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Comment on Air Safety

Draft Guidance on Fatigue Evades Accountability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.

‘Letter War’ Rages While Helicopter Ambulances Continue to Crash

The “letter war” between the two agencies is not improving safety, but it is proof of the old adage that three inches of flame will shield one’s derriere from accountability.

Case in point: the recommendations issued in 2006 to improve the safety of medical evacuation flights, especially those flown by helicopters. The National Transportation Safety Board (NTSB) issued four recommendations. Taken as a group, they are classified RED by the NTSB – for unacceptable response – because the Federal Aviation Administration (FAA) is progressing slowly in implementing them. Progress may be lagging but, boy, the FAA has issued pages and pages of bland assurances to the NTSB that the situation is in hand.

That is debatable. Helicopter emergency medical services (HEMS) flights are falling out of the sky with appalling regularity, killing patients, pilots, nurses, and other people aboard or on the ground. With these continued incidents there is a higher need than ever for helicopter accident lawyers.

While helicopter ambulances continue to crash, the FAA dithers.

While helicopter ambulances continue to crash, the FAA dithers.

Here is the record for the past three years:

HEMS Accidents2008 to Present
Date Location Operator Casualties
5 Feb. 2008 South Padre Island, TX Metro Aviation Inc. 3 fatal
10 May 2008 La Crosse, WI Air Methods Corp. 3 fatal
21 May 2008 Hiram, GA Omniflight Helicopters Inc. None
29 May 2008 Grand Rapids, MI Aero Med Spectrum Health 2 serious injuries
30 May 2008 Pottsville, PA Lehigh Valley Medevac 3 minor injuries
8 June 2008 Hunstville, TX PHI Inc. 4 fatal
27 June 2008 Ash Fork, AZ PHI Inc. 3 serious injuries
29 June 2008 Flagstaff, AZ Air Methods Corp. 7 fatal
29 June 2008 Flagstaff, AZ Classic Helicopter Lifeguard 7 fatal
31 Aug. 2008 Greensburg, IN Air Evac Lifeteam 3 fatal
27 Sept. 2008 District Heights, MD Maryland State Police 4 fatal1 serious injury
15 Oct. 2008 Aurora, IL Air Angels Inc 4 fatal
22 Feb. 2009 Cave Creek, AZ PHI Inc. None
2 July 2009 Loris, SC Omniflight Helicopter Inc. None
17 Aug. 2009 North Captiva Island, FL Lee County Division of Public Safety None
22 Sept. 2009 Page, AZ Omniflight Helicopters Inc. None
24 Sept. 2009 Tucson, AZ Air Methods Corp. None
25 Sept. 2009 Georgetown, SC Carolina Life Care 3 fatal
22 Oct. 2009 Lythe, CA Tristate Careflight LLC None
14 Nov. 2009 Doyle, CA Mountain Lifeflight 3 fatal
25 Dec. 2009 Decatur, TX Air Evac EMS Inc. None
17 Jan. 2010 Reno, NV Air Methods 2 serious injuries1 minor injury
5 Feb. 2010 El Paso, TX Southwest Med Evac 3 fatal
11 Feb. 2010 Cheverly, MD Maryland State Police None
25 March 2010 Brownsville, TN Hospital Wing 3 fatal
2 June 2010 Midlothian, TX CareFlight 2 fatal
Total for the 29 month period: 26 helicopters banged up or destroyed49 fatalities8 serious injuries4 minor injuries

Basically, about two people per month are killed or injured in HEMS flights. The total, 61 dead and injured, exceeds the 50 or so persons on board a regional airliner; and no matter how the calculation is done, being aboard a Part 135 HEMS flight is considerably riskier to life and limb than being a passenger on a Part 121 airliner. The HEMS accident rate is fuzzier, because unlike for airliners, we don’t know how much air time the HEMS industry logged. Suffice to say, though, if Part 121 airliners were crashing at a rate of about 0.90 per month – as are the evacuation helicopters – the airline fleet would be grounded. In this case, HEMS flights are still conducted despite the grim recent record of broken aluminum and shattered bodies.

Now consider the FAA’s pallid response to the NTSB’s 2006 recommendations.

