The Truth is the First Casualty of any Air Crash

Geoffrey Thomas, at in Western Australia, seems to have one of the best factual views of the QZ8501 tragedy. And he is doing a great job posting coverage since the Indonesia AirAsia flight disappeared nearly six days ago. One of his Posts on New Years Day re-declares the maxim that, when anything bad happens in aviation, facts are the first things to disappear.

He’s correct, but it should not be this way. Every nation has an aviation authority, such as FAA in the United States. These agencies are stuffed full of employees, theoretically there to serve the Public. In their early years, these agencies did very important safety and infrastructure development work. But, as these agencies have matured, they seem to have become less and less productive, more about quietly helping the airlines than about aggressively speaking up for safety. So, when an accident or incident occurs, they tend to say nothing. It is as if their speaking up might get in the way of how the accident airline needs/wants to manage the PR spin.

Given this, when an incident like QZ8501 happens, we end up with a deep informational vacuum. Neither airlines nor regulatory authorities take charge to clearly and timely articulate the known facts. And as we all know, where there is an informational vacuum, rumors and other garbage will quickly fill the void. This is happening (AGAIN!) with QZ8501, while victim’s families suffer, and while millions of others ponder just how safe aviation is.

It’s a new year.

Wouldn’t it be wonderful if FAA’s leadership chose to set a new, higher standard for the world to follow, by aggressively working for maximized aviation safety? Wouldn’t it be great if, when a serious accident or incident happens, the relevant national authority would step forward and firmly assert the known facts, and then stay up front to keep us all urgently posted? This is kind of the way NTSB’s Deborah Hersman handled the investigation, in early 2013, when the B787 battery fires were happening.

Can we make that our new standard for aviation safety transparency?

Another Flight to Nowhere: UAL28 off Heathrow, 12/17/2014

A Boeing 767 (United Flight 28) was airborne for nearly five hours over the English Channel, while burning off and dumping fuel to return for a landing at London’s Heathrow airport. The airline is not explaining yet what the issue was, but the flight tracking data indicates the flight diverted to the south after departure, then leveled off first at ten thousand feet, then at twelve thousand feet. It appears to have flown nineteen loops, mostly using up fifteen minutes per loop, and to the southwest of the Isle of Wight.

The low altitudes would suggest their was an aircraft pressurization issue. A passenger reported to the media that the captain had advised they needed to get rid of 20,000 pounds of fuel before they could return to land.

20141217.. UAL28 4hr fuel burnoff after EGLL departure, map

Heathrow was in a west flow. The faint dashed blue line to the west-northwest approximates the intended route to United’s hub airport at Newark, NJ.

20141217.. UAL28 4hr fuel burnoff after EGLL departure, chart

The yellow line shows altitude (mostly at 12,000′), and the gray line shows airspeed. The cyclical patterns on the gray line reflect airspeed variations due to winds aloft.

The incident was well covered in an article at One comment stands out:

“Why can’t airlines actually tell passengers what is happening? Its not like they’ll rip the door open mid flight and start jumping out.”

A good point. It seems plausible that, for aviation mechanical events such as this, airline transparency would be the best course. The current practice of opacity only causes people to wonder, what is the airline trying to hide. And certainly, the 227 passengers on board have a right to know what happened, on the flight they paid for.


“Unfit for Flight” news investigation wins the NPF ‘Feddie’ Award

National Press Foundation recognized Thomas Frank for his USA Today investigative series about aviation fatalities and regulatory capture.

A non-profit foundation, NPF cited Mr. Frank for his “extraordinary investigation” in his series, ‘Unfit for Flight’, which appeared in June. He was given the ‘Feddie’ award, recognizing that his writing helps to show how federal policy affects local government. Judges were also impressed with how the presentation of the  news series “…effectively uses the techniques of digital journalism: video, animation and responsive design. This is modern journalism at its best.”

The series revealed how design defects have been allowed to persist in private airplanes and helicopters for decades, often because of cover-ups by manufacturers. The stories also showed how National Transportation Safety Board crash investigations often overlook the causes of aircraft crashes and deaths, and how the Federal Aviation Administration allows brand-new aircraft to be manufactured under safety regulations that are decades old, thus perpetuating known design flaws.

