What Is FAA Hiding from the Public? And Why??

FAA, like many federal agencies, has a nasty habit of expending lots of time and money working to keep the people in the dark. They are supposed to comply with FOIA laws, but instead they redact the hell out of what should be disclosed. Making matters worse, in recent decades it seems as though most in Congress are ‘too busy’ and/or ‘too inert’ to force FAA to follow the FOIA laws.

Every once in a while, we get a great chance to look past these barriers. Sometimes, FAA’s redactions become unmasked. When that happens, it is like sitting down with the devil, and sharing tea and a candid conversation. So much can be learned….

In this Post, a 27-page FAA memo is offered in two forms, redacted and unredacted. This memo documents how a safety investigation produced copious details and a strong recommendation for corrective action … which was then nixed by a higher FAA official. The heavily redacted copy was provided to an investigative report team. Seeing that so much data was hidden, they filed an appeal. An appeal response letter was eventually sent, rejecting the appeal, but somehow a copy of the unredacted 27-page was included in the appeal response letter.

Here are the two versions, presented as scrollable/downloadable/searchable PDFs. View them side-by-side. See for yourself what FAA chose to redact, when a reporter team tried to help the public understand how FAA was handling a dangerous safety failure involving commercial aircraft maintenance.

Click on the image below for a scrollable view. This is the heavily unredacted version, as initially sent by FAA (and after extensive review by numerous FAA managers). Click here to download the PDF file.

Click on the image below for a scrollable view. This is the full, unredacted version. Click here to download the PDF file.

The Background:

A few days ago, an aiREFORM Post encouraged readers to read the excellent investigative series done by the Tampa Bay Times. In the third article of the series, Nathaniel Lash showed how higher level FAA managers were over-riding the conclusions and recommendations of their field inspectors. The inspectors were investigating how a nut had detached causing an elevator jam, forcing an Allegiant MD80 to do a high-speed aborted takeoff at Las Vegas. This was an extremely serious situation that would have assuredly killed everyone on board, if the nut had failed while actually airborne. A similar failure caused the 1/31/2000 crash of Alaska 261, an MD83 that lost flight control near Santa Barbara and plunged into the Pacific, killing all 88 on board.

The similarities are in two troubling areas:

  1. the casual failure by maintenance crews to properly execute their tasks and to follow needed steps that would identify and fix failures (so as to ensure nuts do not fall off leading to catastrophic crashes); and,
  2. FAA’s gross failure at safety oversight, where key FAA officials knowingly allow maintenance crews to sidestep required procedures.

The latest Times article showed that FAA was found to be covering up dangerous maintenance failures performed by AAR on the Allegiant passenger jet. Note that AAR is a Maintenance, Repair and Overhaul (MRO) operation; over the past decade, airlines have been reducing labor costs related to employing their own mechanics by increasingly outsourcing aircraft maintenance to MRO contractors. Costs may go down, but so do safety margins.

An Outstanding Investigative Series on Allegiant Failures and FAA Hiding Those Safety Issues From the Public

If you are increasingly concerned that FAA appears to be just a hack, a faux-regulator that does not really serve the people but instead enables the industry … you need to read these articles.

If you have felt yourself doubting the veracity of an FAA high official, as they spew glowing pro-NextGen claims while dodging the enormous failures and impacts (like David Suomi, at the Port of Seattle on 4/25/2016; to see the video, click here, then select the April ‘video’ tab, and ‘Item 3c – Briefing’ under the 4/25 meeting) … well, you need to take a look at these articles.

This is where agency corruption goes beyond being an annoyance, to become downright dangerous.

When the Nut is Not Secured…

This photo was shot during an investigation after an Allegiant MD80 was forced to do a high speed aborted takeoff. The castellated nut at the center of the photo has a twisted safety wire, to prevent the nut from detaching. The near-accident was caused by failure to secure the nut, creating a jammed elevator.

Despite FAA and industry efforts to confuse us all, this is not rocket science.

Given the speed and power in aviation, it is absolutely critical that parts not ‘come apart’ while operating.

So, what happens when aircraft mechanics fail to include a cotter pin or safety wire, as in the photo at right? Well, in this example, a hundred or so aircraft occupants are damned lucky they did not end up dead in a post-impact fire in Las Vegas. What exactly happened? While accelerating for takeoff, the nose lifted up on its own and the crew suddenly discovered they had zero elevator control. They cut the power to bring the nose back down and, luckily, had enough runway remaining to come to a safe stop and taxi back to the gate.