A-06-12, Require operators to conduct all EMS flights with medical personnel on board in accordance with commercial flight operations. The FAA stated in March 2010 that, because an IFR [instrument flight rules] flight provides guaranteed obstacles clearance, continuous radio communication with air traffic control, and radar contact, this option provides a HEMS operator with an equivalent level of safety to that of a Part 135 [air taxi] visual flight rules flight. The only problem here is that despite three pages of back-and-forth letters between the NTSB and the FAA, the fact remains that the NTSB’s word – “require” – has not been acted upon. The NTSB characterizes the FAA response to this recommendation as “OPEN – Unacceptable Response.”

A-06-13, Require EMS operators to develop and implement flight risk evaluation programs. The industry had a 94% compliance with risk assessment; FAA is working on a Notice of Proposed Rulemaking (NPRM) to make risk assessments a requirement. Despite promises to issue the NPRM in January 2010, it has yet to be issued. For its slow rate of progress, the FAA response is categorized by the NTSB as “OPEN – Unacceptable Response.” Note that its been four years since the recommendation and an NPRM has yet to be issued; after the NPRM is issued, the FAA will have to consider all comments before issuing a final rule. Action on this recommendation is at least two years away.

A-06-14, Require formalized flight following and dispatch procedures including up-to-date weather. The FAA’s May 2008 publication of Advisory Circular (AC) 120-96, “Integration of Operations Control Centers [OCC] into Helicopter Emergency Medical Services Operations,” only partially satisfied the NTSB recommendation, as an AC does not “require” implementation. The FAA promised an NPRM by January 2010; no such document has been found on the Federal Register. Only because an AC has been issued, the NTSB classifies the response to this recommendations as “OPEN – Acceptable Response.”

A-06-15, Require EMS operators to install TAWS [terrain alert and warning systems]. The latest FF response is dated April 2009, promising to complete work on an NPRM by January 2010. It appears that much was promised by January 2010, none of which was delivered. The NTSB said, “FAA initiated rulemaking process, but little progress has been made.” The recommendation was classified, “OPEN – Unacceptable Response.”

All four recommendations are still “OPEN” and only in one was the response deemed “Acceptable” because a non-mandatory AC was issued. A literal reading of all four recommendations, each of which contains the word “require,” indicated nil progress.

Let us consider just one of the accident flights in the table above: the 8 June 2008 nighttime crash at Huntsville, TX, of the PHI Bell 407. TAWS might well have alerted the pilot to his dangerous proximity to ground. The NTSB issued a recommendation for TAWS two years before the accident.

In February 2009 the NTSB held a three-day hearing on the safety of HEMS flights. After this 3-day conclave, 21 additional recommendations were issued. None of them has been fully implemented. These recommendations were issued right in the middle of the three-year record of HEMS flight accidents in the table above.

The NTSB must be into self-flagellation, issuing 21 additional recommendations on top of the four languishing above.

But this commentary isn’t about the NTSB. It’s about the dismal record of the FAA at stemming the continuing mayhem in helicopter ambulance flights. If the FAA’s job is to protect the flying public – in this case patients strapped to a gurney, and the pilots and flight nurses sent to rescue them – the agency has been a dismal failure.

One thing is evident: had the FAA spent a little less time sending letters to the NTSB explaining why progress was difficult and time-consuming, it might have freed up a few bureaucrats to actually solve the problems.

The Golden Tombstone Award for the Feds

There is something deeply paradoxical and disconcerting about the Federal Aviation Administration (FAA). Here is an agency that touts safety as its highest priority, yet its actions are dilatory, incomplete, and reflect a regulatory lassitude that is inexcusable.

Four recent examples certainly suggest this damning indictment.

First, a 29 June 2010 Notice of Proposed Rulemaking (NPRM) on airframe and engine icing, dealing primarily with supercooled liquid droplets (SLD) that slap and stick on metal, turning to ice. Note, first of all, that this is a proposed rule, not a final rule. In other words, the FAA is seeking comments, and it could be a year or more before it publishes a final rule.

Following fatal icing accidents at Roselawn and Monroe, the National Transportation Safety Board issued two recommendations to the FAA regarding SLD. Both recommendations languish, the NTSB having characterized the FAA reaction to them as “OPEN – Unacceptable response.” The matters contained in the NPRM are intended to respond to the NTSB, but the “Unacceptable response” characterization will remain until the FAA publishes a final rule sometime a year or two hence.

Publication of the final rule won’t immediately effect one airplane. Lets look at the overall evolution, here, from womb to tomb (an appropriate metaphor given the accusation that the FAA is a “tombstone” agency requiring dead bodies to galvanize safety action). Since the ATR-72 accident at Roselawn, it has taken about 14 years and 8 months to bring the SLD issue to the proposal stage. If codified and effective, say, at the beginning of 2011, and application made for type certification of a transport airplane at that time, the airplane will have up to five years to be certificated to this rule, or until 2016 before the first airplane of the type would enter service. It will take several more years for the fleet to accrue significant exposure, necessary to determine if the rule has the intended effect on the safety of airline operations in icing conditions.