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…

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.

<< <> <<>> <> >>

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

Another Tragic Airshow Fatality

20140504.. KSUU Air Show crash, impact & ribbon

The groundcrew was holding a ribbon to be cut by the inverted biplane, but the biplane contacted the runway. The prop appears to be spinning in this image. The white smoke is part of the show.

Yesterday, at the Thunder over Solano Airshow, a 77-year-old pilot was killed during the finale of his performance. Flying a Boeing Stearman biplane, Eddie Andreini intended to invert, then pass low over the runway, and cut a ribbon held across the runway by standing personnel. 20140504.. KSUU Air Show crash, fire, waiting for ARFFNews reports indicate he had aborted two attempts and then, on the fatal third attempt, he impacted the ground while inverted.
20140504.. KSUU Air Show crash, 2012 pilot pic

Mr. Andreini was an accomplished pilot based in Half Moon Bay, CA. He had thirty years of air show performance experience.  According to Colonel David Mott, with the 60th Operations Group at Travis Air Force Base, winds were 10 to 15 knots, gusty at times. Tens of thousands stood in the sun and watched the tragedy unfold. Many were shocked and silenced; some became upset later in what was perceived to be a very slow rescue response. For example, one citizen with a digital camera took shots indicating two-and-a-half minutes passed before the first fire extinguisher arrived, and five-minutes total passed before actual rescue crews arrived.

Airshow fatalities are becoming far too regular. Last year, it happened at the airshow in Dayton, OH. In fact, it was the same scenario. An inverted biplane, but with a pilot and a harnessed wing-walker. Both died in a fiery crash. That airshow crash was a déjà vu moment for me. It reminded me of the fatality I saw in 1997, while working at a control tower near Denver. And, it crystallized in my small mind: I do not like airshows.

Aviation as a Measure of Humanity’s Progress

When you look at the engineering and the speed and the power, Aviation is potentially a true high mark for human achievement. A point of pride. 20140504.. KSUU Air Show crash, crowd picTo think we dreamt this up, created it, developed it, and refined it into a system that has so much potential to serve so many people. To make the world a better place for our grandchildren. And, yet, we continue to scar this incredible accomplishment — and reaffirm our collective stupidity — by misusing aircraft to entertain the crowds with feats such as low-altitude inverted flight. When tragedy then happens, thousands are exposed to how badly aviation can fail. Why has this not changed?

The very agency with the unquestioned authority to stop this is the FAA. Airshows have a rigorous permit process, wherein the maneuvers are clearly defined by the applicant, then signed-off by FAA officials. If a pilot flies inverted to cut a ribbon at ground level, that maneuver was approved by FAA. But here’s where it gets to be disturbing. This agency will chase a hobbyist with a 3-pound drone and slap him with a quasi-legal action, and threaten the same against thousands of other RC hobbyists. Communities are paralyzed to address noise complaints, or have no choice but to reject building plans, because cities and counties all routinely defer to this agency to call all the shots. FAA Whistleblowers — and their families — see their life and liberty arbitrarily destroyed because this agency will not tolerate those within who question authority or who speak up about waste, fraud and abuse. This agency expends an extraordinary stock of resources to hide controller errors, block the release of safety information, obstruct Congress’ FOIA laws, delay responsive and responsible actions, hound its Whistleblowers, and otherwise impede citizen participation.

If ANYTHING happens in U.S. aviation, the vast majority of us wants (and needs) to believe that FAA is on top of it, and no system failures can or will repeat. Even in the latest example, at Thunder over Solano, all the news stories refer to FAA and other safety agencies, as if they deserve great respect. And, yet, this agency continues to fail: FAA only has to say ‘No’, to put a stop to fatal, too-low-to-be-inverted airshow flying. Why has this not changed?