…Safety Eventually Breaks Down

This particular incident has far bigger repercussions. It was one of many incidents that caught the attention of Nathaniel Lash and other reporters, who did an outstanding investigative series, published by the Tampa Bay Times. Here are links to archived PDF copies of the three articles:

The third piece just came out, and it includes an interesting twist. It appears that FOIA was used, and that FAA heavily redacted their response documents. A formal appeal was filed and, eventually, an appeal response letter was sent back by FAA, denying the request to reveal the redactions. BUT… a fully unredacted copy was enclosed with the appeal response! So, now we can see what FAA chose to initially redact (which itself can be extremely revealing).

Was the fully unredacted report enclosed by accident? Maybe, maybe not. Perhaps it was enclosed by someone who had seen too much. FAA employees are real people, often feeling trapped in a corrupt and soulless bureaucracy, and silenced by the fear of losing their paycheck. Sometimes real people become sick and tired of all the lying and propaganda, and feel it is their duty to bypass the corrupt intentions of higher FAA officials; sometimes they make little ‘mistakes’ with big consequences. Lucky for all of us, not all FAA employees are afraid of the agency’s ‘culture of fear’. Some really do blow the whistle, and sometimes they do this in very subtle ways.

Also, for those who really want to dive deep, check out the 27-page unredacted report.

FOIA Failures Are Rampant, by FAA & Other Agencies

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FOIA Failures Are Rampant, by FAA & Other Agencies

Recent news stories, including this one about an ATC-zero incident at Midway [KMDW] in early June, continue to point to the fact that FAA is knowingly snubbing their responsibility to be open and transparent. They are blowing off the FOIA laws. This is not a problem specific only to FAA; it appears to be rampant, at many if not all federal agencies. It is an attitude of arrogance and indifference, with the potential to eventually destroy the credibility and functioning of our entire government.

To his credit, President Obama started his administration with an absolutely glowing declaration about the importance of FOIA. To his discredit, his administration has utterly failed to live up to that declaration ever since. This again goes to attitude: the attitude set at the top enables the attitudes that set in below, at the agencies.

QUOTE

“…The Committee investigation revealed the vast chasm between President Obama’s promises of openness and accountability and the day-to-day management of DHS’s FOIA function by the Secretary’s political staff. The actions exposed in this report highlight not only the Administration’s failures to properly comply with FOIA statutes, but they disclose a concerted effort by DHS political staff to actively thwart a congressional investigation, hide abusive and embarrassing official behavior, and avoid both the shame of public scrutiny and potential criminal prosecution…..”

– Executive Summary, ‘A New Era of Openness?’

For insight into the extent of these FOIA failures, click here to read the full 153-page Staff Report, compiled two years into the Obama administration, after a House Committee on Oversight and Government Reform Hearing about DHS FOIA failures.

Ten Years Later: FAA’s Pattern of Concealment After the Comair 5191 Crash

Among the greatest lessons learned from this year’s democratic party primary debacle was the complicity of the mainstream media in aiding corrupt party officials. Those leaked DNC Emails – nearly 20,000 emails total! – showed an incredible level of collusion between DNC officials (unapologetically hell-bent on defeating Bernie Sanders and nominating Hillary Clinton) and the mainstream media players (also corrupted, hell-bent in their lust for campaign advertising dollars).

Just to be clear, this was NOT a lesson about solely the democratic party; no, this was a lesson about the troubling reality of U.S. politics today… that We The People are being manipulated by the two dominant parties, using tools of propaganda. This is being called ‘engineered consent’ and, yes, this manipulation is being done by both oppressing political parties. In the process, the reigning duopoly that serves up ‘lesser-of-two-evil’ choices each cycle, has all but destroyed our so-called Democracy.

One critical tool of this manipulation is in the repetitive framing and reframing of so-called facts to crystallize acceptance of a historical perspective that fits the needs of the established political powers. We see this in politics, and we see it outside politics in retrospective news stories, for example. One of those retrospectives just happened again: the ten year anniversary of the horrific crash in Lexington, of Comair 5191. Here is a PDF copy:

Click on the image below for a scrollable view; the PDF file may be downloaded; or click here to view original source article.

