Pilot Fatigue: a Problem FAA Still Needs to Address

Flying Magazine published an article by Stephen Pope, Fighting Pilot Fatigue: New Views on Staying Alert.PDFThe article looks at the long history of fatigue-related accidents, and the insights collected in recent years.

The article refers to the Colgan 3407 accident in Buffalo on 2/12/09, as well as the crash of a Beech Baron in Teterboro at 3:05AM on 8/21/2009. Fifty died in Buffalo, in an accident that put HUGE political pressure on FAA about many commercial aviation issues:

  • FAA’s ongoing refusal to resolve pilot fatigue risks,
  • the apparent lower quality assurance standards at commuter/feeder airlines,
  • common long-distance commutes by underpaid pilots,
  • and the deceptive sales of tickets by major carriers, but for flights flown by commuter/feeder airline subcontractors.

Both accidents were fatigue-related, but in a decision that reveals how NTSB can be pressured to help FAA accommodate the financial interests of the airlines, the actual reports were drafted to direct attention at other, non-fatigue issues. This finally caused a minor rebellion by two NTSB members in 2011, when the Teterboro [KTEB] crash report was finalized. Both Chair Deborah Hersman and member Mark Rosekind submitted dissenting opinions. “Despite substantial indications of fatigue effects,” Rosekind wrote in his dissenting brief on the Teterboro crash, “the present accident report fails to acknowledge fatigue’s role in the accident. Based on the factors identified, fatigue was a likely contributory cause.”

In the years since, some minor rule changes have been implemented, but they exclude the sector of pilots most susceptible to fatigue issues: cargo pilots, who commonly work overnight shifts. One such example was the UPS Flight 1354 crash at Birmingham, AL on 8/14/13, which killed two.

So, that’s some of the background. Here are three short excerpts from an article well worth studying, about an aviation risk FAA still needs to address…


EXCERPT “In the last decade alone researchers have made tremendous strides in sleep research, noting in studies, for example, that getting even 30 minutes less rest in a single night can impair performance and memory the next day, and that the effects of sleep loss are cumulative, meaning that the sleep we get is like money we deposit in the bank. If we continually draw down our “sleep accounts” for several nights, the effects can be cumulative — and lethal.”

EXCERPT “GA pilots who fly for transportation are at high risk of flying while fatigued. The same factors that go into becoming a pilot/owner of a high-performance airplane, an attractive income and high-achieving attitude, are often associated with a lifestyle that lends itself to fatigue. Typical GA pilots have crazy work schedules, many family commitments, and hobbies about which they’re passionate but which further impact their schedule. The lifestyle of high-achieving individuals puts them at constant risk of flying while fatigued.”

EXCERPT “The NTSB put pilot fatigue on its “Most Wanted” list of safety improvements and kept it there for 22 straight years, but it wasn’t until the crash of Colgan Air Flight 3407 in Buffalo, New York, in February 2009, in which 50 people died, that the FAA rewrote airline pilot rest and duty-time rules.

The Race Past 400ppm Continues…

…with a new Record High. The Keeling Curve atmospheric CO2 at Mauna Loa measured 402.84 parts per million (ppm) on May 31st, and the May average will soon be announced. A year ago, the May average was 399.76 ppm. Two years ago it was 396.78 ppm; in 2004 it was 380.63 ppm; in 1994 it was 361.68 ppm. Atmospheric CO2 ppm is not just increasing — it is accelerating. In the meantime, government officials fail to address this emerging problem which will raise ocean levels,  intensify weather, and destroy crops. This puts everyone at risk, not just of ‘inconvenience’, but of species collapse.

click on chart to see Keeling Curve at Scripps (ucsd.edu)

Aviation has an exceptionally high rate of CO2 production. An hour spent on a commercial airliner is roughly equivalent to ten hours spent driving a car. In fact, a concerned citizen who minimizes energy consumption can destroy all of their gains by just one long-distance flight. Substituting biofuels is not a solution, as biofuels still contribute to the growing CO2 levels, which are now far beyond what any humans have ever experienced. The only real solutions will include aggressive actions to reduce aviation, such as:

  • the imposition of steep aviation fuel taxes (or an overall carbon tax);
  • the curtailment of aviation subsidies that encourage excessive air travel, especially by businesses and corporations;
  • substantial reduction of air cargo shipment, especially those on all-cargo fleets;
  • and, a careful management of the overall aviation system, to eliminate fuel-inefficient doglegs such as are done when Super-Hubs are used (Atlanta, O’Hare, DFW, Newark, and Charlotte, are among the worst).

