ANALYSIS: Controller Error & NMAC at Houston [KIAH], on 5/8/2014

A small error by an FAA controller at Houston Intercontinental Airport caused two United departures to converge in low clouds, producing a near-midair collision. The USAtoday news video below gives a good overview, with some audio.

…for the ATC analysis, please see page two of this aiR Post…

Helicopters: the Wrong Way to see Grand Canyon

Five days ago, a pilot employed by Papillon was killed when his/her helicopter rolled over while being repositioned on the floor of Grand Canyon. [article] The air tour passengers had already been off-loaded, so none of them were injured when the fatal accident happened. In the five days since, there has been no new information; neither FAA nor NTSB has released the gender, age or name of the pilot, nor have any weather conditions or other pertinent facts been presented to the Public. We are left to wonder why this tragedy happened, and could it happen again.

There have been many fatal air tour crashes around Grand Canyon. In fact, a careful analysis of news stories and the NTSB accident database reveals thirty significant accidents since 1980, some fatal and some non-fatal. A few were horrific, killing six, ten, and as many as twenty-five. Even the minor accidents hint at air tour practices that add unnecessary risk:

  • crowding too many helicopters together at remote landing spots,
  • parking helicopters too close to picnic tables,
  • worker fatigue, due to long workdays for the pilots and mechanics,
  • lack of maintenance oversight,
  • lack of FAA safety oversight, etc.

Here is a link to a list with short summaries for each of the thirty accidents. Each dated event has further links to online news articles and NTSB reports.

Passenger photo taken minutes prior to the 9/20/2003 crash. (NTSB)

Passenger photo taken minutes prior to the 9/20/2003 crash that killed seven. Analysis of this and other photos showed reckless flying and endangerment by the pilot. (source: NTSB Report)

One accident that really stands out happened in August 2001. A tour group from New York filled twelve seats in two Papillon helicopters. The flights had flown outbound from Las Vegas, spent around an hour in the canyon area, and they had taken off from Grand Canyon West Airport for the flight back to Las Vegas. Just a few miles west of their last departure point, the helicopters crossed Grand Wash Cliffs at roughly 5,500 feet, then quickly descended a thousand feet into the space below the tall cliffs. One of the helicopters crashed, and six were killed. The one survivor lost her husband and both legs, and eventually won a $38 Million settlement. A subsequent NTSB report noted there were no local recorded weather observations. In fact, the nearest official weather reporting station is nearly fifty miles south of Grand Canyon West Airport, and is not adjacent to the canyon; the only known weather fact is that it was a very hot day, around 106 degrees Fahrenheit.

The NTSB compiled a detailed investigative report, which included the following insight into the helicopter air tour industry:

  • Investigators interviewed many, including the Papillon manager at the South Rim (Tusayan), who told NTSB: “The mechanics said that Kevin was the only pilot that they felt comfortable with on test flights.” (underline emphasis added)
  • The report suggested that pilots may be motivated to add more ‘thrill’ to the flight to earn larger tips.
  • One passenger from an earlier air tour flight with the same pilot shared her concerns, and backed them up with a copy of her air tour video. She described what air tour pilots call the ‘Thelma & Louise Descent’, in which the pilot crests low over the top of a ridge, then dives into the empty space on the other side. In her testimony, the passenger said her pilot did the ‘Thelma & Louise Descent’ at Grand Wash Cliffs, a classic location for this maneuver. She testified the pilot asked them if they wanted to do the descent, and they all said ‘no’, yet he did it anyway.

There are many professional aviators who have no love for those who make money using aircraft as a form of ‘thrill ride’. For example, the Sundance helicopter pilot who crashed into a canyon wall in September 2003 (killing all seven on board) was known by the name ‘Kamikaze’, and pilots interviewed in that NTSB investigation expressed many concerns about his long history of risk-taking. There is even an online pilot discussion, where a British tourist seeks feedback, with the title: Helicopter over Grand Canyon – which company won’t kill me?

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Grand Canyon is an extraordinary place, but it is certainly not an appropriate venue for aerial thrill rides. We can only hope that the latest tragic fatality will precipitate reform and bring an end to this dangerous form of flying.
GCNP Grandview Trail hike pic

What should YOU do if you are coming to Grand Canyon?