If you read the article and research other U.S. aviation disasters, a clear pattern emerges: FAA’s response consistently is to hide disclosable information, obscure employee/management accountability, obstruct any proposal that would cost money, and delay-delay-delay on what few reforms are eventually emplaced. See for example the 10-year restrospective on the ValuJet Everglades crash in 1996, opined by FAA Whistleblower Gabe Bruno.

A few analysis points about the Comair/Lexington accident:

  1. FAA’s failures surrounding the Lexington crash were many. Not just the chain of seemingly tiny failures that led to the fatalities, but also the many, MANY efforts since to distort facts and reject long overdue safety and culture reforms.
  2. the principle cause of this accident was fatigue, for both the flight crew and the air traffic controller. This was perhaps the most important fact revealed by the extensive NTSB investigation. Cost-cutting by both the airlines and the FAA contributed to a combination of fatigued personnel that led to a chain-reaction of inattention, costing 49 lives.
  3. this accident should never have happened. The same combination of fatigue (in both the control tower and on the flight deck) had occurred over and over again, and continues to occur even today. BUT, the fact that aviation professionals can and will become bored/inattentive/fatigued is a given, and a key part of why so many redundancies are built into the aviation safety system. When simple redundancies – like, re-scanning the runway – are skipped, the system can and will break down.
  4. the controller, Chris Damron, simply failed to look out the window, not even once during the critical 2-minutes between when he issued a takeoff clearance and when he called out the emergency crews, nearly 45-seconds AFTER the crashed jet exploded in flames.
  5. just one look, during the critical 50-second window prior to start of takeoff (the time it took to move forward, turn onto and line up on the runway, finish the checklist and open the throttles), would have produced a quick transmission, cancelling the takeoff clearance.
  6. the transcript at the back of the 174-page NTSB investigative report shows the abrupt end of audio and data recording a half-second after the last audible exclamation by the pilots; thus, it appears that the explosion happened immediately, yet the controller did not make the crash phone call until another 44-seconds passed. It was a quiet Sunday morning, and there were no other airplanes. When he did make the call, his voice was markedly different, with a clear panic (the call was initiated at time 6:28 in the Crash Phone ATC recording, and the airport emergency crews picked up the call almost immediately).
  7. was the controller inattentive? Absolutely. He did not actually watch what played out, or he would have spoken up. He was either focused on nothing at all – resting while on position – or focused on another activity (distracted).
  8. was he possibly resting on position? Yes, quite possibly. It was the end of his workweek and the final hour of an overnight shift, so he was certainly tired. When fatigued while on position, nearly all seasoned FAA controllers do this: they physically rest, even shutting their eyes, while vigilantly listening to audible cues such as the power-up sequence. In this situation, with no other traffic, fatigued controllers are conditioned to apply an internal timer, reflexively waiting another half-minute or so after the last audible jet-noise cue, to then perform the next task for that flight – establishing radar contact on the digital radar display. While waiting, a common physical posture would have him reclined in his controller chair, eyes shut, but otherwise attentive and listening, much like a reliable watchdog. This is a strategy of fatigue management; it is practiced by both controllers and pilots. The pattern is repeated ad nauseum; it commonly creates a workplace boredom that can potentially become a lethal complacency, as happened at Lexington.
  9. how might he have been distracted? Three possibilities: he may have been doing other controller duties, he may have been doing administrative duties, or he may have been distracted with non-ATC activities.
    1. controller duties? not possible. He had no other controller duties to perform, since all his other traffic was gone.
    2. administrative duties? not plausible. The only excuse offered to investigators comes nowhere close to explaining nearly two minutes of inattention. The only cited administrative task was counting fourteen (14) 1″ by 8″ computer-printed paper strips, representing the entirety of his work the previous six hours. Any truthful controller will note this task I a quick finger-shuffling and recording a half dozen figures, thus would require less than 10-seconds. Any competent controller would perform this task quickly, only when traffic allowed, and then immediately scan the runway and airspace.
    3. non-ATC activities? very possible, and indeed likely, if he was not resting on position. He may have been reading, watching a movie or a TV show, playing a game on his laptop, online and surfing the internet, or texting with his cellphone device. In my FAA ATC career, I saw all of these activities routinely happening, and all were accepted by most on-duty supervisors as helpful strategies to manage fatigue.
  10. was the controller’s fatigue excessive and noticeable on the audio? No. Listen to the official Tower ATC recording and, frankly, Mr. Damron sounds professional, alert, and competent. His speech is quick and focused; he is clearly doing tasks that have been done many times before. He efficiently handles a departure push, with three flights to hubs at Chicago, DFW and Atlanta. There is no slurring and no hesitation. Based on this, his momentary inattention would logically happen ONLY if he was distracted into another activity such as using a digital device.
  11. were there larger national-level issues between FAA and NATCA? Absolutely. At the time this happened, controller morale was extremely low and FAA management was imposing draconian work rules onto all air traffic controllers. It was nearly three years later that a mediation panel ordered FAA management to abandon these imposed work rules (aka ‘The WhiteBook’).
  12. would a second controller have helped? Probably not. A few years after Lexington, in 2013, a fatigued controller lost two fatigued pilots when a UPS flight crashed at 4:49am on approach at Birmingham [KBHM]. One of his first actions was to use the tower phone system to call the other controller back to the tower. On overnight shifts, as another fatigue-management strategy, it is very common for paired controllers to alternate; one controller works the combined positions (which is generally easy, since traffic levels are very low), while the other controller can relax, catch a nap, or stay alert with other non-ATC activities (internet, DVD movies, music, studying, etc.)
  13. caused a near-midair collision in March 1989