A Closer Look at the Wrong-Airport Landing at Jabara

Last November, one of the largest cargo aircraft in the world impacted the ground on the flat plains of Kansas. ATC had cleared the flight to land at the McConnell Air Force Base, roughly eight miles further south from where it landed. Thankfully, the impact was somewhat controlled and happened onto a different runway at a different airport. Nobody got hurt.

A copy of the ATC recording (with a transcript) has been posted on YouTube. It is 8-minutes long. It appears to be time-compressed (i.e., long stretches of time between transmissions are removed).

This flight was a Dreamlifter, flying as Giant 4241, which had departed Kennedy Airport on an FAA IFR flight plan. According to a news article, the weather was fine during the 9:40pm landing. The last FAA controllers to work the flight were the radar controllers at the Wichita Approach Control. They pointed the flight toward McConnell Air Force Base, descended it, set it up for a GPS Runway 19L Approach, then issued the charted approach to the pilots. After the FAA controllers ensured that the military tower was accepting the approach, they radioed to the pilots and told them to contact the control tower. The flight crew made the radio call and, interestingly, the speaking pilot started to mis-state that they were on a Visual Approach. As it turned out, they evidently were on a Visual Approach, and were NOT flying the cleared GPS Runway 19L Approach. The evidence suggests that they were landing by simply reading the terrain so easily seen in the generally good flight conditions, but they nonetheless told ATC what ATC wanted to hear. It was minutes later that they realized  they had a problem … they had made their undeclared Visual Approach to the WRONG AIRPORT!

It is interesting to listen to the four people involved in this eight-minute recording — the two pilots, as well as the tower controller and his supervisor. It really sounds like they were all hoping the pilots could just quickly turn around, take off, and land at McConnell AFB, maybe even before anyone noticed what had happened. You can feel their suspending reason for a few minutes … ignoring the fact that this is an enormous aircraft, and it is lunacy to try to consider just flying it out. The Upton Sinclair quote comes to mind. Their ‘dreams’ were quickly dashed at 5:48 on the YouTube video, when the danger of their situation was brought home: a twin engine turboprop suddenly overflew the behemoth. It was sure a good thing that this huge aircraft was hard to miss, parked at the south end of Jabara’s Runway 18.

ATC’s Involvement in this Dangerous Error

So, just to be clear, pilots do not make up approaches and tell ATC any old thing. In this case, the Dreamlifter pilot quickly corrected himself when he first talked to the tower controller, because that tower controller had been notified by the FAA Approach controller that the flight was inbound on a GPS Runway 19L Approach. FAA’s Approach Controllers issued a GPS Runway 19L Approach to this flight.

The red mark shows the approximate position of Jabara Airport, north of the Final Approach Fix (FAF) ‘WARUN’. The underlined ‘3000’ at ‘WARUN’ notes the flight must cross ‘WARUN’ at or above 3000 feet MSL (roughly 1,600 feet above the ground).

When they issued that approach, the FAA controllers took on the responsibility to monitor the flight and ensure the approach was executed. The approach controller had to go through years of training and had to show his trainers that he memorized the critical details, including knowing the safe and legal altitudes for each of the available approaches. That rigorous ATC training conditioned the Approach controller to be extremely vigilant about minimum safe altitudes for flight. Somehow, that vigilance disappeared. In this case,  the flight was supposed to be established on the route segment between the Initial Fix ‘WITBA’ and the Final Approach Fix ‘WARUN’, tracking a magnetic course of 186° and maintaining an altitude at or above 3,000 feet MSL (see the as yellow markings on the AGPS RY 19L Approach details above). Note the carat symbol just equipment at the west of ‘WARUN’ on the approach map view; this is a radio antenna and the VFR Sectional chart shows it to be 421′ above the ground level, just northwest of the controlled airport marked ‘BEECH’.

The pilots missed their runway by roughly eight miles. They put the Dreamlifter down onto the ground miles BEFORE a charted antenna obstruction. So, how can it be that the FAA Approach Control, where the approach clearance was issued, produced no alarms when the 3,000 foot floor was busted (by 1,600 feet!) and when the flight’s projected profile would show a likely collision with the charted antenna? Did the radar automation not create an alarm? Did the controller see it but assume (improperly) that the tower ‘had it under control’? Did the military tower have any equipment or procedures that would have (and should have) detected a busted altitude on such a huge aircraft?