One of the facts gleaned while reviewing more than thirty years of air tour accidents is that very many of the fatalities are from Asia, Europe, and other parts of the world. It appears that Grand Canyon vacations are planned to be very special trips. It also appears these tourists may have been sold the idea that an air tour is necessary to experience Grand Canyon.

In fact, this is completely wrong. Just your first view of Grand Canyon will amaze you.

And, frankly, the helicopter ride is thrilling and scary when you first take off, but after that it is mostly just a lot of monotonous flying. And the noise you have to hear while crammed in the helicopter cabin…? Yeah, all air tour passengers are issued headsets, to help block out the loud noise. Too bad for those in the park below, as the ‘thump-thump-thump’ noise carries everywhere, for many miles.

So, please DO NOT book an air tour before you embark on your vacation. Please wait until AFTER you arrive and see the place, to confirm if you really want to give so much of your money to an air tour operator. And even then, please ask yourself one more time, ‘do I really want to make this noise that diminishes the experience for so many other visitors?’

GettingAroundGCNPMake it your first priority to stand at the edge of the Canyon and see how incredible it is, right there. Then, check with the Grand Canyon National Park maps and just walk some of the miles of flat rim trails (or hike below the rim, if you are more adventurous). The views will amaze you. Ride the free shuttle buses, and get out and find your own quiet vista point while enjoying the sunshine and fresh air. Spend a few bucks and enjoy tea or a beer or a pleasant meal at a lodge on the South Rim, while gazing at the view. The experience is so much more rewarding without the noisy helicopter, the stuffy cabin air, and the bouts of flight-induced nausea.

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…if you would like a quick video tour, please see page two of this
Post, which has embedded links to four different videos….

ANALYSIS: Controller Error & NMAC at Newark, on 4/24/2014

20140424.. KEWR VFR sectionalThe departure was ASQ4100 (ExpressJet, callsign ‘Acey’); arrival was UAL1243 (callsign ‘United’). NTSB’s preliminary report, released on 5/15/2014, says the two flights passed at approximately 160 feet lateral and 400 feet vertical separation.

Here’s the scenario: with strong northwest winds and one of the parallel runways closed at Newark, FAA’s tower set up departures northbound off Runway 4R and arrivals westbound onto Runway 29. TRACON was using the Bridge Visual Approach to sequence arrivals inbound from southeast of the airport. That routing has the flights crossing the Bayonne Bridge at a fix named LAWNE, and the chart instructs all flights to proceed “…to the west end of the Bayonne Golf Course (then) turn left and proceed to cross CHUMR (the NJ Turnpike Bridge) at 500 feet.”

KEWR.. portion of Bridge Visual RY29 after Bayonne BridgeAt the time, winds were exceptionally strong, at 20-25 knots. This tends to mess up timing for the controller trying to launch Runway 4R departures through holes in the Runway 29 arrival sequence. On top of that, arriving pilots tend to bend the rules on the Bridge Visual Approach; they turn left early and thus compress onto the previous arrival. With enough arrival compression, the hole is no longer wide enough to time a departure … but the tower controller may not accurately judge this problem, especially in strong wind conditions.

20140424.. UAL1243 KEWR.apdgAnd so, the near midair happened when ATC launched a departure (green arrow) in front of an arrival (red arrow). ATC audio recordings indicate the conflict was identified at the last second, causing the departure to tip the nose down and stay under the arrival, which was proceeding to abort their cleared landing. Thanks to online aviation websites, the details of this near midair collision are accessible to passengers and the general public.

Fundamentally, the problem that leads to near-collisions like this is the over-scheduling at super-Hub airports like KEWR. FAA proves yet again they lack the will to apply their supreme authority to run a safe system. They let airlines like UAL-COA schedule way beyond the practical safe limits, then just shove it upon the controllers to deal with it and keep it flowing, when runway projects force a normal parallel runway operation to become a dicey crossing-runway operation. All it takes is for the controller to fail to see one arrival while timing the departure, as happened here. This is a systemic problem within an agency that horribly misapplies its abundant resources. FAA places too much effort into shutting down low altitude UAV’s, beating up its few remaining Whistleblowers, PR’ing the facts to hide their many failures and coddling congressional animals (to enable their perpetual reelections). More often than not, FAA’s efforts toward safety are just for show.