    The TV set at another FAA tower, that caused a near-midair when a controller became distracted watching the NCAA basketball playoffs on a sunny Saturday in March.

    what does the controller probably want/need to say? As a retired ATC whistleblower, I spent decades working inside the ATC culture. I do know that concealment of facts is a big part of that culture. I also know that concealment is very destructive to those stuck concealing. My first whistleblowing was about a TV set at my first ATC tower, that was connected to a near-midair collision; I spoke up and endured retaliation, and was eventually fired 6-months prior to turning age-50, to force me to voluntarily retire at earliest eligibility. My gut-sense is that when the investigation started, Mr. Damron wanted to tell the whole story and was probably ready to talk, but was shut down. He would have had both FAA management and the union (NATCA) leadership scaring him into silence, with ample help from the attorneys brought in from the start. It is chilling to imagine his having to live today with the knowledge of what really happened, yet not be allowed to talk about it.]

  14. the controller’s identity was protected for four months, even though the identity had to be revealed eventually. A basic purpose of the NTSB investigative process is to give the public some transparency on transportation safety issues. FAA’s initial opacity was a classic knee-jerk reaction: acting from bureaucratic fear, protecting culturally entrenched failures from becoming exposed, and hoping to salvage what they could by over-controlling the flow of information.
  15. an initial effort was made to pin the blame on the Lexington tower manager, Duff Ortman. This failed when emails soon emerged, showing how Mr. Ortman was rebuffed in his many efforts to secure resources needed to cover the staffing: either two additional controllers, or an increase in allowed overtime funding.  The emails included comments by Eastern Terminal Services Director John McCartney, attempting to brand Mr. Ortman as a ‘renegade’.
  16. TVs, DVD movies, and other workplace distractions have been documented elsewhere and in numerous national news stories, including:
    1. There was the controller at Cleveland Center, who took off his shoes while watching a movie DVD on an overnight shift; he accidently had a hot mic when a shoe tipped onto a pedal-switch. A ham radio operator was doing his thing that night and heard a movie soundtrack on an ATC frequency, so he called FAA to report what appeared to be a dangerous situation. The FAA manager on duty  promised to investigate; while walking down to the control floor, he stopped at the technicians’ desk and mentioned the problem, and they noted ‘well, he’s probably watching a movie!’. Sure enough, he was. Made the national news but NOBODY was disciplined because it was a ‘prior working condition’ and had been condoned by supervisors for more than a decade. An aiREFORM FOIA request [F11-8134] eventually yielded hundreds of pages, including a confirmation that nobody was ever disciplined.
    2. There was the case at New York Center (Ronkonkoma, NY) where in 2010 a new supervisor, Evan Seeley, spoke up about common practices of sleeping on the job, early undocumented departures, and use of personal electronic devices while working. He was then subjected to vandalism and harassment, and found a management team that could do nothing to correct the situation. An OSC investigation confirmed Mr. Seeley’s claims.
    3. There were the many cases of sleeping air traffic controllers in 2011. Eventually, the Air Traffic COO, Hank Krakowski, was forced to resign.
    4. There was another news story that broke in 2012, when a controller Whistleblower at White Plains, NY [KHPN] leaked cellphone images and video exposing widespread napping and personal electronics in the control tower.
    5. And, there was the TV wired into a cabinet at Troutdale, OR (the photo above). This was the safety risk that launched my career as an ATC Whistleblower in 1989, and eventually led to a forced-voluntary retirement in 2009; see that Whistleblower case study here.