More likely than not, there are many other ATC communications NOT included within this YouTube video. The first reaction of the military controller at McConnell Tower should have been to punch a button and talk to his Approach Controller: “Approach, McConnell Tower, be advised that GTI4241 appears to have landed at a different airport.” Or, “Hey, Approach! Did you clear Giant to land here at McConnell, and did you monitor his descent??” Or, even earlier (to proactively prevent the incident): “Hey, Approach! I am looking out my tower window for that huge Dreamliner and not seeing him. What is his location, and is he still setting up for my airport?”

No calls were made in advance of the incident, perhaps because nobody was looking. So, when the post-incident calls were made, the first reaction of the Wichita Approach controller would have been to file an ATSAP report. He or she would make sure they did so, being careful to present the events to conceal any failures, so that they can receive the full ATSAP immunity, and not be held accountable for their negligence. That excessive immunity is the carrot FAA used to bring NATCA on board, to support ATSAP … which FAA wanted as a way to hide safety reports from citizen FOIA review.

What will FAA do? Will NTSB conduct a thorough investigation, or are they being tamped down these days, told to stay out of FAA’s business? Can we expect the ATC aspect of this dangerous error to be covered up, or will the facts be fully presented for Public review? Will FAA share de-identified ATSAP reports so the Public can understand how this incident happened?

A great quote by Upton Sinclair

“It is difficult to get a man to understand something, when his salary depends
upon his not understanding it!”

Upton Sinclair, 1878-1968

This was true in 1935, when published in “I, Candidate for Governor: and how I got Licked.”

…is it any less true today?
Take a look at this example:
…the concealed operational error at
Camarillo, CA on July 25, 2010,

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)…

How I Learned to not like Airshows

Part I: the accident

It was a very hot day in 1997. I was an air traffic controller stationed at Jeffco Airport, named for ‘Jefferson County’, in the area just west of Denver. We were a small group at a growing airport; just a manager and eight or so controllers. And this weekend was our big airshow.

Estimates were that more than a hundred thousand spectators were standing, sitting, and sizzling on the airport grounds. Cars everywhere; a sea of people. The temperature exceeded 100. The sky was clear, with a searing sun. We were lucky; as air traffic controllers, we sat/stood in the air conditioned tower cab, and did not have to do anything but enjoy the show. Managing the different acts was not our job: that chore went to the air boss, out on the field.

At that time, the Jeffco Tower was on the north side of the airport, and we looked south across the parallel east-west runways. The runways were built on a generally treeless, high piece of ground, stretching to the east below a nuclear processing superfund site called Rocky Flats. Off to the west, standing in tall grandeur behind Rocky Flats, was the Front Range and the Flatirons rock formation near Boulder. That view was always a pleasure. To the south of the parallel runways was a small canyon, also running east-west. We could not see the canyon, but we knew where it was by the few trees along its edge and a visible building just beyond.

We watched the Airshow acts. We had a small crowd in the tower, because it was a rare opportunity to invite family and a few friends. During the show, some performers had been offsetting into the canyon. They were screaming in from the east, would slip left and downward to disappear, then suddenly pop up out of nowhere. I am sure it scared a few spectators (ah, hell, it scared me the first time), then gave them a quick thrill. If part of the intent of an airshow is to pump adrenaline, this maneuver was working well.

One of the acts was a retired United Airlines pilot flying his F86 Sabre.  He, too, came screaming in and did a low pass over the runway. He then began a large loop, turning ever more vertical, inverting at the top, turning downward toward the earth, and continuing a huge circle that, in theory, and without other factors, would bring him right back to another highspeed low pass. Three-quarters of the way into this loop, he was a mile or two east of the airport, pointing straight toward the earth, and needing the turn radius to allow him to level off before he ran out of air.

