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.

Is FAA Failing in Their Safety Oversight of Allegiant Air?

On May 11th this year, we were deeply embroiled in the election primaries, with growing evidence that the U.S. election system is in a flat-line failure mode. So, it is not surprising that the 20-year anniversary of the ValuJet crash in the Everglades might have gone unnoticed, at least by some of us.

The crash took 110 lives, and deeply scarred thousands more. The investigation of the crash exposed cultural failures at FAA, and led DoT Inspector General Mary Schiavo to abruptly resign in July of that year (she was THAT disgusted with the inside politics and cover-up, not just by FAA but by the White House, too). The crash and victims were recalled in a Miami Herald article. Subsequent news articles this year have looked at Allegiant Air, noting its many connections back to ValuJet, and presenting evidence that FAA is AGAIN being lax in safety oversight.

Below is a recent news article, critical of both Allegiant and FAA. In the pages that follow, aiREFORM provides an archived collection of articles and other documents related to Allegiant Air. The records are presented in chronological order on the following pages, mostly as scrollable PDF files.

Click on the image below for a scrollable view; the PDF file may be downloaded.

Li-ion Battery Devices Can Ignite, If Crushed in a Seat

(click on image to read the report by the Australian Transport Safety Bureau (ATSB))

(click on image to read the report by the Australian Transport Safety Bureau (ATSB))

The concerns about Li-ion battery ignition hazards grounded the Boeing 787 fleet in 2013, and they continue to make the news. The picture above is from a new investigative report about an actual fire on a Qantas 747. A passenger misplaced an electronic device and it became crushed inside the seat mechanism, creating a hissing sound and igniting. When crewmembers arrived, they “…observed an orange glow emanating from the seat….”

The concerns are not new. The Australian report cites a Safety Alert for Operators (SAFO) issued by FAA in June 2009. Archived copies are linked below.

See also:
  • 9/23/2009 – archived copy of SAFO 09013 (1p)
  • 9/23/2009 – archived copy of Supplement to SAFO 09013 (2p)

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.

A Blast from the Past: Ike, ‘The First Air Force One’, and FAA’s Slow Action about Mid-Air Collisions

If you research FAA’s history, you will find all sorts of interesting stories that most people have never heard of. Here’s an example.

A link was shared to a 5-minute video about ‘Columbine II’. This was President Eisenhower’s Super Constellation, and the only presidential aircraft ever sold to a private citizen post-service. Here is an embed copy:
Watching this video, you will notice a striking fact posted at the start: in 1953, we came close to losing President Eisenhower in a midair collision over New York City. ATC had brought two aircraft with near-identical call signs into a near-collision: Eastern Airlines Flight #8610, and Air Force Flight #8610. Shortly after this incident, a new ATC rule was put in place to always refer to the presidential aircraft as Air Force One. The rule seems to be helping (i.e., we have still not involved Air Force One in a midair collision!).

20160313scp.. view of CRT radar display w sweep, wx (from 'the first air force one')Of course, in 1953 we were actually using the real ‘World War II technology’ radar, plus controllers and pilots had to strain to hear crackling radio transmissions … the sort of ‘antiquated system’ Shuster/Mica/LoBiondo/Rinaldi/Calio falsely claim still exists.

We have seen dozens of cycles of upgrade/change since: new rules, new technologies, and more.

Back in 1953, the REAL antiquated technology was considered cutting edge, and it generally served well, to help handle a boom in air traffic, all being worked by low-paid, chain-smoking air traffic controllers. We introduced higher speeds with commercial jets in the 1960s, and well into the 70’s aviation was continuing to boom. Thus, it is not surprising we had so many ACTUAL midair collisions in the years that followed. Five that stand out on a short list are:

  1. 6/30/1956 – over the Grand Canyon, 128 killed when United Flight #718 collided with TWA flight #2 [the outcome: Congress passed legislation to create FAA in 1958]
  2. 12/16/1960 – over New York City, 134 killed when United Flight #826 collided with TWA flight #266 [the outcome: an equipment upgrade (to include DME), and a speed limit of 250kts when within 30 nautical miles of the airport and below 10,000 feet altitude (see 12/26/1961)]
  3. 7/19/1967 – near Asheville, NC, 82 killed when Piedmont Flight #22 collided with a small plane (Beech Baron) [the outcome: a newly-formed NTSB pressed FAA to develop and mandate on-board collision avoidance technologies; that same NTSB selectively excluded critical information from the investigation/report]
  4. KSAN.19780925.. PSA182 trailing smoke just after midair collision9/25/1978 – over San Diego, 144 killed when PSA Flight #482 collided with a small plane (Cessna Skyhawk) [the outcome: FAA created ‘Class B Airspace’ with enhanced radar control required for all commercial airliners (but only the airliners were required to equip!)]
  5. 8/31/1986 – over Cerritos, CA, 82 killed when Aeroméxico Flight #486 collided with a small plane (Piper Archer) [the outcome: FAA upgraded the Class B Airspace rules to require small planes to also equip with operating Mode C transponders (this corrected the failure after the 1978 midair, when only the airliners were required to equip)]

