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Slay the Excess Carry-On Baggage Monster

In 1997, flight attendant Linda Romano accused her airline superiors with “creating a monster” regarding carry-on bags. To wit, the airline was permitting more, larger and heavier items to be brought on board. The bags are a hazard when inadvertently dropped during loading or unloading into the overhead bin, and they are dangerous blunt-force instruments when hurled out of flimsy bins during in-flight turbulence or crash landings.

Here we are, 13 years later, and the situation is even worse. Worse for two reasons: more passengers are electing to bring bags aboard to avoid checked bag fees, and the so-called “sizer templates” are no longer in use. These templates defined the maximum dimension that carry-on bags could be; anything larger had to go in checked baggage.

Now, bags aren’t mandatorily consigned to checked baggage until the overhead bins are stuffed and the last few passengers to board aren’t able to find a bin with enough remaining room for their “wheelies” and other large bags.

A bill in Congress, ostensibly to bring the situation under control, is weak. H.R. 2870, the “Securing Cabin Baggage Act,” would create a universal size for carry-on bags, instead of allowing each airline to determine its own size limit. But the weakness is in three areas: (1) passengers are not restricted to one bag plus coats and purses, (2) the act is too generous at 22 x 18 x 10 inches in size (50 inches overall), and (3) the bill does not imposes a weight limit per bag.

Of these three shortcomings, (1) and (2) are the most glaring.

Passengers ought to be authorized one bag, period (with exceptions for mothers with infants, the handicapped, etc). And 50 inches overall (L x W x H) is entirely too generous. The size of the bag should not exceed 45 linear inches or, better yet, 39 linear inches as a maximum. Smaller bags would get at the burdensome weight problem and the hazard associated with hefting them into overhead bins (not to mention the risk posed by a heavy bag falling out of the bin onto the passenger seated below).

Airlines should be required to reinstall “sizer templates” at check-in, and these templates should also be installed at the security screening lines; any passenger who gets that far with a big bag should be required to go back to check-in.

The Federal Aviation Agency (FAA) regulates the airlines for safety; the Transportation Security Administration (TSA) regulates the passengers for security. These bureaucracies are not doing their job. The result is a crush of baggage going into the cabin. It’s poorly screened because there is so much of it, increasing the possibility that a weapon or bomb gets aboard. And heavy bags in overhead bins secured by flimsy doors are a safety hazard; bin doors pop open during turbulence, bags fall out and injure passengers. During crash landings, spilled out overhead baggage impedes rapid evacuation.

Let’s face it, incidents involving carry-on bags range from disruption in the cabin, physical and verbal abuse of flight attendants, injuries to passengers, and impediments to speedy evacuations. Why, passengers have been observed trying to grab bags from overhead bins during actual emergency evacuations, when the overarching goal is to GET OUT NOW!

There ought to be a limit. One bag, 45 linear inches. Slay the monster.

The policy of relatively unrestricted carry-on articles isn’t prudent management at all – it’s anarchy. And it’s an anarchy that puts the security and safety of the flying public at risk.

More Investigators, But Still Too Few

Reinforcements are coming, allowing a small dent in the chronic understaffing problem at the National Transportation Safety Board (NTSB).

The House Transportation and Infrastructure Committee on 2 March 2010 approved H.R. 4714, the NTSB Reauthorization Act, which provides funding for fiscal years 2011 through 2014. The funding will provide for a staff increase of about 77 people. The House bill will have to be reconciled with the Senate bill. Once both are combined into one bill, it will go to the appropriators, who will then determine how much money to give the Safety Board. So what the final numbers will be, which will determine how many staffers can be added, will not be known for some time.

However, 77 additional people looks probable and is as good a number as any for discussion purposes.

Put that number in context: the NTSB currently has about 400 people total. That overall figure makes the NTSB one of the smallest agencies in government. Approving a strength increase to 477 is a paltry 19% increase (over a 4-year period, mind).

Why do I say paltry? Because the NTSB is charged with investigating not only accidents but incidents (lesser on the scale of damage and injury) across the board: aviation, maritime, highway, rail and pipeline accidents and incidents.

Let’s look at aviation. The NTSB currently has about 135 aviation investigators and report writers/editors. Of course the NTSB’s Office of Research and Engineering supports all modes (vehicle performance, safety studies, vehicle recorders, materials laboratory), and more than half the work done by the office (presently about 45 employees) is in aviation.

Let’s say 22 of those 45 are devoted to aviation. Add them to the 135 in the office of aviation safety, and the grand total is 157 devoted to aviation accidents, incidents and related efforts (e.g., downloading flight recorders, air traffic control radar tapes, and so forth in support of an investigation).

Borrowing from my Marine Corps experience, 157 is the rough equivalent of a reinforced rifle company – about one fifteenth of a Marine division. In other words, a rifle company is a tiny but important part of a division.

In the NTSB, those 157 people have to cover the entire aviation industry. Not only scheduled airline accidents (Part 121), but air taxi and charter operations (Part 135) and general aviation (Part 91) accidents. The NTSB also gets involved in foreign aircraft accident investigations as an accredited representative – a further tasking for the 157 chosen few.

Roughly, the NTSB has one investigator for every 1,000 airplanes out there in U.S. registry. For every accident, there are roughly 100 incidents. Incidents are often precursors to the more serious accidents, so examining the circumstances surrounding an incident may help stave off an accident. However, NTSB staffing has been too thin to devote much (if any) effort to incidents. Accident investigation has been all-consuming.

Think of what the NTSB should be doing, which includes more special studies like the safety implication of glass cockpits, just concluded. (See Aviation Safety Journal, ‘Glass Cockpits Not Necessarily Safer Than Traditional Instruments’) Why, the NTSB could gainfully employ double the number of people it currently has. That would include not only increasing the aviation investigations to cover more incidents, but also to cover accident and incident investigations in other modes of transportation.

Not just 477 people, but a strength of 800 is not unreasonable to do all the jobs properly.

Neither the NTSB (which requested the extra folks) nor Congress (which approved the plus-up) is thinking bold enough about the size of the U.S. transportation industry and the fact that accidents and incidents provide windows into large systemic breakdowns.

