CVR (left) & FDR (right)
On Friday, just two days after the fatal crash of UPS Flight 1354 at Birmingham, NTSB held their third media briefing. NTSB member Robert Sumwalt did an excellent job of first updating on the newest details, and then fielding questions for 11-minutes, while at all times trying to simplify and ensure*…Both the CVR and FDR are typically magnetic tape devices, and are positioned in the tail section to minimize potential for the data to be destroyed in an accident. his audience would not be blinded by technical jargon. He talked about the aviation data sources including the Cockpit Voice Recorder (CVR),* and the Flight Data Recorder (FDR).* He discussed ATC and then, at 7:10 on the YouTube video, he briefly discussed MSAW.
Minimum Safe Altitude Warning (MSAW) is a safety system built into FAA’s radar that is designed to process data (primarily position, speed, and acceleration) and constantly calculate a probability that the aircraft is getting too low. The terrain is modeled into the computer, and the computer uses the data to project where the aircraft will possibly be in the future.
In March 1993, FAA had intentionally disabled the MSAW at Guam. 53-months later, a jumbo jet crashed short of the runway at 1:42AM on August 6, 1997, and 228 people died.
Normally, if a hazard is sensed by the MSAW system, the controller will see a flashing data block on the radar display, and will hear an audible alert. That is the design, but if the controller is distracted (or if the system has been turned off), MSAW will not help.
NTSB’s deepest concern about the Birmingham UPS crash may be that, again, FAA has failed to use the MSAW system to help prevent a very preventable accident. In the next couple weeks (or even years, if they need to delay), NTSB’s internal investigative discussions will repeatedly go back to 1997, and the accident at Guam that killed 228 people. This crash destroyed lives, spurred lawsuits, stained the pride of an entire nation, and necessitated a huge investigation, plus hearings. Yet, none of this would have happened if MSAW had been properly used by one attentive air traffic controller.Here is a copy of the Probable Cause, as finalized by NTSB 29-months after the crash:
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to adequately brief and execute the nonprecision approach, and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach. Contributing to these failures were the captain’s fatigue and Korean Air’s inadequate flight crew training.
Contributing to the accident was the FAA’s intentional inhibition of the MSAW system and the agency’s failure to adequately manage the system. (highlight emphasis added)
A Closer Look at the Guam Accident…
Here is what NTSB reported, within Exhibit 3U of their investigation:
“…On August 6, 1997, Korean Airlines Flight 801, a Boeing B-747-300, crashed while executing a localizer approach to runway 6L at Guam International Airport. During the ensuing investigation of the FAA radar facility at Guam, NTSB investigators observed that the Minimum Safe Altitude Warning (MSAW) function in the radar system was inhibited from generating low altitude alerts throughout practically all of the Guam airspace. Further investigation revealed that the inhibiting of the MSAW was neither a fluke nor a malfunction but rather was an intentional adaptation change for the purpose of eliminating numerous nuisance low altitude alerts.
The software site adaptation parameters, prepared at Guam in March 1993, changed the MSAW eligibility area to a 1 NM ring from 54 NM to 55 NM. This change reportedly was discussed and agreed upon by the personnel at the Guam facility, Western-Pacific Region and the Technical Center for use temporarily until a better solution to the problem of nuisance alarms could be found. There is no documentation of this agreement. The change became operational in February 1995.
In July 1995 a facility evaluation report stated that MSAW was operating but was inhibited. The report also stated that a notice to airmen (NOTAM) was issued; however, no such NOTAM can be located. In February 1996 a new software build was prepared which included the same MSAW eligibility data as the previous version. The new software version with the 1 NM ring eligibility area became operational in April 1996. The KAL 801 aircraft did not generate any ARTS-IIA MSAW alerts due to the 54 NM inhibited area….” (emphasis added by aiREFORM.com)
In other words, the visual and audible alarms were shut off. The MSAW system did work, and it did detect the altitude problem by Korean Flight 801, and generated signals within the system, but the inhibited system made no sounds, flashed no radar datablocks … and thus no warning was ever forwarded to the pilot. Had the system not been inhibited by ATC, the controller would have seen the first MSAW alert 78-seconds before the actual impact. NTSB concluded that was plenty of time to effectuate a save.
FAA had the technology, but in a ‘cowboy move’ (no offense intended to real cowboys!), they knowingly chose to shut down the technology, oblivious to the fact that on a dark and lonely night, some controller would need the alarms to catch his misplaced attention, to save an accident from happening. And, frankly, when you read the NTSB report on Korean Flight 801 and you see the string of lame and empty explanations offered by FAA (not just the yellow highlights above, but EVERYWHERE in this huge investigative report), you realize this agency/cowboy is a tall-tale-teller … and a safety fraud.