AD 2014-03-03 adopted by FAA (icing hazards on Cessna light twins)

Earlier this week, FAA announced adoption of a new airworthiness directive [AD 2014-03-03] aimed at Cessna’s light twin engine aircraft. This is a new fix to an old problem, as most of these aircraft models were built more than thirty years ago. The most abundant of the group, the Cessna 310, was produced from 1954 until 1980, with more than 6,300 sold (Wikipedia notes the 1978 purchase price was under $148,000). NTSB’s accident records show that there have been 436 fatal incidents involving the Cessna 310 in the last fifty years. Last year, three Cessna 310’s were involved in fatal U.S. accidents (2/14/13 at Vero Beach, FL; 11/12/13 at Junction, TX; and, 12/8/13 at Jacksonville, FL).

Yes, FAA has finally announced their new safety directive. Take a closer look at what FAA wrote when they initiated the proposed rule via an NPRM proposal, on June 3, 2011:

These airplanes’ certification basis did not include Amendment 7 of CAR 3 Dated May 15, 1956, which required an applicant to provide to the pilot the types of operations and meteorological conditions (e.g. icing conditions) to which the operation of the airplane is limited by the equipment installed (CAR 3 § 3.772). Therefore, the pilot may not realize that, even with de-ice boots or other similar equipment installed, the airplane is not certificated for flight into known icing conditions. To address this condition and based on the accident history, there is a need to add a limitation to prohibit flight into known icing conditions due to the limitations of the installed equipment.

So, in 2011, when FAA turned age 53, suddenly a middle-aged agency finds serious limitations in the installed equipment on aircraft manufactured even BEFORE the FAA came into existence? Suddenly, this situation needed new regulation? Naahhhhh.

FAA Whistleblower Richard Wyeroski knows a lot about this issue. He flew (and instructed in) light twins, and he also served as an FAA inspector, before they retaliated against him. Here is his view…

“…(FAA was) controlled by industry and allowed piston twins to fly even when they knew it was dangerous. The accident rate sure does reflect it. This is because of the money!… not safety! Quite frankly there are very few if any piston 135 operators, because the insurance companies have priced insurance too high, and the accident rate is high. So FAA is back peddling and after 30 years coming out with a “cover their puny asses AD” now prohibiting flight into known icing….”

…to read more about light twins, the air cargo industry, insurance rates and the NTSB accident investigations (including links), please click on page two…

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?

Analysis: Kyoto Protocol and Aviation’s CO2 Impact

There is simply no rational denial to this simple fact: the amount of human-created CO2 in Earth’s atmosphere has climbed at an extraordinary rate, and to unprecedented levels.

The earliest fossils of our species, Homo sapiens, date back to 200,000 years ago. Our scientists have compiled a much longer record of CO2 in our atmosphere, going back 400,000 years. That record shows that CO2 levels naturally rise and fall over time, mostly related to wobble in Earth’s orbit around the sun, as explained by the Milankovitch Cycles. As seen in this graph, natural CO2 variation follows a 100,000 year cycle, with CO2 levels bottoming at 180 ppm (parts per million), rapidly climbing to peaks around 290 ppm CO2, then gradually decreasing back to the 180 ppm level. We should have peaked out at 290 ppm around 1950, but the CO2 concentration just keeps climbing. In other words, while a natural history shows the record peaks were 290 ppm atmospheric CO2, we are now way above that and hit 400 ppm earlier this summer. Worse, we have full confidence that, based on the last 55-years of careful measurements, we will see consistent annual rises of 2-3 ppm. Thus, we will peak around 403 ppm in 2014, and around 430 ppm in 2024. All of this added CO2 is energizing our weather systems, which in turn is accelerating land erosion and disrupting the timing of natural growing cycles. The insects and plants are forced to adapt or die, which puts our food supply at risk. The changes are so fast that adaptation is failing … which puts US at risk.