Total elapsed time, approximately 25 years – a quarter of a century – from accident to improvement.

Example 2: an FAA Safety Alert for Operators (SAFO) of 6 July 2010. The SAFO basically says that for stall training in the simulator, the old guidance of training the pilot to recover with “minimum altitude loss” is out. It is critically important that the pilot lower the nose (decrease back-pressure on the control yoke or side stick), add power, and increase speed to recover from a stall. Holding altitude or endeavoring to minimize altitude loss (without good cause, such as a ground proximity warning) can be a death sentence.

The SAFO follows Canadian guidance to this effect issued three years ago. And the change to approach to stall recovery was first urged back in 1999. That was 11 years ago. The FAA gets the “golden tombstone” for this belated action. There are a number of fatal accidents that could probably have been avoided had the pilots responded to the stall warning/upset along the lines suggested in this SAFO.

Example 3: an Airworthiness Directive (AD) issued 7 July 2010 regarding in-flight entertainment systems that do not have an ON/OFF switch in the cockpit enabling the crew to cut power in the event of smoke or flames from the system. While a circuit breaker (CB) does enable electrical power to be terminated, CBs are not to be routinely used as switches as this habit decreases the life of the breaker, resulting in failed circuits, smoke or fire.

The AD makes mandatory a number of Boeing Service Bulletins (SBs) on the corrective action for B777 jetliners (readers may recall the control boxes under the seats that control individual monitors; the boxes also reduce foot room).

Following the 1998 fatal crash at Halifax of Swissair flight 111 from a rampaging fire believed to have begun in the location of in-flight entertainment system wiring, Transportation Safety Board (TSB) of Canada investigators were dismayed to discover there was no installed ON/OFF switch for the entertainment system on the accident MD-11 and commented extensively about the hazard in their final report.

An FAA official concedes, “There is nothing in the FARs [Federal Aviation Regulations] prohibiting the use of CBs as switches.”

Here we are, 12 years after the Swissair accident, 7 years after the TSB final report, 4 years after the Boeing SBs, still dealing with in-flight entertainment systems without an ON/OFF switch. Another 5 years is allowed for installation, bringing the time from the Swissair crash to final fix to a total of 17 years.

Example 4: An AD published 13 July 2010 to prevent windshield cracking caused by loose electrical connections in the window heater. We’re not talking of one or two cracks, but wholesale cracking that impedes vision and has showered pilots and instrument panels with jagged pieces of shattered glass.

Cracked windscreen on an American Airlines B757 en route from Puerto Rico to Philadelphia, diverted to an emergency landing at West Palm Beach, FL, in 2008.

Cracked windscreen on an American Airlines B757 en route from Puerto Rico to Philadelphia, diverted to an emergency landing at West Palm Beach, FL, in 2008.

The FAA recounts 11 reports of smoke and fire from windscreen heaters. The most recent emergency landing resulting from this hazard occurred 16 May 2010 involved a United 757 at Dulles International Airport in Washington, DC.

Although replacement of the windscreen and heater controls is an alternative to the AD, which calls for inspection and repair on over 1,000 Boeing airliners, Continental Airlines notes that access to components requiring inspection is “atrocious.” Limited access, coupled to poor “view-ability” turns a simple task into a very difficult one requiring special tooling.

Given the redesign and tooling work necessary to yield a safer windscreen, one would think that replacement of the whole windscreen and associated electrical circuits would be more than justified. It appears that the original design was marginal from an inspection, maintenance and safety standpoint.

The FAA’s mandate to inspect, not replace, seems totally inappropriate given the cost of an emergency landing, or worse.

Note that the four examples cited here occurred within the last month. More examples for the same period could easily be produced. Add up the number of late, incomplete or token safety measures taken within a year and 50-100 such citations could be counted. Tote up the total over 5-10 years; the number of safety deficiencies is simply staggering.

What this reflects is a tolerance at the highest levels in the FAA for a regulatory torpor more seemly for Rip Van Winkle than for an aggressive regulatory agency with the mission of protecting the flying public. One wonders: does the FAA even recognize how slack and inept it appears?