For further data and analysis, see page two of this Post…

ANALYSIS: Controller Error & NMAC, east of Kona, on 4/25/2014

UPDATED, 5/19/2014…
When this article was originally Posted by aiREFORM, on 5/17 (22-days after the near-collision), FAA was still not sharing information. New information has since been released anonymously. It identifies the conflicting flight as USAir Flight #432, westbound at 33,000 feet. Details are updated below.

On Friday April 25, at approximately 4:16PM Pacific time, the pilot of an eastbound United B757 abruptly descended to avoid a westbound USAirways B757, northeast of Kona, Hawaii. The United flight (UAL1205) was heading from Kona to LAX; it had leveled at 33,000 feet and was established on the oceanic route R578, roughly 200 miles northeast of Kona. Two U.S. Airways flights were enroute westbound, thus nose-to-nose with the United flight. One was USAir663, from Phoenix to Kona, at 34,000 feet; the other was USAir432, from Phoenix to Maui, at 33,000 feet. All flights were tracking along the same oceanic route R578.

An account of this incident was posted online by Kevin Townsend. He notes that some passengers screamed when they experienced the sudden maneuver, and a flight attendant soon came over the intercom with, “the pilot took evasive action to avoid an aircraft in our flight path.” Then, to settle rattled nerves (and distract the passengers), she announced a few minutes later: “Aloha! United Airlines will be offering today’s DirecTV entertainment free of charge. Anyone who has already purchased in-flight entertainment will receive a reimbursement on their credit card.”

It turns out Mr. Townsend is a writer, based in San Francisco, who happened to be returning that Friday from a Hawaiian vacation. He is also a bit persistent and adept at online research and contacting FAA and airline officials, and from this he wrote an article. His article is an interesting read, but also a bit disturbing because he documents that, when he contacted FAA officials, they generally blew him off. It was weeks later before FAA initiated an investigation — and that delay may have allowed ATC audio tapes and other hard evidence to be destroyed. So much for accountability.

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For an analysis of this incident, including flight data and aviation charts,
please see page two of this aiREFORM Post.

An Unusual Midair Collision

Photo source: Tim Telford, via Polk County Sheriff’s Office

On Saturday, March 8, a Cessna was flying touch-and-goes at the South Lakeland Airport [X49]. On his third pass, the 87-year-old Cessna pilot  snagged a parachute. The collision dragged    the parachutist through the air, and caused the Cessna to turn 180-degrees right then nosedive to a hard landing. Both the pilot and the 49-year-old parachutist were taken to the hospital. The parachutist was treated and released, while the pilot was held longer for observation. The accident happened on the U.S. Parachute Association’s ‘Skydiving Safety Day’. USPA reports that in 2013 there were 24 parachute fatalities in the U.S.

Aviation vs. Railroads: Why is FAA so much slower than FRA to address personal electronics distractions?

Last week, FAA posted in the Federal Register their Final Rule, Prohibition on Personal Use of Electronic Devices on the Flight Deck. Essentially, the new rule declares the obvious … that texting (or computer games or sharing pictures of your cute kids or porn files or whatever) is dangerous, distracting, and must cease immediately …or at least once the rule goes into effect on 4/14/14.

A discussion then developed at FlightAware.com. While most of the discussion participants were pilots and all had a keen interest in aviation, some of the participants were U.S. railroad professionals. They made a very interesting point: specifically, that very similar accident histories have produced very different outcomes by the Federal Railroad Administration (FRA) vs. the Federal Aviation Administration (FAA).

In short, here is the comparison:

Rescue workers in front of the Metrolink locomotive lying on its side after penetrating the lead passenger car (left). (photo from Wiki)

FRA: On 9/12/08, a head-on collision at Chatsworth, CA killed 25, injured 135, and caused $7.1 Million in damages. The NTSB investigation revealed the locomotive engineer was texting and missed a safety signal. Twenty months later, on 5/18/10, FRA issued an NPRM rule proposal via the Federal Register. Fifteen comments were received. The Final Rule was posted to the Federal Register on 9/27/10, and went into effect on 3/27/11.

Thus, for an FRA rail safety failure related to a major accident, it took thirty months from accident to effective rule change.