Requirements: Available Only to Those Willing to Pay

Let me repeat the opening to a previous comment on this site: Any time the Federal Aviation Administration (FAA) glosses over something, that’s cause for concern. (See Comment on Air Safety, ‘Hiding Requirements = Suspicion They’re Inadequate’)

The FAA has responded to some questions submitted by this writer about the latest advisory circular mentioned in that earlier blog, AC 20-53B. This document deals with lightning protection in fuel tanks. The earlier version, AC 20-53A contained a precise discussion of the waveforms to be tested against (e.g. “a 25kA/µs rate-of rise for at least 0.5 microseconds…’). The new “B” version of the AC strips out the specific waveforms to be tested against. “B” does not stand for “better.”

The FAA was asked why the specific waveforms – updated or left intact – were removed.

The FAA responded, in part, as follows:

“In the early 1990s, the SAE [Society of Automotive Engineers] Lightning Committee as well as the [FAA] Aviation Rulemaking Advisory Committee [ARAC] Electromagnetic Effects Harmonization Working Group noted that the lightning environment and test waveform definitions existed in several reports, including AC 20-53A … These differences caused conflict between the reports, so the Lightning Committee and the ARAC working group recommended to the FAA that the lightning environment and test waveform definitions be documented in a single report, and removed from the advisory circulars and SAE reports … So the … lightning committee prepared report ARP [Aerospace Recommended Practice] 5412 to document the lightning environment and test waveform definitions …

“With SAE ARP5412, only one document has to be revised, not four or five.”

In other words, the change was made for efficiency and consistency.

All well and good. But, ARP5412 (some 600 pages long) is only available to the public by purchase from SAE. Unless one is willing to pay, the standards in ARP5412 remain a mystery. Are they an improvement on the requirements formerly articulated within AC 20-53A? The FAA says the new standards are the same. This is hardly comforting. AC 20-53A was issued in 1985, before the use of composite materials in aircraft structures became as fashionable as it is today.

There may be a better way to make the requisite waveforms available to the public. Instead of a suspiciously incestuous and secretive SAE document, the FAA could publish a single technical standard order (TSO) outlining the lightning protection standards to be applied. The FAA has published numerous TSOs — for airport lighting, for terrain warning systems, etc.

A TSO for lightning protection could easily be published, available for look-up online at the FAA’s website.

The critical issue here is not that the standards have been consolidated into one document. The issue is that that document is published by SAE. This organization is not the regulator and therefore is not responsible for the currency of the test standards and is not accountable to the public, as the FAA would be if the requisite lightning protection waveforms were in an FAA-published TSO.

The difference is one of government standards lurking in the shadows or open and available for all to see.

Behind an Inflated Percent, Reality

Beware the glib statistic. Case in point, the claim by the Federal Aviation Administration (FAA) that 94% of the airplanes in the airline fleet are covered, or will be, by Aviation Safety Action Program (ASAP) crew reporting and Flight Operations Quality Assurance (FOQA) data. FOQA data tell what happened in terms of an airplane’s deviation from prescribed procedures; ASAP provides the human element, the explanation for why the event occurred.

The two programs are essential and complementary safety building blocks. As such, one would think they would be required as part of an airline’s FAA-issued operating certificate. They aren’t; why they are not is a separate discussion. For the moment, both are voluntary safety programs.

In its January 2010 report, “Answering the Call to Action on Airline Safety and Pilot Training,” on page 14 of this 200+ page report, we see the 94% figure touted by the FAA (remarks in parentheses are my comments):

“• Twenty-two operators currently have both FOQA and ASAP programs in place (Note: this is 22 of 98 Part 121 scheduled airlines, or slightly fewer than 25%, which is considerably less enthusiastic than the FAA’s 94%).

• Twenty-eight operators have ASAP and state their intention to implement FOQA (Note: not now, but sometime in the future).

• Ten operators with ASAP did not state their intention to implement FOQA. (Note: we can presume they are not).

• Nineteen operators who have neither program at present stated that they will establish one or both. (Note use of weasel words).

• Three operators stated that they do not intend to establish either FOQA or ASAP (Thereby making a mockery of the FAA’s oft-proclaimed “one level of safety” by not planning to have in place precisely those programs needed to routinely evaluate the safety of flight operations. Note also that the responses total up to just 82 of 98 carriers asked to provide responses to the FAA).

“To summarize, the responses show that:

• Ninety-eight percent of aircraft operating under Part 121 are flown by operators that have, or intend to implement, ASAP (Note: this is based on 82 airliners queried, but the percentage under the most generous interpretation is closer to 80% given that there are 98 carriers. Note also that the metric has subtly shifted from operators to the percentage of aircraft).

• Ninety-four percent of aircraft operating under Part 121 are flown by operators that have, or intend to implement, both programs (When will these ASAP/FOQA programs be in place? Not stated; could be in 5 or 10+ years).”

A typical FAA report; hyperbole, not clarity.

A typical FAA report; hyperbole, not clarity.

It’s important to note that this “action” plan was launched after the National Transportation Safety Board (NTSB) last spring identified endemic, industry wide safety deficiencies that were not limited to the circumstances surrounding the fatal crash of Colgan Air flight 3407, a Dash 8-Q400, in February 2009.

On 2 February, the NTSB held its final hearing on the crash investigation, in which some two dozen recommendations were issued on airplane design, crew training, and safety programs needed at carriers across the industry. The FAA’s “Call to Action” report issued on the eve of this hearing, metaphorically speaking, was an attempt to blunt criticism of lax FAA oversight.

It didn’t work. NTSB Member Robert Sumwalt groused, “I don’t know where this 94% came from, and I don’t believe it.”

Colgan Air was a so-called regional carrier, operating short hop flights for Continental Airlines.

Sumwalt said, “Only 2 of 27 regional carriers have FOQA programs.”

That’s a scant 7%.

Sumwalt went on, “Even if it was 98% [instead of 94%], the 2% [not participating] would mean the bottom feeders” who might most benefit from FOQA programs.

NTSB Chairman Deborah Hersman recalled, “Colgan last May said it would have FOQA by last July.”

Still no FOQA at Colgan.

NTSB staffer Roger Cox noted that the Dash 8-Q400 twin-turboprop “has no FOQA data being acquired in the U.S.”

The airplane is operated in Europe, but FOQA data acquired there is not shared here.

The 94% figure pushed by the FAA takes two separate measures – those that already have and those that intend to have ASAP/FOQA – and lumps them together. This creative addition yields a comforting situation that does not apply today and who knows when it will apply in the future?