[QUOTE]: FAA’s Culture of Corruption & Cover-Up

Aside

QUOTE

“…Over and over, when the FAA is caught asleep at the wheel, those in charge rattle their sabers, fire low level individuals and allow the management that refuses to play by the rules to stay in power. Soon it all slouches back into a comfy system because the FAA does not like oversight, does not tolerate whistleblowers, and will say whatever it takes for the cameras to stop rolling and the members of Congress to stop having hearings. I know because I shined the light on FAA malfeasance and cover up for five years when I headed the independent oversight agency United States Office of Special Counsel (OSC)….”

– Scott Bloch, in a 5/29/2011 blog post about endemic FAA corruption

Click here to read the original blog post.

Multiple Awards won by Mario Diaz’s Series on FAA Failures

U.S. News reporters who ask the hard questions and do the investigating to expose FAA failures are rare. One of the best today is Mario Diaz, at PIX11 News, serving the New York market area. He won multiple award for ‘Below the Radar’, a five-part series that aired in mid-2014. This website posted twice about the series, first in mid-May (after the first four episodes), and again in mid-August (after the fifth episode).

Mario’s awards include:

A compilation of the full series of five episodes has been posted at YouTube. It runs nearly 30-minutes, and offers much to think about:

(click on image to see the full video of the investigative report)

(click on image to view the investigative report at YouTube)

NTSB’s Preliminary Report on the Monck’s Corner Midair Fails to Present Critical Airspeed Data

It took NTSB ten days to release a report on a midair collision that killed two men, when their Cessna was broadsided by a USAF F16 ‘training flight’ north of Charleston, SC [KCHS]. A PDF copy of the report text has been created, and includes footnotes pointing at areas needing further detail and investigation.

As noted earlier on this website, both FAA and NTSB need to become more immediately transparent on serious incidents, especially low-altitude fatal midair collisions. At a minimum, we should be able to see radar presentations (showing positions at key times, as well as datablocks that reveal altitudes and groundspeeds at those times), just as we should be able to listen to a copy of the audio between the F16 pilot and the KCHS approach controller.

What new information was produced? Here are a few key points:

  1. Very significantly, the impact occurred at just 1,500 feet altitude, an incredibly low altitude for an F16 to be passing at high speed near a small general aviation airport (Berkeley County, SW of Moncks Corner, [KMKS]).

    20150720scp.. VFRmap re Moncks Corner midair (showing Shaw AFB E to KMYR S to KCHS)

    VFR sectional showing: F16 departure from KSSC (orange triangle), F16 practice approaches at KMYR (orange square), final destination for F16 at KCHS (orange circle), and approx. route of Cessna from KMKS toward KCRE (red line).

  2. The report notes a 10:20 departure by the F16, a flight to KMYR to conduct two instrument approaches, then a flight to KCHS for another practice approach. Thus, it took just 40-minutes for this F16 to fly 79 direct nautical miles to KMKS, fly two approaches, then fly 63 direct nautical miles to the collision near KMKS. The time used up to fly two practice approaches at KMYR is substantial, thus suggests: this F16 was likely screaming through the sky, and at only 1,500 feet altitude (though interestingly, at the initial press conference on July 7th, the USAF commander said they believe the collision was at 2,500 to 3,000 feet altitude).
  3. Although NTSB provided many valuable details, they made absolutely no mention of a hugely important factor: the F16’s airspeed leading up to the collision. Historically (and this goes WAY back to the almost weekly fatal midairs that happened in the 1960’s, when jets were first introduced commercially), airspeed differentials are a major contributing factor to midair collisions. Certainly a Cessna at just 1,500 feet altitude would have very little opportunity to avoid a fast-moving jet pointed straight at the Cessna. This pattern, with NTSB failing to mention a very pertinent detail in their Preliminary Report, is a repeat of what happened a year ago when a student from Germany was killed in a crash near St. Cloud, MN, for which there was strong evidence an arriving Allegiant flight was too low and too close, creating a wake turbulence upset.
  4. The controller’s handling suggests a systemic ATC aversion against ‘controlling’ military training flights. ATC should never have allowed the F16 pilot to scream along at just 1,500-feet, particularly since the collision was at roughly 18-miles northeast of the runway in Charleston. Typically, a normal stabilized approach descends roughly 300-feet per mile, so a ‘controlled’ civilian flight would expect to be descending through 5,000+ at 18-miles out. Had the F16 flight been properly controlled, ATC would have held the flight higher, to at least 3,000 or 4,000 feet, and with a moderate (even minimal?) airspeed consistent with safe operation of the F16 while mixing safely with low-altitude civilian flights. In the image below, note the TACAN approach is normally flown via a 24-mile arc (much further out) and has a crossing at LADRE at or above 3,000 feet. It appears ATC dove the F16 early to enable the pilot to get under the scattered layer, to conduct a quicker ‘visual approach’ to land KCHS Runway 15.