…and how that informs the Birmingham investigators
NTSB has been through this very many times. They have a job to do, and in the present configuration they are doing that job very well. They are not just investigating these aviation accidents and pigeon-holing data; they are also informing; they are empowering us citizens to better understand aviation in a clear and true light, absent the spin and PR that has become so too common these days. But, again, NTSB has been through this very many times. FAA and other aviation interests have deep economic interests to protect, thus there has always been enormous pressure on NTSB to not go too deeply into areas that show negligence by controllers, mechanics or others who did not make the list of fatalities. It is much easier to simply assign blame to the deceased, or to find a low-budget scapegoat guilty of a marginally innocent mistake. Much easier, and costs a lot less money. And, so, in the past, that is what the NTSB reports have almost always concluded: sorry, some dead pilot did this.
The thing is, these accidents do not happen in a vacuum. They *…I worked 22-years as an FAA air traffic controller, and I experienced this TV problem. I saw the corrupted culture that would justify the use of television sets in the control tower work environment. And, I saw the adverse consequences to those who spoke up to clean it up.linkhappen within a system filled with professionals and technologies, and with a level of redundancy that has made it clear: today, the biggest vulnerability has come to be boredom and inattention,* because bored people doing repetitive work become complacent, drop their vigilance, and pick up their distracting devices. And, then, when people die, and a few scared managers and scared union leaders come swooping in to guide their testimony, the one controller who knows the whole story learns to stay quiet. And so, a normally reliable controller has to carry his dark secrets to the grave, all because he let down his guard just one too many times.
I am not saying that the controllers at Guam or Lexington or Birmingham are absolutely hiding a dark secret. I am saying that, if they are, they will live better if they follow the instinct they were born with (and not the one they acquired at their workplace) and fully participate in the investigation. Tell the truth, the whole truth, and nothing but the truth. For, the truth will set us all free from the hell of a corrupted work culture. And man oh man, it is hell…
Maybe, just maybe, today’s NTSB is bold enough to press through and get the unabridged story. Pull out the real facts, and inform all of us, so that FAA and others in aviation can actually learn, and grow. And begin to do their intended jobs: protecting lives.
Sixteen years after Guam, it is the least respect we should show for those 228.
Here are some links…
…Includes a brief Executive Summary, a list of 36 conclusions, a statement of Probable Cause, and a list of 16 recommendations.
8-18-1997Memo from Jay Riseden to Jeff Griffith (1p)
…Mr. Riseden was an FAA automation specialist dispatched to Guam immediately after the accident, to identify and correct MSAW deficiencies. In this memo, he reports that he found the Guam MSAW parameters had been set “…to generate alarms on aircraft only if the target was between 54 nautical miles and 55 nautical miles from the ASR-8 (radar). Why and under what circumstances this parameter was so set is unknown….” He also reports his corrective actions. [NOTE: Mr. Griffith was one of the highest officials in FAA’s Air Traffic program; he retired in 2002, and is presently listed as the VP of Aviation at the WCGroup, a major contractor for FAA.]
2-19-1998ATC Factual Report (23-pages)
…This report contains the definitive summary of ATC performance. It includes the interview summaries for three ATC personnel: Marty Theobold (FAA CERAP/radar controller) at pg.13; Kurt Mayo (contract tower controller), at pg.17; and Sherie Ewert (manager at the contract tower). Signed by Richard Wentworth, Chairman of the ATC Group for the NTSB Investigation.
…FAA’s Operational Support Directorate made this 14-page presentation at the KAL801 Public Hearing, in Honolulu. The aim was to explain MSAW. At page 12, it states that on “…October 3, 1997, FAA established a method for strict configuration management of MSAW.”
3-25-1998Two Articles about the NTSB Hearings in Honolulu
…These articles appeared in the Honolulu Star-Bulletin. The first article, Two Systems Down in KAL 801 Crash, reviews ATC system deficiencies and controller testimonies, as discussed at the hearing on the previous day (3/24/98). The second article, Air crash survivor wants answers, describes the escape from the wreck and the ongoing consequences for Korean passenger Kim Duck-hwan.
FAA.govFAA’s webpage presenting an ‘Accident Overview’ for KAL801
…This is FAA’s final (some would say ‘slanted’) presentation on the events leading up to the crash of KAL801. It appears heavily weighted toward pilot error and failed crew resource management, with an emphasis on subservience in Korean culture as a potential hazard in aviation. It is very thin on the simplest, easiest way to have prevented this accident: ensure MSAW is functional, and the controllers are using it.