Better to have started with all airlines subject to FAA oversight, then listed those that have ASAP/FOQA and the number of planes operated by each carrier. Then do the same for those carriers without ASAP/FOQA who plan to implement in the next two years. And, finally, those carriers who are more than 2 years away or not planning ASAP/FOQA programs at all.

From these simple, straightforward numbers, one can tabulate far more meaningful rates of participation. The present tortured but conveniently obscure method reminds one of the aphorism, “You can drink freely from a clear stream and suspect poison in muddy water.”

The FAA has dumped a heap of mud into the public waters. Inevitably, questions would be raised about the credibility of the agency’s rosy 94% estimate.

Hiding Requirements = Suspicion They’re Inadequate

Any time the Federal Aviation Administration (FAA) glosses over something, that’s cause for concern. I have in mind a 2006 document that will be highly relevant in coming months to the certification of Boeing’s new B787 jetliner.

The document in question is Advisory Circular (AC) 20-53B, “Protection of Aircraft Fuel Systems Against Fuel Vapor Caused by Lightning.” This document is especially relevant to the B787. The airplane is the first airliner to be built primarily out of composite materials, in this case carbon fiber-reinforced polymer (CFRP). In a nod to the airplane’s vulnerability to lightning strikes, and their potential to ignite flammable fuel-air vapors in fuel tanks, Boeing has decided to provide an inerting system, whereby a nitrogen-enriched flow of air will be pumped into the void spaces of the B787’s fuel tanks to render them less susceptible to lightning energy penetrating the tanks and triggering an explosion that could blow a wing off.

Think about this for a minute. Boeing is using CFRP to save weight over traditional aluminum construction, thereby (hopefully) making the airplane 17% more fuel efficient compared to the B767 – which the new B787 will replace in the product line up. Yet the danger of lightning is so serious that Boeing is adding the weight of an inerting system to the new airplane.

This is because lightning behaves differently against a composite structure. Against traditional aluminum, lightning has a tendency to play along the surface of the wings and fuselage.

Lightning strikes a conventional aluminum jetliner shortly after takeoff and is diverted from interior mechanical, electronic and human contents.

Lightning strikes a conventional aluminum jetliner shortly after takeoff and is diverted from interior mechanical, electronic and human contents.


Against CFRP, lightning will penetrate through the skin and play havoc with vital mechanical, electronic and fuel systems. Boeing is doing a number of things to minimize this vulnerability on the B787. In addition to inerting the fuel tanks, it is embedding a fine metal mesh in the composite. The purpose is to disburse the lightning strike around the airframe to prevent concentrated damage.

Gap are a problem. A slight gap between a wing-skin fastener and the hole it goes into could be a source of sparking as current jumps the gap. Boeing will install each fastener precisely and seal it on the inside to ensure a snug, spark-free fit. There are 40,000 fasteners on the B787, and they must be perfect for the life of the airplane to assure protection against lighting.

Lightning will penetrate even the slightest gap where fasteners are used.

Lightning will penetrate even the slightest gap where fasteners are used.

Any gap inside the wings, where the wing skin meets internal structural spars, could cause a spraying out of electrons in a lightning strike. This phenomenon is called “edge glow.” Boeing will seal all edges with a nonconducting goop.

The question is what are the energy levels, intensities and durations or waveforms that must be protected against?

The 2006 AC doesn’t say. This is significant for three reasons: 1) this AC was issued by the FAA at a time when the B787 program was starting in earnest; 2) the 2006 AC replaced AC 20-53A, issued in 1985, that contained a useful and precise discussion of the waveforms to be tested against (e.g., “a 25kA/µs rate-of-rise for at least 0.5 microseconds …”) that is missing from the new AC; and 3) the British Air Accidents Investigation Branch (AAIB) recommended after a glider accident from lightning that the certification standards in AC 20-53A need to be upgraded because they’re not adequate for protecting airplanes, “Particularly those which utilize significant amounts of composite material in their primary and control structures.”

The new AC has stripped out the energy levels, referring the searcher instead to a third party document, the Society of Automotive Engineers (SAE) Aerospace Recommended Practice (ARP) No. 5412A. The AC says this document “offers methods you can use in determining lightning strike zones and the aircraft lightning environment.”

These technical requirements could easily have been included in an annex to the new AC. But this course wasn’t followed, and the technical requirements are spelled out in ARP 5412A instead. This document is not available to the public. One must be a registered member of SAE and a fee is required for access to ARP 5412A.

Thus, a simple, straightforward comparison of the lightning protection energies in the original AC and the current edition is not possible. One should also note that compliance with ARP 5412A is not essential; whatever standards it contains should be considered guidelines. One is left to speculate:

— The new standards are the same inadequate (to the AAIB) standards of yore (AC 20-53A), only now they’re concealed in a third party document.

— The new requirements relax those of yore, on the assumption that fuel tank inerting, with its nitrogen enriched air filling the void space in the tanks will make up for the decreased protection against lightning by limiting the chance that a bolt of electricity will ignite any fuel-air mixture. If this is so, then the “belt and suspenders” approach to safety is out the window.

— The new standards are improved, but not to the extent called for by the AAIB.

— The new standards are upgraded 8 or 9 fold, as called for by the AAIB, but this development is not easily discerned because the new waveforms are in an SAE document (which, by the way, the industry is not obligated to follow).

Even though lightning protection is supposedly improved on the B787 through internal metal wire or strips to divert the energy, through inerting the fuel tanks, through improved fasteners and such, the average passenger has no way of knowing if the airplane is more resistant to lightning strikes. The waveforms that must be protected against are the critical measure – and the FAA is now effectively treating them as a state secret, held by a trusted third party for use by insiders. The FAA is not practicing openness, and as the title of this essay suggests: hiding requirements = suspicion they’re inadequate.

If you, or someone you love, have been injured in an aviation related accident and would like our Chicago aviation lawyers at Nolan Law Group to review your case, please contact us.

An ‘A’ to ‘Z’ of Failures in Service & Failings of Design

With the recent first flight of Boeing’s all-new 787 airliner, the airplane begins a long process of certification by the Federal Aviation Administration (FAA), such approval being necessary for the airplane to routinely carry passengers in revenue service. There are huge unknowns about the airplane’s unprecedented use of composites, the heat generated by its electrical systems, and other issues that will bear on ultimate approval by the FAA.

First flight of Boeing's B787 in December 2009, with employees in foreground cheering the event.

First flight of Boeing's B787 in December 2009, with employees in foreground cheering the event.