    Red circle marks the approximate midair location.

    Red circle marks the approximate midair location.

  5. The simple fact is, if this controller had asserted earlier and aggressive control of the F16 flight, or if the controller had NOT told the F16 pilot to turn south (which turn was delayed by the F16 pilot), there would have been no midair collision. I.e., timing and timidity conspired to translate ATC instructions into two fatalities and two destroyed aircraft.

As a former air traffic controller (forced into early retirement due to whistleblowing), I find this incident and the post-incident handling very troubling. Two men lost their lives unnecessarily, but the F16 pilot and the FAA controller were also victim. They have to live with what they saw unfold, and they will forever wonder, what could they have done differently to have prevented this accident?

An FAA that routinely looks the other way while F16 pilots scream at low altitudes is only enabling risky flying that will eventually produce tragic consequences. Frankly, it would not be at all surprising to see this controller retire on a stress-related disability, primarily because FAA is so eager to accommodate aviators, they too often fail to assert real and needed safety controls.


UPDATED 7/20/2015

Trends in Aviation Transparency: Passenger Documents In-Flight Engine Failure

The trend in aviation has been toward careful micromanagement of information, by both the airlines and the regulatory officials. So, when an airplane issue happens (an accident, an in-flight failure, or even a disappearing flight), or when ATC makes a mistake, it is nearly impossible for the press to produce a solid, informative news article. Often, in fact, the stories do not get into the news. It seems that, if the Av-Gov Complex had it their way, there would be no transparency in aviation. Increasingly, what transparency we have is driven by personal electronic devices, social media, and independent blogs.

So, it is a pleasure to see the occasional news story that DOES happen, when a passenger snaps a picture from her airplane seat. In this case, a Dash-8 feeder flight from Kansas City [KMCI] to Denver [KDEN], operated as Republic Airlines Flight 4936, was flight-planned to cruise at FL240 but levelled at FL200 (20,000 feet) when the crew had to shut down the number one engine due to low oil pressure. Here’s the photo which helped ensure the world would learn about this incident:20150123.. Republic 4936 DH-8 engine out, passenger photo
The flight then turned around and landed back at KMCI. Total flight time: one hour.

(click on image to view flight data at FlightAware.com)

(click on image to view flight data at FlightAware.com)

2015-01-17: Transcript for the Near-Collision at KJFK

The following transcript is based on the archived ATC recording at LiveATC.net: KJFK 1-18-2015 0300-0330Z. The airline codes are: BWA (Caribbean Airlines); JBU (JetBlue); AZA (Alitalia); UAE (Emirates); AAL (American); VRD (‘Redwoods’, aka Virgin America); AMX (Aeromexico); UAL (United). Flights below are color- coded: red (arrival) and green (departure).

The arrival sequence was: AMX404 — VRD56 — BWA526 — AAL32 — JBU302. ATC applied positive control on both VRD56 and AAL32, issuing: “…right Juliet, hold short of two-two-right, remain this frequency….” Importantly, this clearance was NOT issued to BWA526. Also, a full five minutes passed between the time ATC issued the ‘hold short 22R’ to VRD56 and then AAL32; thus, the arrival spacing was averaging one per 2.5 minutes, which is a relatively calm arrival rate.

The departure sequence was: JBU1337 — AZA611 — UAE206 — JBU1295. For each departure, ATC had the aircraft ‘line up and wait’ on the runway, then issued a takeoff clearance after the previous arrival had finished taxiing across the runway downfield. Again, at the time the controller cleared JBU1295 for takeoff, he had done nothing to ensure BWA526 would hold short of the same runway.