Safety Research That Gathers Dust on Bookshelves Not Helpful

For a highly pertinent example of the Federal Aviation Administration (FAA) not following-up on its own research, look no further than its requirements for life preservers. I use life preservers as my prime example because, unlike avionics and other esoteric electro-mechanicals of airplanes, most people understand the problem of floating for extended periods in cold water.

Cold water is the key. Water saps the body’s heat at a much faster rate than cold air. With the body numb from cold, muscle coordination atrophies, the mind loses concentration – the will to live is sapped much quicker. In cold water, even if one’s head is kept above the waves, one can die from the cold even if the airway is free to breathe. And remember, many survivors of a ditching may be suffering from shock and trauma even before they grab a flotation aid and evacuate the sinking airliner. These people are doubly vulnerable to the effects of cold water.

Every seat cushion and life preserver on an airplane used for flotation must conform to the FAA’s Technical Standard Order, in this case TSO-C13f, issued in 1992, dealing with life preservers.

The TSO covers a great deal about the required preserver performance. Herewith, selected passages:

“This technical standard order (TSO) prescribes the minimum performance standards [emphasis added] that life preservers must meet …”

“This standard covers inflatable (Type I) and noninflatable (Type II) life preservers. Both Type I and Type II preservers are divided into the following four categories: Adult, Adult-Child, Child, and Infant-Small Child.”

“For coated fabrics used in the manufacture of inflation chambers, the maximum permeability to helium may not exceed 5 liters/square meter in 24 hours at 77 degrees F or its equivalent using hydrogen.”

“The force necessary to operate the mechanical inflation means may not exceed 15 pounds when applied through the pull cord.”

“(A)t least 75% of the total number of test subjects … can don the life preserver within 25 seconds unassisted, starting with the life preserver in its storage package …”

“After donning, inadvertent release by the wearer is not likely.”

The TSO lists the required color of the vest (international orange-yellow), the readability of instructions (a minimum viewing distance of 24 inches with illumination no greater than 0.05 foot-candle), and material properties (separation rate must be 2.0 to 2.5 inches/minute). Buoyancy, survivor locator light performance, and salt-spray standards are laid out in detail. Oh, and the preserver must be comfortable to wear in the water.

The TSO is absolutely silent on a critical matter: its aid in heat retention in cold water. A 1985 report by the FAA’s Civil Aeromedical Institute (Report No. DOT/FAA-AM-85-11) on the development of a better life preserver noted:

“If a life preserver provides a measure of thermal protection, not only are the chances of death caused by hypothermia decreased, but also the chances of death caused by drowning decrease.”

Citing a number of accidents where aircraft crashed into cold water, the FAA required research into a preserver that would not only keep the person afloat but would also “provide increased thermal protection in the event of accidental submersion in cold water.” This requirement was in addition to a donning time of 15 seconds, and all the buoyancy, marking and storage requirements of the existing TSO.

During water immersion, the body loses heat at about 26 times the rate it does in air. A close fitting life preserver was designed to minimize degradation of the body’s core temperature in the upper torso (most heat is lost from the trunk, not the limbs).

Test subjects, outfitted with rectal thermometers, were required to wear a prototype preserver in cold water, and a trial was also conducted with the standard life preserver found on airliners today. Pages and pages of graphs show that the prototype preserver retained about 50%-60% more body heat.

Based on rectal temperatures of subjects in 55 degree water, the report concluded:

“(T)he mean estimated predicted survival time was greater for subjects wearing the prototype life preserver than when the same subjects wore the standard PFD [personal flotation device].”

Note, this prototype preserver met all the other requirements for storage (in the same space), for buoyancy (35 pounds), for ease of donning (about 18 seconds), and so forth.

Note also that the improved life preserver report was produced in 1985, a good seven years before publication of the current TSO. Even the FAA apparently has forgotten about this report and its life-saving findings. It had no effect on the TSO or any other FAA requirements for life preserver effectiveness.

Basically, passengers today rely on either the seat cushion, with absolutely no thermal protection, or an obsolescent preserver that was not designed with heat retention as a basic function.

The improved design could be produced at about the same cost. Why was it not pushed by the FAA? One suspects industry resistance at the total cost – which could be absorbed through a multi-year program of fielding the improved model, estimated to cost about $35 apiece.