It may be useful to recount an A to Z of failures of design and failures in service on other airplanes. To be sure, there is an unsubtle distinction between systems that are prone to failure and those that are of a faulty design. And some failures are, indisputably, the result of systems that are simply both.

The message here is that history is replete with shortcomings on airplanes whose design was not nearly as advanced as the 787. Here’s a dear hope that Boeing and the FAA thoroughly wring out the 787 before the airplane, two years behind its original schedule, is pressed into widespread use by the airlines.

Herewith, a forget-me-not of fatal flaws:


A. Attitude sources (instruments) scattered around the cockpit with no readily available visual correlation with each other. The hazard here is that when a pilot’s attitude instrument fails, the resulting unusual attitude needs to be very quickly compared to two other widely scattered instruments on which the display attitudes are also rapidly changing. In other words, correlation is soon impossible and the situation quickly goes beyond recoverable limits. Main and standby attitude displays should be twinned (i.e., placed close to one another so that non-harmonious movements will become immediately apparent).

B. Circuit breakers (CBs) that were never designed as switches necessarily being used as such by both flight crew and mechanics. Continual tripping/reset of CBs changes their critical tripping threshold and can ultimately prevent CBs from performing their designed crucial function – tripping as a result of thermal overload, resulting in no circuit protection and a system failure or fire.

C. Aromatic polyimide wiring, which has the fault embedded within its name. Known generically as Kapton wiring, the aromatic moniker describes the fact that the insulation dries out with age, becomes hydroscopic (water loving), cracks and takes up water, becoming increasingly vulnerable to arcing and flash-over. The suitability of Kapton for aeronautical applications was never properly tested. Once in general service, it was too expensive to replace, except when it began knocking out or bringing down large numbers of military aircraft, thereby affecting defense preparedness. Although Kapton wiring is no longer being installed in its naked form, it is still being used with a Teflon outer coating (e.g., TKT wiring insulation).

Kapton wiring arcing.

Kapton wiring arcing.

D. Leading edge de-icer boots that allow ridges of ice to build up behind the boot, affecting the basic aerodynamics of the wing and the ailerons.

E. Turboprop propellers that rotate in the same direction on port and starboard wings. The complication is that in heavy icing conditions the asymmetric build-up of ice on wings, empennage and fuselage leads to a premature “one wing first” stall, followed by rapidly a rapidly unrecoverable autorotation.

F. Flawed flap actuation on the whole range of CRJs (commuter regional jets) – a design feature that’s almost impossible to rectify. The Transportation Safety Board (TSB) of Canada said:

“(D)espite best efforts by the industry and regulators alike to reduce the number of flap failures in the CRJ fleet, that number is increasing. A CRJ flap failure clearly has the potential to lead to a much more serious incident or an accident.”

G. Forward-facing inlets on tail-mounted APUs (auxiliary power units) on a range of jets, making the APUs prone to ingestion of anti-icing fluids.

H. Transponders that don’t alert sufficiently (aurally and visually) upon inadvertent switch-off that can also disable TCAS (Traffic Alert Collision Avoidance System) and lead to midair collisions.

I. “Triply redundant” critical systems (e.g., ADIRU’s, or Air Data Inertial Reference System) based upon multiple simultaneous raw data feeds that are vulnerable to simultaneous disabling (such as the ubiquitous three pitot heads and internal ice blockage when pitot heaters are overcome by supercooled droplets during protracted cruising in clouds).

J. Auto-throttles that rely upon singular radar altimeters, which in some intermittent failure modes can close the throttles to idle without generating any alerts, per the Turkish Airlines B737G crash in Amsterdam.


K. Automated flight systems that can auto level off, but not increase power via an autothrottle (the Buffalo low-altitude stall crash of a DHC8-400).

L. Throttle levers that do not move and alerts that do not continue (RETARD calls) when a lethal situation develops (Congonhas A320 pilot left the engine with the deactivated reverser up in the flight range after touchdown and reverse selection.

M. The failure to provide leading edge devices on the wings of the entire early range of CRJ’s and Challenger business jets, leading to numerous take-off accidents due to light icing/hoar frost on supercritical wing sections.

N. Confusing ON/OFF oxygen valves and insufficient warning devices of this; pressurization failure/failure to pressurize led to a number of hypoxia death crashes (e.g., Payne Stewart Learjet crash).

O. Use of an identical warning horn to signify takeoff configuration warnings on the ground and pressurization warnings airborne (Helios B737 accident, Athens).

P. Failure to assess the flammability risk of ullage fumes in center-section fuel tanks located above heat-producing air conditioning packs (TWA Flight 800).

Q. Failure to provide pulsing highly-directional deterrents (strobes) for birds along projected flight paths, which would prompt the flocks to take “dive and avoid” escape measures. Such directional strobes should be mandatory for twin-jets on climb – and on descent/early approach – below 20,000 feet.

R. Failure to adopt fail-safe jackscrew designs for critical applications (e.g., non-redundant structural assemblies such as the MD-80 T-tail’s horizontal stabilizer, the Alaska Air crash scenario). For that matter, the commercial industry is far behind the U.S. Air Force, which implemented automatic lubrication, different long-lasting allows, and protective sleeves to avoid contamination on horizontal stabilizer jackscrews found on jet transports.

S. Certification of rudder controls that are either susceptible to unwanted reversals (B737) or are overly sensitive to rudder inputs (A300). Together, these two flaws have killed hundreds.


T. Decades of certifying aircraft insulation blankets for fire resistance that actually burn (FAA had used Q-tips soaked with alcohol and only on samples laid flat). Alcohol is a relatively “cool” burning fuel, favored by magicians for flame effects. No tests were performed for vertical mounted insulation or the arcing effects of wiring faults under much hotter temperatures.

U. Failure to provide “stay awake alerts” for two pilot crews (dead-man buttons that must be pressed at least every 20 minutes or sound an alarm, a seat vibrator and a flight attendant alert). This feature is even more important now that cockpit doors are locked and must be released from the inside.

V. Failure to provide a software enabled credibility check to stop fatigued pilots inadvertently entering Zero Fuel Weight into their flight management computer, thereby causing low powered/premature rotation take-off accidents.

W. Failure to provide take off acceleration warning systems to guard against inadequate reduced power take-offs leading to take-off overruns (B747F at Halifax).

X. Failure to guard against leading-edge slat components punching holes in wing fuel tanks at the leading edge (e.g., the China Airlines B737-800 burn-out at Narita).