FAA: On 8/27/06, Comair Flight 5191 took off from the wrong runway at Lexington, KY, then crashed, killing 49. The tower controller had failed to specify the runway and the pilots, evidently fatigued from a short night’s sleep, failed to notice they were on the wrong runway. The controller had nearly a full minute to look out the window and see the problem and ‘save’ the situation with a timely radio transmission. The tower controller failed and the accident happened. Seventy-seven months later (!!), on 1/15/13, FAA issued an NPRM rule proposal via the Federal Register. Sixty-three comments were received. The Final Rule was posted to the Federal Register on 2/12/14, and will go into effect on 4/14/14.

Thus, for an FAA aviation safety failure related to a major accident, it took ninety-two months from accident to effective rule change. Ninety-two months; yes, nearly eight years!

So, in summary, a railroad safety rule by FRA takes 30-months, while an essentially identical aviation safety rule by FAA takes 92-months.

Why does it take FAA so much longer to pass the new safety rules? Most likely, the delay is directly related to FAA (and industry) efforts to protect their financial bottom line: mistakes happen, people die, and those who might have saved the tragedy feel compelled to obscure their culpability, to protect their own interests. So, they maneuver to maximize distance from any risk/liability exposure. In other words, a conscious effort is made by aviation professionals — including some very highly paid FAA officials — to guarantee no accountability for system failures.

ATO’s COO David Grizzle Announces he plans to Leave in December

This is a MULTI-PAGE post — click on the page numbers at the bottom of each page

Part One: The Announcement

Dave Grizzle pic, speaking at podium
The number one person in charge of air traffic control at FAA is the COO, Mr. David Grizzle. Within FAA he is also known as ATO-1.

On Tuesday, August 13th, it was announced that Mr. Grizzle will be retiring his position in December, and returning to work in the private sector. Here is the email announcement by his boss, FAA Administrator Michael Huerta: (highlights added)

From: Michael Huerta
Sent: 08/13/2013 10:24 AM EDT

Subject: Personnel Announcement

Dear Colleagues –

I wanted to let you know that David Grizzle has announced he will leave his position as Chief Operating Officer of the Air Traffic Organization this December. This is a loss not only for the ATO but for the agency as a whole. David’s bold and innovative leadership style has helped lead the ATO through a number of very challenging situations. His deep commitment to changing our agency’s culture and fostering collaboration has created real change here at the FAA – change that will last for years to come.

David has served the FAA and this Administration in a number of capacities. Before he took on the role of COO he was our Chief Counsel and also wore the Acting Deputy Administrator hat for a time.

We are grateful for David’s service and wish him the best as he returns to the private sector next year. He will also finally have more time with his family and his farm down in Virginia which I know he loves and has missed over the last several years. On a personal note, I will miss working with David on a daily basis. I have come to rely on his counsel and I truly value his unique approach to issues.

Over the next several months we will be working to find David’s successor and as we do, I know the ATO’s strong team will continue to operate our nation’s airspace system safely and efficiently.

Please join me in thanking David for his service and commitment to our shared safety mission.

…and here is a copy of the News Release by NATCA: (highlights added)

NATCA Statement on News That FAA ATO COO David Grizzle Will Leave Position
Tuesday, August 13, 2013
Contact: Doug Church, 301-346-8245

WASHINGTON – NATCA President Paul Rinaldi released the following statement, responding to the announcement today that David Grizzle will leave his position as Chief Operating Officer of the FAA’s Air Traffic Organization this December.

“Throughout David Grizzle’s tenure at the ATO, we worked together to strengthen the NATCA-FAA collaborative relationship. That has resulted in many successes, from modernization to labor relations, which have helped continue to make our National Airspace System the world’s safest and most efficient. Our relationship has also established a model in the federal government for labor-management partnership, and improved the workplaces where the safety professionals that NATCA represents can do the jobs they love while having their input and expertise valued in a shared NATCA-FAA mission of ensuring aviation safety.

“NextGen is happening now and that’s a credit to the progress made by NATCA and the FAA in working with David. We’ve also grown our safety reporting systems, including the Air Traffic Safety Action Program, to move toward a true safety culture at the FAA. We thank David for his contributions.”

There is more to the story. Much more.

First, there is an interesting person at the heart of this story. And, second, this person has an opportunity to greatly serve aviation AND the larger Public, by responsibly acting with resolve and intention … during his final months as ATO-1.

MULTI-PAGE: …Part Two begins on the next page (click below)…