Consider this: humans did not even become aware that their atmospheric CO2 level was climbing so rapidly and was clearly connected to fossil fuel consumption until the 1950’s, and it took another three decades to begin to frame international solutions to the emerging Climate Change problems. We are way behind the curve on this. Furthermore, there is no evidence that this CO2 upward trend will change, without a concerted human effort to cap CO2 emissions … which means, curbing personal consumption of energy. The low-hanging fruit is obvious: better insulation; lifestyles that are more locally focused; and less travel, which will particularly impact Aviation.

How did we get to this situation?

Anthropogenic CO2 emissions since 1750. Note the dramatic rise in fossil fuel use (red line), starting around 1951

The human habit of massive CO2 generation via the burning of fossil fuels is a relatively recent development. As this graph shows, fossil fuel use barely rose until the late 1800’s. The earliest increases in fossil fuel consumption were the use of coal, to power machines in the early Industrial Revolution. But, real changes in the rate of fossil fuel consumption correlated with the development of railroad transportation systems (late 1800’s), followed by the development of the automobile and its marketing as a mass-consumption item (just after 1900), and lastly by the rise of modern global lifestyles (with suburban commutes, international air travel, and thousands of mass-marketed gas-powered convenience devices such as lawnmowers, from the 1950’s onward).

This unprecedented increase in anthropogenic CO2 emissions puts aviation on a collision course. Someday, and likely within the next 5-10 years, Aviation will have to resolve the fact that, when a person chooses to fly, they gain the convenience of speed while making a disproportionately large contribution to the atmospheric CO2 balance. This is a clear tradeoff, with the passenger gaining a personal ‘luxury’ at a cost to the environment. So, if we are ever to become serious about addressing Earth’s CO2 balance and minimizing Climate Change impact, energy use in Aviation is among the low-hanging fruit — and it will be one of the first and easiest targets used to reduce our emissions.

The Kyoto Protocol

The acceptance of the fact that we have a CO2 problem, and that it will drastically change our world via Climate Change, generally began in the 1980’s. A key step was international agreement to be bound by the Kyoto Protocol. Essentially, all participating nations set targets, with commitments to reduce their CO2 emissions at future dates. A first commitment period sought modest reductions (around 4-5% below 1990 levels) during the 2008-2012 timeframe; a second commitment period sought more substantial reductions during the 2013-2020 timeframe.

The U.S. is by far the leading source of atmospheric CO2. Can the U.S. become a leader in solving this problem?

The treaty also recognized that developing countries had a much smaller per capita impact; specifically, for 2010, an average person in a developing country caused barely a quarter of the CO2 emissions by an average person in a developed country. Because of this disparate per capita impact, UNFCCC placed a larger burden upon the developed nations to reduce their CO2 emissions.

This larger burden was the basis for U.S. rejection of the Kyoto Protocol. Many would reasonably see this U.S. rejection as a declaration that we as a nation are ‘exceptional’ with our right to consume far in excess of the average world citizen.

Here is a short chronology of the Kyoto Protocol:

  • 1988: The Intergovernmental Panel on Climate Change (IPCC) was established jointly by the World Meteorological Organization and the United Nations Environment Programme.
  • May 9, 1992: The United Nations Framework Convention on Climate Change (UNFCCC) was adopted in New York. A condition was that the new Protocol would not be entered into force until ratified by at least 55 nations attending the convention.
  • December 11, 1997: The Kyoto Protocol was adopted in Kyoto, Japan.