Y. It should be impossible for an aircraft to remain pressurized on the ground and prevent escape from a burning fuselage (Riyadh L-1011/Chicago DC-10 with electrical failure).

Z. It should be impossible to interchange potentially lethal parts between different marks of the same model (e.g., ATR-42/ATR-72 fuel quantity indicators).


One could go on, probably doubling this list. The point is that aircraft designs have gotten into production with shortcomings that should have been identified – and addressed – during certification. Entirely too much is “fixed” after the fact by the airworthiness directive process, when hundreds of aircraft are already in service.

Ten Years Between Accidents & Ten More Years of Half-Measures

Once again, we have proof that the most dangerous part of the flight is during landing, when speed has to be reduced from about 130 mph to 10 mph to safely exit the runway. The latest evidence of this high-risk period comes from the landing overrun of an American Airlines twin jet at Kingston’s Norman Manley International Airport, Jamaica, on the rainy evening of 22 December.

The airplane’s wheels touched down, but speed was not appreciably abated and the B737-800 with 154 passengers and crew aboard roared off the end of the runway, ripped through a perimeter fence, split apart and came to a halt just a few feet from the ocean surf.

Ninety people were taken to hospitals with broken bones, contusions and bruises; four people were hurt seriously, although none of the injuries was considered life threatening. Injuries to crew are unknown.

Ten years ago, on 1 June 1999, the captain of an American Airlines MD-82 twin jet was killed in similar circumstances landing in a thunderstorm at Little Rock, Arkansas. The first officer was badly injured, as were a dozen or so passengers, some of whom escaped the wreckage though splits in the fuselage as the airplane ground to a halt just short of the Arkansas River.

The two cases, then and now, raise a simple question: what has the aviation industry learned in the intervening decade to prevent a repeat?


Kingston, Jamaica, 2009 -- going off the end of a wet runway and stopping just short of the ocean.

Kingston, Jamaica, 2009 -- going off the end of a wet runway and stopping just short of the ocean.

Little Rock, Arkansas, 1999 -- roaring off the end of a wet runway and stopping just short of the Arkansas River.

Little Rock, Arkansas, 1999 -- roaring off the end of a wet runway and stopping just short of the Arkansas River.

The following issues will doubtless be examined by the Jamaica Civil Aviation Authority, assisted by a team from the U.S. National Transportation Safety Board (some of whom, hopefully, were participants in the Little Rock crash investigation – their memory of the particulars of that crash will be especially pertinent):

— The role of the dispatcher. Every airline flight is a collaborative effort between the cockpit crew and the dispatcher at the airline’s flight operations center. Was this flight dispatched into an area of known thunderstorm activity? At certain U.S. airlines, it is policy to avoid thunderstorms entirely. The lack of such policy at American Airlines in 1999 had much to do with the set-up for the accident. If the dispatcher recommended delayed landing until the thunderstorm passed – say about 20 minutes – the accident might have been avoided as well. And of course there is the subject of alternate airports if the field at Kingston, Jamaica, was not usable because of severe thunderstorms.

— The utility of weather radar in the cockpit. In the 1999 crash investigation, questions were raised about the adequacy of the flight crew’s knowledge and training in the use of the airplane’s on board weather radar. The practice of “avoiding the red” on the radar display in the Little Rock crash was clearly insufficient. The areas depicted in red may show the most intense rainfall, but not necessarily the most turbulent convective activity.

— Time of day. As at Little Rock, the crash at Jamaica was late at night. Not only is poor visibility a factor, but also the matter of crew fatigue. At Little Rock, the captain was clearly fatigued, as evidenced from the cockpit voice recorder (CVR) indicating his non-responsiveness to the first officer (FO: “Want 40 flaps?” Captain: “Oh yeah, I thought I called it.”).

— Support from the tower. At Little Rock, the tower controller did not suspend operations, even though the airport was experiencing a Level 6 thunderstorm, considered “severe” on a six-point scale. The wind shear detectors at Little Rock were also not placed optimally for assessing the wind shear hazard.

— Touchdown point. Exactly how long is the runway at Kingston and where did the B737-800 touch down? Reportedly, the runway is 8,786 feet long, and the B737-800 landed long — about halfway down, due in part to a tailwind component. At Little Rock, the airplane touched down long on the runway. Given the circumstances of aircraft configuration, the airplane did not have enough paved length remaining to stop, no matter what procedures were employed by the crew.

— Configuration. At Little Rock, the crew had failed to arm the spoilers, so they did not deploy on landing. The spoilers kill lift and put maximum weight on the main landing gear. With about 95% of the airplane’s weight on the main landing gears, braking effectiveness is optimal. This wasn’t the case at Little Rock, where only 10% of the airplane’s 127,000 lb landing weight was on the wheels, and the airplane hydroplaned down the runway. Hydroplaning also occurred at Kingston, from early accounts.

— Reverse thrust. Did the crew at Kingston apply maximum reverse thrust to aid in deceleration? The flight data recorder (FDR) should reveal much. At Little Rock, the crew did not apply maximum reverse thrust. With a late touchdown, no spoilers, insufficient reverse thrust and delayed braking, plus hydroplaning, the Little Rock aircraft roared off the end of the runway at more than 100 mph. One passenger on the Kingston jet recalled, “The airplane did not seem to be slowing down when it landed. There was a loud sound, then a huge thud, and then we started to feel rain through the top.”

— Cabin safety. When the airplane landed hard at Kingston, overhead bins popped open, spilling carry-on bags and articles. The spillage contributed to the general sense of passenger confusion and frustration during the subsequent emergency evacuation. This bin spillage was a problem in the Little Rock crash, too. The flimsy overhead bin doors were a problem in 1999, and they’re still problematic in 2009, when passengers are carrying even more items aboard the aircraft. The locking mechanism on the doors needs to be strengthened. The manner in which ceiling panels are affixed also is an issue.

— What safety area? Every runway is supposed to have 1,000 feet of unpaved ground as a safety area off the end of the runway. This was not the case at Little Rock, where the Arkansas River floodplain was right off the end of the runway. The airplane hit runway lighting poles, which were not frangible, badly damaging the airplane but the poles helped stop it short of the water. At Kingston, the airplane was damaged by dunes, which had the effect of stopping it just 10 feet short of the ocean. At Little Rock, after the accident the airport authority installed an Engineered Materials Arresting System (EMAS), a porous form of concrete, to assist in stopping airplanes that cannot stop on the paved runway. The wheels bury themselves in the porous material and the airplane is quickly brought to a halt (without damaging the airplane itself and with only minor degradation to the landing gear). It is interesting that the Little Rock installation was hastily completed after the accident. Had EMAS been installed at Kingston, the airplane would have been stopped before plowing into dunes and splitting open, damaging the almost-new B737-800 beyond repair.

