be protecting."

The USCG/BOEM hearings are not sounding credible. Said one commentator: "Our government is covering for BP in a blatant disregard for the people of this country they profess to be protecting."

The Coast Guard/BOEM hearing was carried on C-SPAN radio; anybody familiar with NTSB investigations into air crashes would have been outraged at the quality of questions and the non-responsiveness of the answers. Truly, the NTSB serves as a model for conducting such inquiries.

BP’s executives were asked about the safety culture among deepwater drilling crews. They were not asked to produce that statement affirming commitment to safety. The executives replied that the safety culture differs for deepwater and shallow water crews. They did not outline specific difference, nor were they asked to. The answers were more along the lines of different procedures, which is not the same as the safety culture. The executives declared that any person who observes a safety violation can stop the operations; they were not able to cite a single instance where this was done.

It was also evident that BOEM’s predecessor agency, the Bureau of Minerals Management (BMM), excised nil oversight of BP’s safety culture, much less oversight of its drilling operations. If the Federal Aviation Administration (FAA) exercises infrequent oversight of airline and repair station operations – once a year or less – the agency nevertheless is a paragon of action compared to BMM/BOEM. Unfortunately, the comparison was not made by the inquisitors, because they obviously did not know what the FAA declares in policy documents and practices about a robust safety culture.

In the FAA, there is at least lip service paid to the need for a just safety culture at both the national and the regional airlines. In BP, where deepwater and shallow water operations are analogous to national and regional airline operations, there is not even a recognition of the need for a common safety culture.

Nor is there a single document, as in the airlines, directing operations. Recall that every airplane contains an aircraft operations manual (AOM), spelling out for aircrews exactly what procedures are to be followed. A common manual applies to maintenance, as well.

At the hearing, BP executives testified that at least four different manuals were on the Deepwater Horizon spelling out procedures for drilling operations. The executives were not familiar with the manuals, or the differences between them, or the circumstances under which they must be referred before undertaking an operational evolution.

It is as if the captain and first officer on an airliner had four separate AOMs, with an unspecified number of differences between them and no guidance as to which should predominate.

 The blow out preventer (BOP) was the last line of defense against catastrophe, yet many of its critical components were either inoperative or hooked up incorrectly. Unlike in the NTSB and the FAA, there was no discussion of the danger attendant to a “single point failure.” In the airlines, safety is built on the ethic of redundancy – two, three or even four back ups for functions that simply must perform (e.g., hydraulic and electrically powered engine and flight controls).

For relevance to aviation, consider this reaction to the Coast Guard/BOEM hearing:

“For the people on this saga reconfiguring and plumbing hydraulics on deep water BOPs, hopefully please keep them away from Boeing or Airbus.”

Nor was there any discussion of documenting which components of the BOP were inoperative. One recalls the Master Minimum Equipment List (MMEL), which must be approved by the FAA for each airline. The MMEL lists which items of airplane equipment can be inoperative awaiting repair (usually a 10-day window) – for example, one can fly with a weather radar inoperative, so long as the back up fulfills the function.

There is apparently nothing like the MMEL in drilling operations, so any number of systems can be inoperative and there is nothing to prevent the operation from proceeding. In the airline industry, the MMEL is the FAA’s way of guaranteeing that a minimum level of safety prevails.

Nor is there anything like the flight data recorder (FDR) in offshore drilling operations. Recall that the FDR captures key engine, flight and system parameters and records them in a crash-hardened box for retrieval by investigators should the airplane crash. The data recorded by the black boxes have been instrumental in unraveling the cause of numerous crashes. There is a maritime equivalent of the FDR – the voyage data recorders – but such an instrument was not aboard the Deepwater Horizon. The Deepwater Horizon is treated like a vessel when the rig is underway, but not when it’s stationary conducting drilling operations (when a different chain of command prevails, just to add to the confusion – imagine two captains for an airliner, one for taxiing and another for flying).

Moreover, many airlines now operate flight operations quality assurance (FOQA) programs, in which each flight is recorded, and later downloaded to identify and correct any “exceedances” (such as deploying flaps at too great a speed). FOQA programs have been instrumental in improving safety and crew conformance with set procedures.

Again, there doesn’t seem to be any equivalent in the oil industry – despite the fact that drilling and refining operations are dangerous, with the potential to wreak multiple air crashes worth of damage.

What comes through the Coast Guard/BOEM hearings is that the offshore oil industry has miles to go before it’s got minimum standards equivalent to those in the airline industry. Worse, it is also evident that the Coast Guard/BOEM questioners are not aware of how far behind they are in requiring rudimentary safety standards and providing industry oversight equivalent to that afforded by NTSB investigations. The questions asked at the Coast Guard/BOEM hearings were vague and open-ended; the responses were similarly vacuous.

One observer characterized the hearings thusly:

“Some [BP executives] have simply refused to answer questions or deflected accountability. And the best our … inquirers can do is huff and puff and act indignant.”