The midairs have declined, but they still happen. More often than not, the midairs and near-midairs of the past couple decades have nothing to do with equipment and everything to do with controllers/pilots who are distracted, bored or excessively fatigued. And, particularly with ATC, sometimes they are just too cocky, having seen that they will not be held accountable should they screw up.

See also:
  • (5/9/1999) – An Actual Midair Between a Helicopter and a Cessna at San Jose’s Reid-Hillview Airport. This one was swept under the rug, and a key event in this website creator’s process of learning, while an FAA ATC, just how corrupt his employer was/is.
  • (7/25/2010) – Safety Failure: A Concealed Error at Camarillo Tower. A clear controller error by a newly-certified controller, witnessed by a supervisor. This one was also swept under the rug. Since then, all three Camarillo personnel who cooperated in the coveruup (One’ Nielsen, Kevin Pruitt, Robin Dybvik) have been promoted into higher management positions. The website creator learned about this incident from a former coworker who was concerned about the cover-up; frankly, stories such as this exist at many – if not most – control towers.  (see also documents within this 60-page FOIA lawsuit ‘Discovery’ package)
  • (4/24/2014) – ANALYSIS: Controller Error & NMAC at Newark, poor awareness caused a near collision at the main runway intersection, between a commercial arrival and a commercial departure; the arrival saw the conflict late, then abandoned their approach and climbed to pass over the departure.
  • (5/8/2014) – ANALYSIS: Controller Error & NMAC at Houston, a momentary oversight by ATC causes a conflict between two departures, resolved by on-board TCAS automation directing evasive maneuvers.
  • (8/9/2014) – ANALYSIS: How AOV Covered Up the KCMA 7-25-2010 OE, a team is flown to Camarillo to conduct an investigation – 10-months after the incident! That night, the investigator sends a detailed email to Tony Ferrante, FAA’s top person for safety. Two months later, this all gets watered down in a 5-page memo that selectively deletes key data points. This post reveals the Cover-Up strategies and sequence.
  • (8/24/2015) – Quote by Scott Bloch, in a 5/29/2011 blog post about endemic FAA corruption; includes a link to the source article)

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

FAA, NTSB Need to Accelerate Transparency about Midair Collisions

Two men were killed three days ago, when their Cessna was broadsided by a low-flying Air Force F16. This was a tragic accident that should never have happened, and would not have happened if any of the following practices had been followed by FAA:

  1. ensure the instrument approach procedures designed and approved by FAA do not create high-risk conflicts with nearby airport operations (in this case, the GA field at Moncks Corner);
  2. regulate military jet instrument practice in civilian airspace to include much slower maximum airspeeds (i.e., if  ATC cannot ensure that the route is clear of all other aircraft, then ATC must restrict the military jet to much slower speeds, as they would a civilian jet).

The Cessna occupants died, so it is easy to try and pin the blame on them for having just taken off and being in the wrong spot when the collision occurred. But, based on statements made to reporters in the immediate aftermath, it is clear that FAA’s controllers were working the jet, and that it was at a very low altitude either setting up for or actually on a published instrument procedure. It is also clear that high-speed low-flying military jets were a huge concern in South Carolina, even a week prior to the midair. For example, a news article on June 29 generated the following selected reader comments:20150707scp.. Comments re low-flying SC military jets, from recent WYFF article, 'Fighter jets heard, spotted over Upstate'

There appears to be a developing trend toward more aggressive military training flying, with more impact upon residents below. This incident reveals the worst-case consequences of this trend. The ATC clearance issued by the radar approach controller to the F16 pilot is a matter of documented fact. It is recorded digitally, and the audio data is saved, by FAA. Likewise, the radar data used by the controller working the F16 just prior to the midair collision is also digitally saved. This data will show conclusively, where the actual collision occurred (the lat/long as well as the altitude), the flight directions of the two aircraft at time of impact, and what opportunities ATC had to ‘save’ the accident from happening.