— The response. At Little Rock, the airport rescue and fire fighter (ARFF) response was delayed because of uncertainty about the crashed aircraft’s location. The fire fighters originally went to the wrong end of the runway. The Kingston airport ARFF response, however timely or not, will surely get close scrutiny. As at Little Rock, ARFF personnel were trying to locate a wrecked aircraft on a dark and stormy night.

So once again investigators will have issues to address that were not fully resolved in the ten years after the 1999 accident. And that raises an ugly question: why is the industry so tardy on correcting obvious, basic safety deficiencies? It could well take ten additional years to redress similar shortcomings revealed by the crash at Jamaica.

Copying A Good Idea

Every now and then, one comes across an example of a safety program that could be emulated by the Federal Aviation Administration (FAA).

In the UK, there is a program known as CHIRP, for Confidential Human Factors Incident Reporting Program, in which pilots, flight attendants, air traffic controllers and mechanics can anonymously report safety problems. The best, or most instructive, of the reports are published quarterly by CHIRP Feedback, an electronic bulletin. There is nothing comparable to this program in the U.S., and there should be. To be sure, there is the aviation action safety program (ASAP), but those confidential reports are not regularly mined and pertinent examples regularly published for the benefit of the industry.

Although separate from the Civil Aviation Authority, CHIRP is funded by it. To be sure, many operators in the UK support their own confidential reporting schemes. But CHIRP covers all operators and its feedback goes to the community at large – providing a very useful insight into trends across all operators.

Here is an example, with the CHIRP response:

“Our company is increasingly using the threat of disciplinary action when investigating the details of company safety report events. It is so bad that I am now no longer submitting any safety reports unless they do not concern how I have operated the aircraft. I recently have had two events that would merit input to the flight safety review of the airline but I fear that may be disciplined if I report the incidents.

“The problem is that if you submit a safety report the investigating officer believes he is entitled to pull the whole flight data for the entire flight and not the relevant data relating to the incident. For example, if a go-around is flown one might be asked to explain why you flew a certain speed 100 NM from destination! It’s a complete blame culture. The management believe that they are reacting to the safety events in the business but, as no one is filing any safety reports, they are missing what is really going on and cannot effectively manage areas of ongoing high risk. In some cases, First Officers are dragged into the office if a safety report is submitted in order to gain as much extra information as possible before the Captain has to account for him/herself.

“I have also heard that during command line training new captains have been advised not to file a safety report unless it appeared on the list of events that required to be reported; otherwise they could render themselves liable to being disciplined.

“I seek a guarantee of no disciplinary action being taken except in cases of gross misconduct or, if this cannot be given the introduction of a confidential reporting system within the airlines.

CHIRP Comment: With the reporter’s consent, the concerns were raised with the company, who subsequently provided a detailed reponse.

“The company policy relating to the use of data or information recorded by the Flight Data Monitoring program has been negotiated and agreed with the Pilots’ Company Council and, in the case of company safety report investigations, was strictly limited to the ASR [aviation safety reporting] event.

“Company safety investigations were always conducted separately from administrative/disciplinary procedures and some management functions had been recently restructured to enhance this policy.

“The company kept under review the number of company safety reports submitted; the overall number had not reduced significantly. Notwithstanding this, in independent safety audit of company bases was shortly to be undertaken.

“In CHIRP’s, this report is a reminder of the importance of ensuring that company safety and disciplinary policies are segregated and that this is clearly understood by all relevant employee groups.”

Amen to the last point. What is useful here is not only the basic pilot report, but the CHIRP investigation, comment and publication in an air transport safety newsletter. The 12-page newsletter is circulated electronically to all licensed pilots, air traffic control officers, and maintenance staff. What a marvelous idea – worthy of emulation.

Failing the Test of Transparency

Before the end of this year, the Federal Aviation Administration (FAA) hopes to have a new proposed regulation on flight and duty time posted for public comment. “Scientifically based” rules accounting for sleep debt, circadian rhythm disruption and other factors are badly needed.

Not only are updated rules one of the National Transportation Safety Board’s “Most Wanted” items, the new FAA Administrator, Randy Babbitt, recognizes that outdated regulations here are a “safety hot button.”

“As I’d think we all agree,” Babbitt said recently, “this comes up in accident investigation more often than it should.”

“My goal here is to make this one of those things that used to happen in aviation,” he vowed.

To help craft the Notice of Proposed Rulemaking (NPRM), Babbitt convened what’s called an Aviation Rulemaking Committee (ARC) to recommend new rules. He gave this expert panel 45 days last summer to deliberate and submit recommendations to the FAA. In turn, the FAA will take the ARC report and use it to craft the NPRM, which will be scrubbed by the Office of Management and Budget before it’s posted on the Federal Register in December for public comment.

After a comment period of, say, about a year, the FAA will then publish a final rule, and that will have an effective date of about 2012. No wonder the rulemaking process is dubbed “deliberative.”

Obviously, the ARC report has a considerable influence in shaping the proposed rule.

The term “ARC” raises an important question. How is it different from “ARAC,” which is short for Aviation Rulemaking Advisory Committee. Over the years, the FAA has convened all manner of ARACs but this is the first time in at least a decade where the FAA has resorted to the ARC process.


Under the umbrella of ARC, a lot happens out of public view. Here is an explanation from an FAA official:

“An ARAC is covered by the Federal Advisory Committee Act, meaning that we have to publish a notice so the public has an opportunity to say that they want to be involved. We don’t have to include everyone, but the opportunity has to be made public. The 1996 Reauthorization Act gave the FAA Administrator the authority to establish an ARC, a small group of experts to give the FAA advice on a specific subject. The ARC is a deliberative process so the ARC recommendations on pilot fatigue would not be released under FOIA [Freedom of Information Ac]. We also do not have to open membership up to the public.”

There you have it: the ARC process is the very opposite of the “transparency” called for by the Obama administration.

The FAA official assures that the ARC recommendations will be made public when the proposed flight time/duty time regulation is released for public comment.

Making the ARC’s final report available is not the same as observing the process by which the report is developed (the options not considered, the horse trading to yield compromise measures, and so forth).