Now, to us in the tower, and to the hundred thousand below, it just looked like an airshow act. So, when the F86 sidestepped out of sight into the canyon, it was just like what others had done earlier, though they were all smaller and slower aircraft. So, for maybe two seconds (which seemed like two minutes), we all just knew he would suddenly ‘pop’ up out of the canyon. Not this time.
Our next image was an enormous cloud of orange, black and white.
photos (at Flickr)

video (read the comments, too)

Part II: the aftermath

That was Sunday. The Airshow came to an abrupt close. The crowds picked up their coolers and folding chairs and proceeded toward the various exit gates. Many of the gates were near the control tower, so we had a new view from our air conditioned perch: heads tipping up and down, some staying up, with long, shocked looks. These people really trust that we, as FAA air traffic controllers, do our damnedest to ensure flying is safe, and to erase unnecessary flight risks. Some of these people did not really know if we had controlled that F86 into his fiery crash; some probably thought we did. Very few of these people knew, as I had learned a few years earlier at Troutdale (more about that below), that there is an ugly habit within FAA, that sweeps safety failures under the rug.

So, we watched from the tower as all the people walked away. Once the airfield was cleared of spectators, we then spent a couple hours launching small planes. There were many pilots, who had flown in for the show, and they all needed to get home, many to hug their families after seeing such a horrible tragedy. We were a cold, sober, and suddenly very professional bunch, keeping those departures away from the crash-site and getting done with our own work, so we could go home, too. I went home to a room I was renting from a wonderful retired couple, on the west edge of Boulder. I spoke with them briefly, clinically, like a controller. My wife, and my two young children, were a thousand miles away, at our home in Oregon.

It was a few days later that I got a phone call from some controller on the East Coast. It was her job to assist in a stress debriefing. Via phone. She was supposed to help mend the psychological damages, help make sure we can talk and process and move on. I talked. I sort of processed. And I think, yeah, I moved on. But what I moved on to was a realization that there is something wrong with my employer, the FAA. At that time, in my heart, I could feel that something about FAA was broken. We were failing. We not only could do better, we had to do better.

So there I was, talking on the phone to a stranger, in a stress de-brief about this accident. And I shared something with her. How was I feeling? Well, all I wanted to do, the day I saw that happen, was go home and hug my young children. But I couldn’t. In March 1989, when I was working at Troutdale, I had been a whistleblower – I spoke up about a practice that caused a near-midair collision. I then endured immediate retaliation, which I survived. But then, in early 1996, the FAA management at Portland achieved retaliation by reassigning me to work in Colorado. My young family remained near Portland, to stay close to extended family. On the day that F86 crashed, I went home to a room in Boulder; I was a thousand miles from the healing and growth that comes from a loving family hug.

That was the part of my talking that brought out some tears. Big guy like me, crying on the phone to a stranger. Must have had her wondering what to do next.

Then, there was the other part. The angry, critical part. I asked her: do we know, were there routines in this Airshow, acts we all dumbly watched, that were known to be too risky, and thus prohibited, at least on paper? Were these risky routines denied on paper but allowed anyway? (remember, this was Day Two, so all of these maneuvers had passed muster the day before) Were those sidesteps into the canyon by ANYONE an approved and safe procedure, per the FAA personnel who signed off on the airshow plan? Was it approved for an F86 to do that loop, starting essentially at ground level (vs. the obviously safer higher base of say 500’ or 1,000’)?

I told her, I had seen before how FAA would sweep safety failures under the rug. I shared with her some of the details about that Troutdale near-midair that I spoke up about, and how it had brought on such hurtful retaliation. I told her, it is just wrong, it feels like we are so hollow – we always speak of safety, but we hide our failures; and those who do speak up, we get rid of them.

And, I told her about that last burning image from the F86 crash. No — not the towering fireball, but the REAL last image: the hundreds of shocked people, walking by in a crowd, looking upward at the tower as they walked by. It was on their faces. They depend on us.

On this day, at this airshow, in my heart: we failed.


Call it a flashback. I dunno. I saw this picture, from today’s Dayton crash, bit my lip thinking about a wing-walker and a pilot lost in that tragedy, and I just had to share this story from 1997.

Another Airshow Tragedy: Dayton, June 22, 2013