These digital files are immediately retrievable by FAA, thus have already been shared with NTSB. When Boeing 787’s had battery fires a few years ago, NTSB did a fantastic job showing the problem (with pictures of a burnt battery, no less) in a timely news interview. Likewise, when the Asiana flight crashed while landing at San Francisco, NTSB again was wonderfully transparent. We need this transparency, not only to help answer the reasonable questions and concerns of many citizens, but also to accelerate the ‘lessons learned’ from aviation tragedies, to help active pilots avoid tragic repeats. It has been three days, and FAA needs to post these files online, for the world to see the scenario that led to this tragic midair collision.

The Need for Safely Designed Approaches

Many people do not realize that the flight of the arriving F16, reportedly doing instrument practice into Charleston AFB [KCHS], is not at all random. That is to say, the flight was communicating with FAA ATC, was flying in accordance with an ATC clearance, and was either on or joining a published approach procedure. These published procedures are supposed to be designed so as to minimize safety hazards. Dozens of different offices have to sign off before a new procedure is finally published, so it should never happen that a procedure is published that routinely puts aircraft at risk of collision. That said, take a look at this published approach, the RNAV (RNP) Z Runway 15 to KCHS:


(click on image to view larger PDF copy)

Note the fix KREIS (upper red box), with a hard altitude of 3,000 feet. Note also the first speed restriction is at JCEEE fix, 4.4 miles after KREIS fix (lower red box). 20150707scp.. Midair VFRmap, showing potential routes & KREIS fixThe lat/long for KREIS places it as indicated in red on the VFRmap portion. A left-turnout departure by a Cessna from KMCS to Myrtle Beach would approximately follow the green curve. The red line leading south to KREIS fix would approximately depict an arrival from Shaw setting up to fly this published procedure (i.e., a radar vector or a ‘Direct KREIS’ clearance). It is common practice for pilots to level off at the next crossing altitude (in this case 3,000 feet) at least a few miles before arriving at the fix. So, IF the arriving F16 was in fact being set up for this published approach, the pilot would have likely been screaming along, even in excess of 300-knots, and at a very low altitude of just 3,000 feet. Also, look closely at this published approach and it quickly becomes clear: with the annotations about ‘Radius to Fix required’ and very advanced (low) RNP requirements, this is clearly an approach NOT for regular GA flights, but most likely for military use.

We do not know if the F16 was flying this approach or another. FAA can easily answer this question, as they need to do with no further delay. As a matter of practice, to best serve the entire public (not just the narrow interests of aviation), FAA needs to routinely and immediately disclose audio recordings, transcripts, and radar presentations that depict the facts, following significant aviation incidents such as midair collisions. Clearly, a timely internet posting at the FAA website would be both effective and efficient.

FAA Opacity on Safety Data: the ATSAP Black-Hole

It is also highly likely that the FAA controller immediately filed an ATSAP report. This program grants immunity to controllers if/when they have an incident, so long as they voluntarily report what happened. The controllers are not required to report all details, and being human, they tend to report a story that places them in a positive light. But, even with that, they do report important details, that need to be disclosed if the public is to understand the incident. Regrettably, FAA has gone to considerable effort to permanently conceal all ATSAP report content; i.e., the details reported are held in such strict confidence that FAA even tries to hide them from Judges. Despite the fact FAA could easily (and routinely) sanitize the report contents with minimal redactions (similar to the way NASA ASRS reports are slightly altered) and then immediately disclose the amended report, FAA refuses to do so. Thus, when people want to learn from tragic accidents that ATC failed to save, there are no facts to be studied. Instead, we have to wait until months and years later, when a fully sanitized and carefully coordinated story is released by FAA and NTSB.

Midair Collision at Moncks Corner, SC, on July 7, 2015

CBS46 News

News reports indicate that an Air Force F16 flying a short flight from Shaw AFB in Sumter, SC [KSSC] to the Air Force Base in Charleston, SC [KCHS] broadsided a Cessna C150 over Moncks Corner, SC. The Cessna is believed to have just departed the Berkeley County Airport [KMKS], southwest of Moncks Corner, and was reportedly heading east for Myrtle Beach [KMYR]. Note that the straight-line distance from Shaw AFB to KMKS is 52nm, and from Charleston AFB to KMKS is 17nm. In a TV news interview, the Shaw AFB commander indicated the collision occurred when the F16 was at 2,000- to 3,000-ft altitude.

Orange line shows approx. route for Cessna, to Myrtle Beach. Green line shows extended centerline to KCHS Runway 15 (the F16 final course). Collision at center of red rectangle (approx.).