I know because I observed two ARAC deliberations in the late 90s. One was an ARAC dealing with fuel tank inerting (an outgrowth of the TWA Flight 800 disaster where the center fuel tank exploded). The industry-dominated ARAC concluded that inerting fuel tanks was too expensive, although the ARAC had information that technology could be installed for a cost of about 25¢ per passenger ticket.

The other was an ARAC on electrical wiring (an outgrowth of the Swissair Flight 111 disaster, where arcing led to loss of the airplane). Again, the industry dominated group denied there was a problem and fought tough wiring inspection protocols.

There was a stillborn effort in 2001 to strengthen the ARAC process. While full ARAC meetings were required to be held in public view, the working group meetings were not. The working groups were comprised of industry foot soldiers doing the detailed work crafting policy and recommendations.

A senior FAA official cautioned that opening the working groups to public scrutiny would have a “chilling effect” on the candor characterizing the discussions.

Chris Witkowski, representing the Association of Flight Attendants, was unconvinced. “I fail to see why there isn’t a more transparent process. The openness of the ARAC (i.e., the full committee) serves as a ploy to justify the closed deliberations of the working groups,” he charged.

Basically, the ARC process is the ARAC working group process writ large.

Which bears directly on its makeup and its recommendations. Of the 18 members of the ARC, one was from the FAA. Eight members were from pilots unions and nine individuals represented airlines and operators.

The NTSB, which wants the flight/duty time regulations updated, did not have a seat at the table. There was not a single outside expert on the ARC, despite the fact that there are any number of esteemed specialists in industrial scheduling and sleep that could have been called in to help craft new regulations based on the best “scientifically based” research. Instead, a process of “incestuous amplification” was at work – industry insiders without a single representative likely to say, “Wait a minute.”

The issue of pilots commuting to their duty stations, for example, was not addressed by the ARC. Roger Cohen, President of the Regional Airline Association, which had three members on the ARC, said, “The ARC [report] does not address commuting, so the rulemaking may not address commuting either.” With three subordinates on the ARC, Cohen should know. The status quo – airlines expect pilots to report for work rested and ready, the pilots unions not willing to question commutes over multiple states and/or time zones – seems untouched.

As one airline observer noted:

“These ARC deliberations could have a drastic impact upon a wide cross-section of the commuting flight and cabin crew community. If taken towards any logical conclusions (i.e., commuting is a fatigue factor and needs to be addressed and mitigated), then the specter of crew basing will arise … There is undoubtedly a thick veneer of vested interest protecting the status quo.”

Babbitt told Congress, “I am pleased to report to you that the ARC met its charge and that we are currently reviewing its recommendations.” He went on to wax eloquent about the ARC’s work, “Although our review is ongoing, I would like to share with you how pleased I am with the work that we accomplished in the ARC.”

This declaration of confidence in an industry-dominated body meeting out of public view has to be taken on faith, and a whole lot of skepticism.

Distracting Attention From Systemic Safety Shortcomings

The recent fines proposed to be levied on US Airways and United Airlines by the Federal Aviation Administration (FAA) give the impression that the agency is in charge and getting tough on safety transgressions. The alternative view is one of the FAA grandstanding, involved in token penalties to demonstrate that it is on top of the safety situation.

Credence for this dour interpretation comes from the FAA’s total lack of rigorous enforcement of the Service Difficulty Report (SDR) system, by which carriers are supposed to report significant maintenance problems. Reporting is spotty and does not focus on serious problems; rather, the SDR database is clogged with minor, frivolous reports having negligible impact on flight safety (e.g., burned out light bulbs).

There is a way to clean up SDR reporting and to make it a more useful cross-comparison of safety-related events and trends.

On 14 October the FAA announced a $5.4 million fine against US Airways and a $3.8 million penalty against United Airlines. One gets the impression that in both cases the FAA is acting capriciously and in a manner calculated, if anything, to discourage the airlines from reporting problems.

US Airways was fined for failing to comply with three airworthiness directives (ADs) and for failing to conduct maintenance inspections. The proposed fine escalated due to multiple flights conducted by the same aircraft without the requisite inspections. Meanwhile, the larger issue goes unaddressed: US Airways submitted SDRs only 16% of the time for incidents of smoke, fire, cracked windshields, blown tires, engine and landing gear problems that were found in a Google database search. SDRs are required to be submitted to the FAA, not only for trend analysis at an airline, but for spotting trends across the industry. Focusing, as the proposed penalty does, on a few isolated transgressions is really beside the point then US Airways SDR reporting discipline is woefully lacking.

The proposed penalty on United Airlines is similar – over 200 flights of one B737, which was forced finally to return to the departure field due to low oil pressure indications. Upon teardown, it was found that two shop towels, rather than protective caps, had been used to cover openings in the oil sump area when maintenance was performed in December 2007.

In this case, United filed an SDR in a timely manner, which said in part:


Even though United filed the SDR, it got fined anyway. This seems a perverse way to encourage SDR reporting, especially since United’s filing rate is only about 30%, per the method used to determine the 16% reporting rate above for US Airways.

Both carriers have 30 days from receipt of the civil penalty letter to file rebuttals. If the past is any predictor, the fines will be adjusted downward by 25% to 50%, or voided entirely. The FAA’ announcement of the proposed fines could be interpreted as indicative of a “get tough” attitude when, in fact, the ultimate financial penalty is both substantially less and a disincentive to report anything via the SDR system.

Simply put, the FAA is not enforcing its most powerful and prominent self-reporting system. With full reporting of SDRs, the FAA would have a means of measuring, across the board, maintenance impacts on air safety. Let the record reflect that United contracts out its maintenance, which saves money. But everything has a price. Contract maintainers can use non-licensed mechanics to perform work, so long as the job is overseen by a licensed power plants and airframe mechanic. By just publicly fining United, we learn nothing about how the error came to be made in the first place. Was this a case of non-licensed maintainers making a mistake? If so, how was it missed by a certified mechanic, assuming he was actively overseeing the work of the non-licensed juniors.

Indeed, it is not clear that the SDR generated the proposed fine. If the penalty was the result of a whistleblower call to the FAA’s hot line, that draws attention to a non-functioning SDR reporting system. This certainly does not engender public confidence that the FAA is on the ball, so the whole effort focuses on proposed fines for isolated transgressions, rather than the FAA’s systemic negligence regarding SDR reporting and the use of the database for useful analysis.