    Before & After: mining of the Alberta Tar Sands

  • 2001: The U.S. Senate voted to reject the Kyoto Protocol because it did not set binding goals on the lower-impact developing countries. President Bush then withdrew U.S. endorsement of the Kyoto Protocol.
  • 2002: Russia and Canada ratified the Kyoto Protocol.
  • February 16, 2005: Kyoto Protocol entered into force (became effective).
  • 2009: A new administration under President Obama raised the possibility that U.S. leaders would take action in support of the Kyoto Protocol. Later that year, another Climate Change conference was convened at Copenhagen, and produced new CO2 emission targets.
  • 2011: Canada, under new Prime Minister Stephen Harper, withdrew from the Kyoto Protocol. At the same time, Canada was ramping up Tar Sands mining, with destruction of vast areas of Alberta, Harper’s home province.
  • 2012: another UNFCCC, this time at Doha, Qatar, produced amendments to the Kyoto Protocol. The list of greenhouse gases (GHG) was revised, and participating nations amended their commitments to reduced CO2 emissions.
  • 2013: My country, the United States, is still reeling from the greed that precipitated the 2009 financial collapse, at the end of the Bush administration (which was started under regulatory repeals in the Clinton administration). As such, we remain obsessed with job creation and continue to dodge any meaningful commitment to curbing our appetite for excessive fossil fuel consumption.

So, how is Aviation dealing with this situation?

It appears that Aviation has two key strategies: first, to simply delay, and then delay some more; and second, to somehow develop a means of powering aviation without fossil fuels. Neither is a real solution. And, the evidence is absolute, that FAA is working hand-in-glove with aviation leaders pursuing these two failed strategies.**The same ‘delay, delay’ strategy is also being used by other officials, beyond FAA. For example, see this article WEB with many archived document copies, showing how Copenhagen was just a repeat of Kyoto, twelve years earlier. In fact, many of the officials involved have not changed.

There are many news articles — and they are increasing in frequency — touting research and funding for aviation biofuels. The Public is made to feel there is an imminent and wonderful technological solution to the problem, and the image of college students doing research projects and new jobs to reduce unemployment does not undermine that sales job. The Public is made to believe this, because the PR campaign is so well engineered. But, the core solution is frankly not yet defined. At this point, it is all just smoke and hologram.

The fact is: the world population continues to grow, and many will protest if/when we find land is being used to grow aviation fuel instead of food. Eventually, something has to give.

FAA’s MSAW Failures: 16 years and no progress?

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…

  • NTSBNTSB’s 22-page Abstract, summarizing the full KAL801 report.
    …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.
  • 3-24-1998AOS MSAW Briefing
    …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.

UPS Flight 1354 crash on approach to BHM, on 8/14/13

Fatal Air Crash

Investigators scour a hillside looking for evidence in the fatal crash of a UPS cargo plane in Birmingham, Ala., on Friday, Aug. 16, 2013. The twin-engine Airbus A300 aircraft went down on Aug. 14 during a flight from Louisville, Ky., while attempting to land.

Three days after the accident, here is a summary (with links) of the data, facts, causal theories and investigative focal areas for the crash:

  • The crash happened at 4:49AM when an Airbus 300 flying from Louisville [KSDF] to Birmingham [KBHM] first clipped trees and a powerline at Treadwell Road, then impacted a hillside, broke apart and erupted into flames. Both pilots were killed.
  • The flight crew’s workday began with a 9:30PM Tuesday departure out of Rockford IL, a stop in Peoria, IL, and another stop at Louisville, KY. The flight to Birmingham was their third leg in an overnight work shift.
  • Weather was not an apparent issue. The hourly METAR weather sequence, produced just four minutes after the accident, was: KBHM 140953Z 34004KT 10SM FEW011 BKN035 OVC075 23/22 A2997 AO2 SLP141 T02330222. [Translation: 4-knots of wind from the north, visibility ten statute miles, few clouds at 1,100′, ceiling 3,500′ broken, and an overcast layer at 7,500′] On the other hand, it was a very dark sky; the moon had set at 6:08PM the evening before, and the sun was not due to rise until 6:09AM.
  • The flight had been cleared by ATC to execute a Localizer Runway 18 approach. The approach was unusual in that the normal landing runway for this cargo flight is the 12,000′ Runways 06/24. NTSB has said that the runway assignment was due to work on the runway lights for Runway 06/24. At least one news article discusses the hazard of landing larger aircraft on the 7,000′ Runway 18.
[Q: Is there evidence of cockpit discussion regarding runway selection? Do the tapes show a pilot request to ATC? Do the tapes show an assignment of the runway (by the tower, by approach, or even by the center controller) with an explanation? Could the flight crew have landed on the longer runway, if they requested (i.e., was it a matter of trucks on the runway and changing a few lightbulbs, or was the runway lighting substantially out of service?)?]
  • NTSB reported on Friday that the Ground Proximity Warning System (GPWS) onboard the Airbus 300 did announce “sink rate, sink rate” seven seconds prior to initial impact, alerting the flight crew to an excessive descent rate hazard. At four seconds prior to initial impact, one pilot commented out loud that he/she had the airport in sight.
  • *…Unfortunately, FAA has a past history of fatal accidents in which MSAW had been disabled, so as to eliminate ‘nuisance alarms’. The most serious of these accidents happened in August 1997, when Korean Air Flight 801 crashed on approach to Guam, killing 228. wikiFAA’s radar includes a Minimum Safe Altitude Warning (MSAW) system designed to produce alerts so that the controller can quickly advise the pilot. Typically, MSAW compares the flight altitude and descent rate to a digital terrain model, then generates the alert. Thus, an aircraft about to clip a tree and powerline at one mile north of the runway threshold should be detected by MSAW, and it should generate an alert.*
  • Red boxes show eight of the homesites for airport-related house removals between 2006 and 2010. Oddly, the one house immediately east of Treadwell/Tarrant Huffman remains today.

    The impact location was an open field on rolling hills. Images at Google Earth show that roads and structures (apparently past homes) were removed from parts of this location between March 1997 and February 1998, in what appears to have been airport-related earth grading work. Further analysis of these images shows the removal of a smaller group of houses between 2006 and 2010. Three of those houses were immediately east of the Treadwell/Tarrant Huffman road intersection; the other houses were removed from areas further south, and to the east or west of the expanded airport boundary (encompassing the runway safety area to the north of Runway 18).

  • NTSB has established that the pilot flying was Cerea Beal, Jr. Other sources show Mr. Beal, age 58, was a father and resident of Matthews, NC, near Charlotte, and flew for UPS since 1990. The pilot not-flying was Shanda Carney Fanning, age 37, from Lynchburg, TN, flying for UPS since 2006. Both pilots had substantial hours of flight experience, including time in the Airbus 300.
  • *…NOTE: controllers typically work the overnight shift at the end (day five) of their workweek, in shift rotations that increase personal fatigue but lengthen the controller’s weekend time away from work.There were two controllers on duty in the Birmingham tower, but one was reportedly on a break. The working FAA controller was interviewed by NTSB and described flashes typical of a powerline strike, than a red flash on the hillside, when the impact erupted into a fire. At the time of this Friday NTSB briefing, they had not yet interviewed the controller who was on a break.*

Some links…

    • 8-16-2013Member Robert Sumwalt holds third press briefing
      …YouTube video, with updated info, followed by answering press questions.
    • 8-17-2013NTSB: Black box data reveals UPS 1354 equipment normal
      …NTSB member Robert Sumwalt held the fourth and final media briefing for the UPS crash, revealing that inspection of the Flight Data Recorder and UPS maintenance records has found no aircraft basis for the accident. He also advised they will conduct a flight test with a similar Airbus 300, to see how the approach is flown and also to study UPS’ instrument approach procedures.
    • 8-20-2013Autopilot, Autothrottles Engaged in UPS Crash
      …An article at Flying magazine with some info to add to. Suggests a distinct similarity between the UPS crash and the SFO Asiana crash a month earlier: both were unstabilized approaches where pilots were apparently depending on automation. Also, both were nonprecision approaches that lacked glidepath automation, and the flightcrews oddly failed to use the visual glidepaths (PAPI lights) to ensure they were at a safe approach angle.
    • CommentsDissecting the Birmingham UPS A300 Crash
      …Check out the comments in this 8/16/13 Flying magazine article. The comments by Jim Underwood are especially worth reading.
    • KBHMaiREFORM webpage for Birmingham Airport
    • KBHMAirport Diagram
    • UPS1354The flight, as presented at FlightAware.com