This is not the only case where the FAA has developed something that enhances safety that does not find its way into the airline fleet. In 1979 the FAA Technical Center published a report on its successful fuel tank inerting system. This 600-pound system displaced explosive fuel-air gasses in fuel tanks with inert nitrogen enriched air. The technology was tested in an FAA DC-9 airliner and passed all performance criteria with flying colors. The weight of the inerting system, we should note, was comparable to or less than the weight of many in-flight entertainment systems, which the airlines have aggressively deployed.

The FAA never mandated that this inerting system be installed on airliners. In 1996, TWA Flight 800, a B747, blew up when volatile vapors exploded in the plane’s center fuel tank. Now the FAA has ordered a less-capable inerting technology to be installed in all but the oldest airliners, and to get the job done by 2018 – fully 22 years after TWA 800 exploded. (See Aviation Safety Journal, August 2008, ‘Significant Regulatory & Related Activity’)

In light of all this, a couple pertinent questions arise. First, why does the FAA bother to explore new technologies or equipment if the results of its efforts just gather dust in obscure reports? Millions of dollars could be saved by closing down the Civil Aeromedical Institute and the Technical Center. This writer cannot think of a single technology or improvement that has been adopted as a result of the work at these subordinate agencies.

Second, if the Civil Aeromedical Institute and the Technical Center are going to be retained, and they continue to develop useful devices and techniques for the safety of the industry, there is an obviously related and relevant question: why isn’t there a link between the FAA’s development efforts and FAA requirements for implementation or adoption by the airline industry?

There is no evident linkage. In an FAA that touts safety as Job #1, advances to safety developed by the agency’s most committed and best minds seems to languish somewhere around Job #0.

The Chimera of Airline & Oil Drilling Industry Safety

At a Congressional hearing 15 June on the BP oil-drilling and ecological disaster in the Gulf of Mexico, a legislator declared that if the airline industry operated with the same sloppy standards as the oil industry – no functional blow out preventer, inadequate training of staff, failure of warning systems, history of less severe incidents where greater disaster was narrowly averted – no one would fly.

The lawmakers assailed the oil spill plans across the industry. Oil company executives representing Exxon Mobil, Chevron, ConocoPhillips, Shell Oil and BP looked on meekly as Congressmen charged their disaster response plans looked suspiciously alike, including references to nonexistent walruses in the Gulf of Mexico and a marine science expert who’d been dead for four years.

BP rig

The airline industry was held up as a model for the oil industry to emulate when it comes to safety.


One doubts many passengers (or Congressmen) are aware of the airline practice of operating an airplane for days with key safety equipment inoperative. Under the minimum equipment list (MEL), a weather radar, for example, can be inoperative for up to ten days and the airplane may still fly. For just about any safety system on the airplane, there is a grace period between when a system fails and when it must be repaired.

Worse, there is no upper limit on how many airplane systems can be inoperative under MEL and the airplane can still be dispatched for a passenger carrying flight. To put it rather technically, the set of all MEL outages is not enough to cancel a flight and get the airplane in for repairs.

A hearing with top airline executives to explore why the MEL was different for the same model airplane in service with two different airlines would be an interesting exercise in squirming and evasiveness.

The public’s enthusiasm to fly might be jolted by the obfuscations and self-serving rationales offered up by airline executives as to why maintenance procedures vary by airline..

The absence of key safety systems in the Deepwater Horizon blowout is similar to the MEL situation. The drillers were in a hurry (time pressure akin to schedule pressure in the airlines) so the decision was made to rush ahead without key safety systems (the equivalent of MEL).

One of these days, 80%-90% of MEL-excused items will combine into an airliner catastrophe.

It would be interesting to see the number of passengers refusing to fly if a green light/red light display were mounted on the cockpit bulkhead facing the boarding area in the cabin. The display would indicate the status of each MEL items, green for fully functional and red for inoperative. Imagine such a board with ten items, six of which have green lights on, four of which have red lights. How many passengers would continue to their seats? How many would raise questions? How many would turn around and get off the airplane?

Nor are passengers aware of the months or even years allowed under Federal Aviation Agency (FAA) practices to correct what are called “unsafe conditions,” which go far beyond MEL items. Under the airworthiness directive (AD) system, mandatory corrective action must be taken. AD’s cover everything from faulty checklist procedures to potential fuel vapor ignition sources, to windshield heater problems, to cracked engine parts, or anything else on the airplane where the FAA has determined that the problem poses an intolerable risk to the flying public. But the ADs are generous in the extreme in allowing airliners to operate with extant problems awaiting repair.

If the Minerals Management Service (MMS) has an equivalent to the AD process (doubtful, given its reputation for collusive coziness with the oil industry it “regulates”), compliance time may be as scandalously generous as that allowed by the FAA.