The Coast Guard/BOEM hearings just don’t compare to NTSB inquiries, where acting indignant is a sure way to get in big trouble. Any number of former NTSB chairmen and board members can provide the Coast Guard/BOEM advice on how to conduct independent probes that get to root causes while educating the public.

The NTSB has earned a reputation for thoroughness, in part because Chairman Hersman herself digs deep.

The NTSB has earned a reputation for thoroughness, in part because Chairman Hersman herself digs deep.

It is probably too late for the Deepwater Horizon investigation, but unless the NTSB instructs the Coast Guard/BOEM in how airline safety practices and accident investigations are conducted, the offshore oil industry will likely engage in token measures that lag shockingly behind the norm in aviation.

Sen. Stevens Crash Underscores Dismal General Aviation Safety Record

The 10 August plane crash in the wilds of Alaska that killed former Sen. Ted Stevens (R-AL) is the latest in a long line of crashes that have killed politicians. Not that politicians as a group engage in risky behavior, but they do tend to fly more than the average Joe. As a result, the “normal” accident rate is highlighted because crashes involving public figures tend to be covered in the media.

The typical flying architect, doctor or businessman – whether piloting his own airplane, or being flown by an air taxi operator – rates a mention in the local newspaper, but rarely is the crash covered in, say, the New York Times or NBC News.

What the Stevens crash illustrates is the vast difference in safety depending on how one is in the air.

Consider the three major groupings:

— Part 121, which comprises the scheduled nationwide and regional airlines that carry paying passengers.

— Part 135, which covers the on-demand charter or air taxi operations which, again, transport paying passengers.

— Part 91, the general aviation operators, or basically pilots who fly their own airplanes and a few non-paying passengers.

And these three categories also involve successively greater levels of risk. The grim statistics belie the Federal Aviation Administration’s (FAA) vaunted “one level of safety.”

Had Stevens and his companions flown on a Part 121 carrier, statistically they would be in one accident for every 670,000 hours flying time. This calculation, and others to follow, are based on National Transportation Safety Board (NTSB) figures for 2009, the most recent year for which the NTSB has calculated the number of accidents, the number of flight hours, and the deaths and injuries.

Had Stevens and his buddies flown on a Part 135 on-demand charter, they would be exposed to one accident (fatal and nonfatal) for every 61,000 hours flying.

If Stevens and company climbed aboard a friend’s or acquaintance’s airplane, Part 91, they would be exposed to accidents at the rate of one every 14,000 flying hours, statistically speaking. In fact, this is the type of operation in which the red DeHavilland DHC-3T was operating, with a pilot and eight passengers aboard the single engine, high wing floatplane. Five of the nine aboard died.

DeHavilland DHC-3T similar to the one that crashed.

DeHavilland DHC-3T similar to the one that crashed.

A Part 91 operation does not have to file a flight plan with the FAA, nor is it required to have safety equipment found routinely on Part 121 and Part 135 operations. In this case, the Part 91 DeHavilland was not required to have a terrain warning device, which is significant. The wreckage was found at the end of a 100-yard gash through forest, the gash pointing toward the top of the ridgeline. It is apparent that in the fog and rain the pilot saw the rising terrain too late to clear it. A terrain warning device might well have alerted him to the hazard a good minute before the ridge appeared out of the mist.

Scene of the crash with airplane wreckage just above and to the right of the photo's center.

Scene of the crash with airplane wreckage just above and to the right of the photo's center.

One of the most common attributes of Part 91 accidents is also germane: starting the flight in visual conditions, then finding visibility compromised by clouds – instrument conditions – but the pilot presses on in the hopes of finding a hole in the clouds.

In any event, the three statistics can be summarized thusly:

— One would have to fly 12 hours a day for 150+ years on a Part 121 commercial scheduled airliner to be involved in an accident. Commercial flying is 10 times safer than charter Part 135 operations, and about 50 times safer than Part 91 flying.

— One would have to fly 12 hours a day for 14 years on a Part 135 on-demand charter plane to be involved in an accident. Given that many of the “protections” built into Part 121 airline operations are also part of Part 135, this accident rate is atrocious.

— One would have to fly 12 hours a day for just 3 years to be involved in a Part 91 general aviation accident.

Consider the spread: 150 years between accidents aboard an airliner; 3 years between such mayhem aboard a general aviation aircraft.

Here’s betting that people who fly as passengers on general aviation airplanes implicitly assume the operation is as safe – or nearly so – as an airliner, and probably equal in safety to an on-demand operation.

It isn’t so. General aviation airplanes are involved in accidents at an average rate of four per day, and about one of these accidents every other day involves fatalities.

If Part 121 and Part 135 airplanes were killing people at the rate of one airplane-full every other day, the fleets would be grounded.

