Reactive Versus Proactive Safety

After a crew attempted to fly across country on battery power (that normally expires in 30 minutes), the flight ended badly but not disastrously: with an emergency landing 22 September at O’Hare (ORD) in which the B757 went into the grass because there were no antiskid brakes, no thrust reversers and no spoilers and, oh by the way, no pitch trim. All of these systems depend on electric power, of which there was none, naught, nada at almost two hours past the time when the battery registered nil electrons. (See Aviation Safety & Security Digest, ‘An Ostensibly Minor Malfunction Escalates To An Accident,’ home page.)

The National Transportation Safety Board (NTSB) is investigating, and the report is probably months away. And with good reason; investigators have a lot of issues to explore.

Not the least is this message, sent out by the flight department at American Airlines after the incident:

“SUBJ: NEW ELECTRICAL CHECKLISTS

A RECENT FLIGHT DIVERTED INTO ORD AFTER COMPLETELY DISCHARGING THE BATTERY IN FLIGHT. THE CREW FOLLOWED THE CHECKLISTS CORRECTLY, WHICH COME DIRECTLY FROM BOEING, AND [WHICH] DID NOT DIRECT THE CREW TO LAND AT THE NEAREST SUITABLE AIRPORT … NEW CHECKLISTS WILL DIRECT THE CREW TO LAND THE AIRCRAFT AT THE NEAREST SUITABLE AIRPORT IF THE BATTERY IS DISCHARGING AS WELL AS ADD A LIST OF ALL ITEMS ON THE STANDBY AC, STANDBY DC, BATTERY BUS AND HOT BATTERY BUS. YOU WILL SEE THESE CHECKLIST REVISIONS SOON.”

Boy, does this message raise questions.

First of all, hasn’t the industry learned anything after the Swissair flight 111 tragedy of 1998? In that crash into the waters off Nova Scotia, Canada, that killed all 229 aboard the MD-11, the crew attempted to diagnose where smoke entering the cockpit was coming from before deciding to divert to Halifax. The airplane was downed by a raging electrical fire above and behind the cockpit.

Canadian investigators determined that some 20 minutes elapsed from smoke first wafting into the cockpit to loss of most instruments and control of the aircraft. The word went out: when faced with an electrical emergency, and especially if an electrically-stoked fire is suspected, land immediately.

Indeed, manufacturer Boeing put out a Flight Operations Bulletin in June 1999, before the investigation was completed in the Swissair crash, enjoining operators to “land as soon as possible.” As Tom Melody, the Boeing senior manager and chief test pilot for MD-11 customer service, said in the bulletin, “Don’t delay … consider whether you would rather be on the ground – or in the air” with the prospect of an electrical fire raging in some unseen region of the airplane.

That bulletin went to all Boeing’s MD-11 customers, including American Airlines.

Apparently, the bulletin had no effect on the checklists Boeing provides its customers.

Apparently, American Airlines did not look at all of the checklists for the Boeing aircraft it operates and take action to modify them. Note the whiff of blame in the message American sent to its flight crews: “Boeing [checklists] … did not direct the crew to land at the nearest suitable airport.”

Oh, and it appears that pilots were not given clear and unambiguous guidance as to which systems were connected to the various flight essential busses.

Now, after the accident at O’Hare, American is galvanized into action, promising checklist revisions “soon.”

Not soon enough to prevent the emergency landing at O’Hare.

This is the second time American’s procedures have been questioned. After the November 2001 crash of American flight 587, an Airbus A300-600, in New York City, killing 265, the airline’s advanced aircraft maneuvering program (AAMP) came under scrutiny. There was a belief among some NTSB investigators that AAMP predisposed the first officer, who was flying the airplane, to aggressively whap the rudder back and forth, which caused the tailfin to snap off.

Thus, the flight department’s belated memo raises serious questions about how the airline – any airline for that matter – provides aircrews with guidance and training before they get into serious trouble.

Afterwards is often too late.