From the MEL the congressmen could look at maintenance, and ask why inspection and lubrication intervals were different for the same airplane at two carriers. Each airline has its maintenance program separately approved and inspected by the FAA. Recall the lubrication intervals approved for the elevator jackscrew on Alaska Airlines MD-80s, which meant the airplanes went years between lubrications. The crash of Alaska Flight 261 in January 2001 was the direct result of the failure to lubricate the jackscrew, which stripped its threads and failed. Subsequent inspection of other airlines’ MD-80 lubrication indicated that the largest fleet operator of MD-80’s, American Airlines, had rigorous lubrication schedules and procedures. American’s jackscrews were found to be in “like new” condition. But in the industry overall, the belated jackscrew maintenance inspections revealed that practices varied widely.

The “best practices” of one operator were not emulated by all. The FAA doctrine of “one level of safety” was compromised – a fiction, really – from the outset.

Similarly, the executives appearing before the House Energy and Commerce Committee hearing all outlined differing safety standards for oil drilling.

In neither the airline industry not the oil drilling industry are “best practices” adopted for application by all operators. Anarchy prevails, abetted by the government’s lax regulators.

The situation is worse for the oil drilling industry given the consequences. The FAA’s slack practices might result in an airliner or two crashing, but when the MMS fails to enforce regulations, the consequence is not only the 11 lives lost when the rig blew up, but hundreds of miles of coastland pollution, thousands of wildlife killed, and the deleterious effects of oil contamination persisting for decades.

A comment at “The Oil Drum” website (www.theoildrum.com/node/6543) specifically compares the oil drilling and airline industries:

“A cursory study of reports generated after the 1977 Ixtoc disaster, along with incident reports like the ones above. Lead me to believe that offshore drilling will always have a risk of catastrophic environmental failure. Saying otherwise is like saying commercial aviation aircraft will cease crashing to the ground tomorrow because we understand every possible failure and have the technology to counter every failure.

“The sad truth is the types of failures we face in offshore drilling are not completely understood. The list is certainly lengthy, but it is not complete. Surprises will happen. Usually, they are controllable and adjustments can be made in the future to compensate for them. That still leaves us with the analogy of the airliner falling from the sky. A single unanticipated failure, or a combination of failures, may have no solution. All aboard the airliner will die. Likewise, the well will leak for months.”

In the airline industry, unpleasant surprises are minimized (not eliminated) by analysis of potentially fatal combinations. The process is called “failure modes effects analysis” (FMEA). In the airline industry, these analyses are supposed to demonstrate that the probability of catastrophe is one in a billion. Virtually no airplanes in service live up to this standard, but one in 100 million has been demonstrated. Mechanical failure, human error, unforeseen environmental effects, and other real-world factors combine to yield a lower safety standard, but we start from a theoretical of one in a billion flight hours.

The oil drilling industry starts from a lower threshold: one in a million. When real world shortcomings reduce the standard further, the result is the history of lesser breaks, mechanical failures, and human confusion that preceded the Deepwater Horizon mega-blowout. That sad and scary history is fully documented at the website above.

The higher one in a billion standard might prompt the following to be examined:

The shear in the blowout preventer (BOP) is the last line of defense, physically cutting the drill pipe. It was not truly fail-safe. Just like critical flight controls feature two or three actuators, why weren’t there at least two functional shears? If one failed, the other would cut the riser. The comforting statistics caught up with the Deepwater Horizon, just like they did in the case of B737 rudder reversals, where a history of a hundred or more events finally culminated in a fatal crash. And that was with a one in a billion probability.

There are reports of low batteries (might not operate valves), questionable accumulator pressure (not sufficient to operate rams), and other alterations that were not fully documented. My bet is that when all mechanical failures are accounted for, the “on paper” risk of an uncontained blowout was not one in a million, but closer to one in a hundred or even one on ten.

Then there are contributing factors that should be familiar to airline industry accident investigators:

Inadequate training of staff for them to properly undertake the risks of their actions. This observation applies not only to the oil drilling industry, but to the regional airline industry, where accidents have resulted from poorly trained pilots.

The corruption of data in one incident caused the drilling rig to get invalid information about where it should be, causing it to move. Recall the corrupted airspeed data on Air France Flight 447, resulting in the airplane flying too fast in the “coffin corner” of the maneuvering envelope, going out of control and crashing into the Atlantic. Added automation can increase safety, but not when the automation is fed bum data. The automation can then become a killer.