The accident rate for Part 91 airplanes is a little known scandal. Operators of these aircraft ought not be allowed to kill themselves and their passengers at this rate. One hopes as the NTSB investigates this tragedy that the larger issue of Part 91 non-safety is addressed, with a clear call to the FAA that improved standards and oversight are long overdue.

Most Turbulence Recommendations Don’t Reduce Injuries

Investigation of the 20 July 2010 turbulence incident involving a United Airlines B777 over Missouri has just begun, but already a broader question arises: why haven’t all the National Transportation Safety Board (NTSB) recommendations to combat exposure to turbulence had an effect? People are still thrown about the cabin from turbulence, injured and occasionally even killed.

The latest incident involves a United B777 cruising at 34,000 feet, about 60 miles southeast of Kansas City, right into a wall of convective turbulence rising at 50-100 mph. The flight crew apparently made no evasive action (to be explored by NTSB investigators, for sure), and the airplane’s 265 passengers and crew were subjected to what one passenger described as “just a huge up and down.” Four flight attendants and about 20 passengers were injured to the extent that hospitalization was necessary. Fortunately, and unlike past turbulence encounters, there were no deaths. (See Aviation Safety Journal, ‘Turbulence During Flight Injures Scores; After Years of Such Events, Why Do They Continue?’)

The NTSB has been issuing recommendations to counter turbulence encounters and injuries since the early 1970s. Either the recommendations are not relevant to the real dynamics of the problem, the Federal Aviation Administration (FAA) has not responded effectively, or some combination of both factors must be at fault.

For in-flight turbulence, since 1972 the NTSB has issued 46 recommendations. A summary of each recommendation may be found at Aviation Safety Journal. (See ASJ; ‘Long History of Turbulence Recommendations; Most Miss the Target’)

From these nearly four dozen recommendations, a number of inferences can be made:

— Deaths seem to be a much greater stimulus for NTSB recommendations than injuries. The recommendations are the result predominantly of fatal crashes.

— Of the 46 turbulence-related recommendations issued, 19 (41%) deal with the cruise phase, where most injuries occur. If the number of deaths and injuries in cruise were considered, the order probably should be reversed, with 60% of the recommendations addressed to the cruise phase of flight.

— Of the two “OPEN” recommendations (e.g. awaiting final FAA corrective action), none deal with passenger or crew safety during turbulence.

— Of the 18 “CLOSED” recommendations concerning turbulence in cruise, some have been overtaken by events, others are airplane specific and only one (A-73-002) deals with interior design to reduce injuries.

— No NTSB recommendations deal with flimsy overhead bin latches coming open during turbulence and spilling their contents onto passengers sitting below.

— None of the NTSB recommendations address the chronic problem of standing flight attendants being injured or killed during turbulence.

— None of the NTSB recommendations address the continued failure of all passengers to remain buckled up while seated.

— None of the recommendations address galley carts in the aisles. One can envision a means to secure them: a track in the floor, and a foot-pedal operated upside-down “T” fitting on the bottom of the cart to anchor it when stationary. Coffee pots could be secured by straps (coffee pots have been known to fly about during turbulence, scalding passengers).

— None of the NTSB recommendations address the dangerous practice of “lap children,” despite the history of such children being hurled to their injury or death during in-flight turbulence.

 — None of the recommendations address cockpit-cabin crew coordination when turbulence is expected.

The NTSB claims it has a 90%-95% acceptance rate for its recommendations generally. In the area of turbulence, it has about an 80% acceptance rate, under the generous allowance that if the action was closed by the NTSB for even the flimsiest reasons advanced by the FAA, that recommendation counted towards the overall acceptance rate.

It is also evident, from the recent injuries on the United Airlines flight over Missouri that the successfully implemented NTSB recommendations have had nil effect over the past 30 years at reducing injuries during in-flight cruise.

The FAA has done the easy things that cost little, thereby garnering a high acceptance rate to the NTSB recommendations. The difficult efforts that require money tend to generate a huge amount of delaying correspondence and result in either a slow death to the recommendation or it being held in an “OPEN” status by the NTSB in the slim hope of implementation.

The NTSB may wish to reconsider the process of generating recommendations. It seems that many are “down in the weeds,” offering much in the way of detailed, tactical advice. Meanwhile, the major issues – such as aircraft certification (see A-94-056) – which seem straightforward, languish in a miasma of “do nothingness.”

Average time for recommendation on turbulence to be classified “CLOSED – Acceptable Action” is on the order of four years. The longest period to acceptance is 18 years. Given that most of the recommended actions in this category are simple, the time seems excessive and not behooving of a pro-active safety culture at the FAA. Then again, the sheer volume of NTSB recommendations has to be taken into account. Fewer, more strategic NTSB recommendations might reduce the workload at the FAA – at a “cost” to the NTSB of a lower percentage of “CLOSED – Acceptable Action” about which to crow.

And if nothing is changed, recommendations coming out of the NTSB’s investigation of the United turbulence event will take 4-18 years to resolve, and the method of FAA implementation may have marginal effect on staunching injuries.