Additionally, there is no evidence that the controller needed to be in any hurry. AMX404 was crossed prior to takeoff clearance for UAE206 (at time 27:35). Then, it was a full two minutes later, when VRD56 was crossed prior to takeoff clearance for JBU1295 (at time 29:41). And notice on the transcript that, immediately after clearing JBU1295 for takeoff, the controller does NOT focus on BWA526; instead, he diverts his attention to a nonessential flight, a VFR Cessna overflight whom he tells to maintain at or below just 500-feet altitude under departing jets (an approval that in itself is arguably unsafe).

So, what happened?

This appears to be a classic same-runway controller error, where the controller simply ‘temporarily forgot’ about one of his aircraft. Happens all the time. This is why controllers are trained to scan all the time, and this is also why it is valuable to have more than one controller watching the runway areas. Had this controller been in training, his instructor would have written him up for a ‘POSNI’ (Positive Separation not Insured). Then, again, the instructor’s job is to make sure situations like this never happen, so it might also have been swept under the rug….

Of course, the BWA56 flight crew was a major part of this error, too. Most pilots would have stopped short of the runway and radioed ATC advising they were holding short, and asking for further instructions. But, it is up to the controller to ‘control’ the traffic, by issuing crisp and timely clearances that keep the aircraft flowing and out of trouble. This controller, on this particular Saturday night, was surprisingly sloppy with his phraseology, and it came back to bite him.

It is worth saying again: this sort of incident happens all the time, where a controller temporarily spaces on one aircraft. This latest incident is just the ‘big league’ version of a very similar scenario, the 7/25/2010 Controller Error at KCMA. That, too, was swept under the rug. In fact, the Camarillo controller error was concealed by the tower supervisor, then the tower manager, then the hub management, then the regional QA people, and eventually even by Clay Foushee and Tony Ferrante at FAA Headquarters.

ANALYSIS: 2015-01-16.. Forced Landing of an Air Tour Flight Near Halawa Falls, Molokai

A Cessna Skyhawk flying an apparent air tour lost engine power and crashed in rough forested terrain, while touring near Halawa Falls in the northeast part of Molokai. The tour passengers were a Japanese couple and their daughter. News reports indicate that the pilot and two passengers had minor injuries, but the mother was hospitalized with serious injuries.

20070819scp.. C172 forced landing field on Lanai, pilot pic (M.Richards)

The pilot, happy for his good luck. (click on image to view article/source)

The pilot, 35-yr-old Michael Richards, had previous experience with forced landings while flying this same aircraft type. On August 16, 2007, he was doing an instructional flight with N5207D, a C172, when he lost engine power; all three survived (the instructor, his student, and an observer/student). Then, on June 24, 2014, Mr. Richards and a student lost power at 2,000-feet and made a forced landing with N66540, ending up in a plowed pineapple field, near the Waipio Costco.

The most recent forced landing was with N5660E, a C172 registered with an operator named Hawaiian Night Lights LLC.

20070819scp.. C172 forced landing field on Lanai (M.Richards)

(click on image to read article about another forced landing, involving the same pilot, in 2007)

Is the Safety Oversight Missing?

Interestingly, neither the 2007 nor the 2014 forced landings are included within the NTSB aviation accident database. They clearly should have been. On the same day as the 2007 Hawaiian incident, another student pilot had a hard landing at an airport in Keystone Height, FL; that incident, far less significant (and far more common) than an in-flight engine failure, was investigated and added to the NTSB database [LAX07CA256]. And, on the day before the 2014 Hawaiian incident, another C172, in Miami, FL, had a hard landing when the pilot’s seat slid during touch-and-go pattern practice. It was written up at NTSB [ERA14CA331].

So, it will not be a surprise if neither NTSB nor FAA produces an investigation and report for the latest incident. They should. These are commercial activities. Just like the ‘instructional flights’ sold to tourists on ultralights are ‘commercial’ and generally overlooked by FAA. In fact, two died ten months ago in Kauai, the latest in a long history where both pilots and paying passengers have died in commercial flight accidents.

An agency that takes civil action against those who use low-altitude drones to capture real estate or news photos, should be far more concerned with ensuring safety in commercial air tourism. Get the data on these incidents, share it widely, and clean up Hawaiian air tourism before the next fatality happens.


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