Risk-Taking

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

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

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

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

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

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

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

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

 

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

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

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

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

march5weather

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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