Let me give three examples of high-profile cases where SDR reporting was either nonexistent or superficial:

1. Recall the 15 January 2009 ditching in the Hudson River of the US Airways A320 struck by birds. (See Air Safety Journal, ‘Hearings Reveal Definition of Ditching Needs Upgrading’) Two days before, there was a “loud noise” of an engine compressor stall noted in the media. Under the FAA rules for filing under the SDR system, this type of engine anomaly is a reportable event. What’s in the SDR database? Nothing.

2. Remember the 13 July 2009 event where a hole popped open in the roof of a Southwest Airlines B737? (See Air Safety Journal, ‘Torn Metal Skin on Southwest Jet To Be Evaluated’) Southwest did file an SDR, but misstated the problem, saying that the skin was cracked. That’s quite a gloss on a rupture that opened a 1.5 foot hole over passengers who say blue sky where the ceiling was supposed to be. Although no required supplemental report followed a promised evaluation, three others have been filed for loose exit light lenses and a flashlight battery replacement.

The ruptured skin as viewed from inside the rear of the passenger cabin.

The ruptured skin as viewed from inside the rear of the passenger cabin.

3. Then there is the case of the United Airlines B777 that had the electrical failure at London’s Heathrow Airport on 26 February 2007. Arcing inside a power panel in the lower bay caused molten metal droplets to fall down onto insulation blankets below. The blankets ignited and a fire spread underneath a floor panel to the opposite electrical panel, causing fire damage to structure, cooling ducts and wiring. The case was investigated by the UK’s Air Accidents Investigation Branch. (See Air Safety Journal, ‘Regulatory Lassitude Contributed to Electrical Fire’) United filed an SDR, which said only, “Smoke coming from fwd outflow valve after engine start.” No apparent cause or supplemental reports were filed, although both are required by FAA rules. Insulation blankets, we should note, are supposed to be fireproof, so the fact that the full-fledged fire was spread by burning insulation is noteworthy and quite serious. Given improved standards for qualifying insulation blankets, why are we dealing with insulation fires in these new-generation B777s anyway?

Burnt aircraft structure and insulation blankets located below the B777's power panel on the right side. The fire spread to the left side of the belly hold.

Burnt aircraft structure and insulation blankets located below the B777's power panel on the right side. The fire spread to the left side of the belly hold.

Here’s a reporting system with about 30% compliance across-the-board in 2008 for the airline industry, where the reports that are submitted are incomplete and outright misleading as to severity. Reporting compliance for 2009 is estimated at 40% — still less than half.

The partial SDR database is also clogged with what can only be described as frivolous reports. Frivolous here means those reports filed that result from the expected wear and tear of the operating environment. These frivolous reports comprise anywhere from 53% to 92% of filings submitted by the airlines.

For example, some carriers report all structural cracks, regardless of acceptability. According to a retired licensed FAA structures mechanic, formerly with the late Eastern Airlines, perhaps 5% of corrosion or cracks found exceeded the acceptable limits. The SDR regulations say reporting should be for “cracks, permanent deformation, or corrosion of aircraft structures, if more than the maximum acceptable to the manufacturer or the FAA.”

Emergency lighting systems are another category where frivolous reports abound. Emergency egress lighting, a network of floor lighting, emergency lights and exit signs, powered by rechargeable batteries, are kept in a charged state by the normal aircraft electrical system. When that source fails, or a switch is turned on, the battery-powered lighting system activates. The floor lighting wiring is subject to foot traffic and damage to the wires. Both the chargers and the light bulbs are subject to failures.

Failures of the lighting system must be reported via SDR. However, routine replacement of bulbs and batteries may constitute anywhere from 15% to 78% of a carrier’s SDR filings. Such filings should be comparable per airplane among carriers. They are not.

Frivolous filings waste more than half of the FAA’s time and labor for inclusion into the database. For the carriers, these filings serve to “prove” that SDR improvement initiatives through the years are all too costly. There’s nothing like unchallenged padding of the database to demonstrate the burden of further reporting.

The National Transportation Safety Board (NTSB) has written the FAA at least four times during the period 1993-2002 complaining that the SDR database is incomplete (and this is in the face of a mountain of frivolous reports, mind). Its 1993 letter was the most explicit:

“Attempts to effectively use the SDR data base in recent Safety Board investigations have revealed that the current program is incomplete and of limited value in identifying accurate service defect histories because many reportable service difficulties are not reported to the FAA.

“This situation was identified during the Board’s investigation of an accident involving the failure of a Cessna 208 landing gear shimmy damper and cracking of the engine/nose gear mounting structure. The FAA SDR database revealed only two reports of engine mount cracking and no prior reports of shimmy damper failure; however, data supplied by the airplane manufacturer [Cessna] showed 17 reports of engine mount cracking and 250 reports of shimmy damper failure.”

The Government Accountability Office (GAO) has also detailed many shortcomings of the SDR system:

— It contains only a small percentage of actual occurrences.

— Vagueness in reporting requirements and airlines’ concerns about public access to SDR data contribute to low SDR reporting.

— Doubt about the system’s capabilities and effectiveness has discouraged SDR reporters …

— FAA analysis of SDRs occurs rarely or not at all.

One can easily see how the current practice of levying fines against the airlines can be viewed as capricious, arbitrary and even counterproductive (why submit an SDR that could be used to impose a fine?).

There may be a better way. To encourage all operators to submit SDRs, the FAA could impose a civil penalty of, say, $10,000, for each occurrence where a required SDR is not submitted. One submits that a penalty of $10,000 for not submitting a piece of paper will, in short order, result in SDR submissions. The FAA’s principal maintenance inspectors (PMIs) at each airline can audit submissions for noncompliance. Absent SDR reports can be identified through Google incident searches, or through manufacturer’s reports that are not found on the FAA’s SDR database.

Frivolous reports that needlessly pad the database can be handled similarly. Any report submitted that is not in compliance with FAA reporting requirements can be the subject of a $5,000 fine.

After about a year, reporting rigor will be much improved, and the FAA will have a much more usable database for identifying problems and trends across the industry.

The current method of levying civil penalties on the airlines gives the impression that the FAA is getting tough on the airlines. This toughness is illusory.

Imposing real discipline in SDR reporting is far more meaningful. The public might not understand the significance, but the airlines, the FAA, and the NTSB definitely will comprehend the difference between token oversight and a truly “data driven” safety program.