The failure of warning systems (lights, etc.) that aren’t noticed when things are working normally, but which can bite when something actually does go wrong.

It is readily apparent that the BP blow-out resulted in short cuts – from design to operations – with little pretense of any risk avoidance whatsoever. Similar short cuts and their disastrous consequences have been seen in the airline industry.

The risks need to be assessed against the one in a billion probability of cascading failure, based on incidents and operational experience – not rosy, comforting assumptions about mechanical and human reliability. This observation applies to both the airline industry and the offshore oil drilling enterprise.

And the “best practices” identified at one operator need to be adopted by all operators. That’s where the federal regulators come in; they should force recalcitrant operators to adopt them or face termination of the federally issued operating license.

Former chairman Jim Hall of the National Transportation Safety Board was asked to comment on the lack of common “best practices” in both the airline and the offshore oil drilling industries. He offered a mouthful, but on close reading his comment is eminently sensible:

“With the increased dependency on technology and the many inter-related systems, the Federal Government needs to move from a regulatory structure of minimum standards to a structure of ‘best practices’ policed by independent investigative bodies with a more robust role in defining the best practices.”

The FAA and the MMS are capable of realistically defining the one in a billion safety calculation, and they are in a position to define and require the best practices that can support the realization of good operational safety. Neither agency currently demands these things to minimize the risk of catastrophe.

Definition of Professionalism Not Coming Anytime Soon

Greater “professionalism” is badly needed in the airline industry, but no one person or organization seems to have defined it succinctly yet broadly to capture the qualities needed. That much is evident from a 2½ day forum on the subject of pilot and air traffic controller professionalism held 18-20 May by the National Transportation Safety Board (NTSB). It may be quite feasible to define the term, but the Federal Aviation Administration (FAA) is not likely to embrace it in regulations, as such action would put the FAA’s own culture and practices on the spot.

The NTSB held the forum because of findings over the past few years of lapses in both pilots and controllers of standards one could expect of professed professionals. Pilots have been found violating the sterile cockpit rule with excessive and distracting chit-chat, in some cases contributing to fatal accidents. Controllers have been found talking on the telephone about personal business while disaster unfolded on their radar screens. Air traffic control is often about timely intervention –which necessitates are solid awareness not based on assumptions. If a pilot is told to do something, the healthy controller attitude is first to assume that he might not, perhaps because the pilot has misunderstood or is pressured, fatigued or distracted. Reliably detecting airborne errors is the signature theme of a professional controller. It demonstrates a level of maturity that comes with experience, and it’s an ingrained attitude that is a good example for junior controllers. After all, effective on-the-job training of junior controller is fundamentally reliant upon establishing norms and teaching precedents.


At the forum, about 40 different presenters offered about as many different perspectives on the term “professional.” Here is a representative smattering:

“Professionalism means recognizing the public trust and SOP [standard operating procedures] adherence.”

“Professionalism is a series of traits that focus on outcomes and are consistent with the values of the organization.”

“Professionalism is how you do the work, whether you’re following SOPs all the time.”

“Professionalism is an outgrowth of commitment, knowledge, discipline, passion and judgment.”

“An aviation professional consistently exceeds minimum standards, continuously improves, and helps others to do so.”

“A professional pilot possesses the physical, mental and emotional attributes to do the right thing – because it is the right thing to do.”


Discourse along these lines clearly frustrated the NTSB. Member Robert Sumwalt expressed his reaction thusly: “Right now, professionalism is this glob that we can’t put our hands around.”

Chairman Deborah Hersman put the matter more diplomatically, but pointedly:

“One thing that strikes me is that defining professionalism is somewhat elusive. We heard a number of panel members say that they can see it in actions; the difficult part that remains is defining professionalism and creating a culture of professionalism at all levels.”

It is possible to come up with a definition that is broad yet specific, and that captures both the detailed job performance and the general standards expected of employees. Herewith, a working definition:

“A professional individual is technically competent, an ethical exemplar, with presence of mind and strength of character in difficult circumstances, working within a structured top-down culture where safe operations and mutual trust are paramount, whom we would want all others to emulate.”

This definition covers a lot more than just activities in the cockpit or airport tower and associated air traffic control facilities (e.g., en route control centers). This definition covers the flight line, the corporate offices, and the individual’s personality and personal appearance. Why appearance? Because appearance not only influences third party perceptions – the travelling public – it adds to the aura of command and solicits respect. There is a reason for the pilot’s uniform being modeled after that of a naval officer.