Shaw AFB is in upper left corner, Charleston AFB is near bottom left corner. Orange line shows approx. route for Cessna, to Myrtle Beach. Green line shows extended centerline to KCHS Runway 15 (the F16 final course). Collision at center of red rectangle (approx.). (click on image to view sectional at VFRmap.com)

Focal areas of the investigation will include:

  1. What was the precise lat/long, altitude, and time for the actual midair collision? This should be easily produced from FAA radar records.
  2. What is recorded by FAA/ATC on the radio communications? (this should show precisely what the F16 pilot requested, what ATC issued, whether any transmissions were made to help the F16 pilot not collide with the Cessna, etc.)
  3. For the F16, what time did they depart Shaw AFB, and was this just a quick hop to Charleston AFB, or was it more involved, including setting up with ATC for an instrument approach?
  4. What was the route of flight, altitude at top of climb, and flight condition (level, descending, on a radar vector or DME arc, etc. at the moment of impact) for the F16?
  5. Exactly what was the so-called ‘instrument training’ reportedly being done by the F16 pilot, during the minutes leading up to the collision? (in particular, experienced pilots will note it appears hazardous and not consistent with published instrument approaches, for a military jet to be so low, so far from KCHS, and in the vicinity of Lewisfield Plantation)
  6. For the Cessna, the airport and runway of departure, route of flight to the point of impact (left downwind departure off Runway 3 at KMKS?), flight condition (particularly, had the flight levelled or was it still climbing, at the point of impact?), and first and last times the radar target was displayed for ATC.
  7. What guidelines are local GA pilots advised to follow, as set up by FAA/ATC, to minimize the risk of conflict with Air Force training to KCHS Runway 15?

See also:

ANALYSIS: Another Frontal Passage Tragedy, this time in Plainview, TX

Early news reports indicate that the tragic death of three family members in a small airplane crash in Plainview, TX was likely caused by wind turbulence related to a frontal passage. Plainview is 35-miles north-northeast of Lubbock, at the bottom of the Texas Panhandle. Earlier this year, another frontal passage caused three Texas air crashes in the same day; miraculously, there were survivors in one of those three accidents.

Adding to the tragedy is the fact that all four accidents would not have happened if the pilots had elected to wait for the front to pass. An advancing cold front is hard to not notice, when a pilot checks the weather outlook before flying. Just like controllers, pilots have to avoid complacency. Pilots have to be vigilant about weather risks, and always incline toward staying on the ground if there is ANY doubt as to the level of weather risk.

Not just pilots, but passengers too, need to be aware of the potentially insurmountable hazards associated with weather, especially with the emerging evidence of weather intensification related to record atmospheric CO2 levels. Intensified weather can even destroy larger aircraft, as happened with Indonesia AirAsia Flight 8501, an Airbus A320, which crashed after encountering extreme weather over the Java Sea, killing 162 last December 28th.

The NEXRAD Sequence

The weather risks associated with the Plainview crash are well illustrated by the progression of weather radar maps. A loop of hourly images for the entire day of 5/29/2015 is viewable at WeatherUnderground.

These radar maps are a NEXRAD (Next-Generation Radar) product. NEXRAD is a network of 160 high-resolution Doppler weather radars installed in the 1990’s. They provide enhanced capability for tracking precipitation and severe weather.

Here is an image from nearly three hours before the Plainview accident. It shows a large weather buildup west of Amarillo, growing and progressing southeastward. The accident airport is depicted by a pink circle, north of Lubbock:20150529at1900CDT.. NEXRAD KPVW marked up

And here is the sequence of hourly weather images, at 8pm, 9pm, and 10pm local time. Notice how the front builds and quickly moves NW to SE, and pay attention to the airport location (see above, just below the Interstate-27 symbol, near map center):
20150529at2000CDT.. NEXRAD KPVW

NEXRAD image at 8:00PM local time.

20150529at2100CDT.. NEXRAD KPVW

NEXRAD image at 9:00PM local time.

NEXRAD image at 10:00PM local time.

NEXRAD image at 10:00PM local time. Notice the green line to the southeast and ahead of the fast-moving front (marking the front edge of the mixing zone?).

Here is the sequence of weather observations (METAR), as recorded by the on-airport AWOS-3 system. It reads like a classic frontal onset: clear skies and light winds from the east. A pleasant evening. The winds then become calm, just before a roiling sky suddenly clouds up, temperatures plunge, and the altimeter and winds spike. This flight took off in the narrow window of calm, just ahead of the storm.20150529.. KPVW METARThe sequence suggests a very high probability that the pilot may have encountered wind shear and even rolling turbulence shortly after becoming airborne. In their study of weather, pilots are trained to expect turbulence aloft, that there is an intense zone of mixing in the steep band of air just ahead of an arriving mass of colder air.

FAA and NTSB need to emphasize to all pilots, that weather hazards need to be deeply respected, and that complacency has no place in the cockpit. Going forward, a less aviation-promotional and more safety-assertive stance by regulators can prevent incidents like this from repeating every few months.