“Technically competent” means more than just adherence to SOPs in the cockpit or control center. It means not only knowledge of them and adherence to them, but the degree to which these SOPs are executed. Are the radio readbacks prompt, clear and precise, for example.

“Presence of mind” is a term used to convey the ability to focus and keep a cool head in extreme circumstances. For instance, Capt. Chesley Sullenberger and First Officer Jeffrey Skiles, the two pilots who successfully ditched their US Airways A320 in the Hudson River, had presence of mind; both were outwardly cool, focusing on options and procedures and keeping their emotions in check. They had “presence of mind.” Then there’s Captain Marvin Renslow and First Officer Rebecca Shaw, who allowed their Colgan Air Dash 8-Q400 twin-turboprop to stall on approach, and then applied grossly incorrect procedures after being panicked by the sudden departure from controlled flight. They didn’t have “presence of mind” and unfortunately let the stun-power of surprise kill themselves and 47 others aboard.

“Strength of character” refers to the ability to maintain one’s position in the face of contrary pressures. For example, insisting on the highest standards of safety in the face of corporate pressure to fly with only minimal safety margins.

“Mutual trust” means more than just a junior/senior relationship in the airline or in the air traffic organization. It means management has the self confidence to listen to an employee, and the employee feels free to state his position without fear of retribution.

“We want all others to emulate” covers the employees communication skills, pleasant personality, personal appearance and other aspects of performance that are worthy of copying. For instance, casual swearing or comments loaded with sexual innuendo are immature and destructive of morale. A pilot with bad breath or a fat, sloppy personal appearance is not the image one wants to project to the public. It isn’t necessary to be a rail-thin moralist, but the airline has a right to expect and enforce an image of pride and competence. Beyond image, there are the unseen background factors in which professionalism is rooted: a code of conduct, integrity, and high ethics.

The hard part is getting the FAA to give this suggested definition, or any other, the force of regulation. That would require floating the proposal to industry as a proposed regulation. The airlines are likely to respond that the FAA should stick to matters of aviation, per its congressionally mandated charter. If there were to be any costs to the industry associated with this definition, expect strong airline resistance in these tough economic times.

But if this definition were propounded in a nonbinding advisory circular (AC), such objections could not hold sway. An advisory circular is a form of articulating optional “best practices” – albeit normally of a quite technical nature.

There are identifiable problems with the FAA publishing an AC: such a document might be perceived by the FAA rank and file as an abject exercise in hypocrisy. There is virtually nil protection against retribution for those in the FAA who speak out about shoddy practices in airline operations, about hastened and pressured efforts to certify new aircraft designs, about the FAA’s reluctance to engage air traffic controllers in assessing new equipment technologies, low morale at the agency, etc. The top-down fealty to safety in an atmosphere of mutual trust is lacking in the FAA. For the agency to propound such “professionalism” for all others while its own house is in unhappy disorder will be seen as an example of “do what I say, not what I do.”

There is also the conundrum of whether the AC could be utilized by employers – government or industry – as a basis for remediation or dismissal. Pervert the exalted intent of a helpful definition and it could become the basis of demonstrable abuse. Professionalism has leverage only so long as it’s not “in disrepute” as a flogging tool (As in “the floggings will continue until morale improves”). In some contexts, professionalism, as with virtue, has to remain the great unspoken.

The NTSB, though, has been evaluated by employees as one of the best places to work in government. Why, the NTSB scores so well this matter is covered on its website under the heading “The Best Place to Work in the Federal Government 2009.” There is not a comparable box on the FAA’s website, for an obvious reason – the FAA rates near the bottom in terms of employee satisfaction. The NTSB scores above 75 and is improving. The FAA scores a dismal 49 and is getting worse.

When the FAA rises in the eyes of its employees to a similar level as the NTSB, it may be time to publish an AC on professionalism. Or perhaps it could issue a coda. A coda is a theme or motif, often a summation of preceding dictums and/or an underlying sentiment. Professionalism may be best seen as a postscript that essentially states the overlaid (yet underlying) goal of achieving “the best that you can be.”

In whatever form, the aviation industry demonstrably needs some guidance on professionalism, but the FAA will first have to address and redress the cultural dysfunction in its own house. It may ultimately prove to be one vital area in which the NTSB can go beyond its limited charter and pleading recommendations – setting standards by the unsubtle reproof of sterling example.

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