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

Aside

QUOTE

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

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

Click here to read the original blog post.

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.

October 4, 2014: A Fatal HEMS accident in Wichita Falls

20141004.. crash fire pic, Wichita FallsShortly before 2:00AM local time, an emergency ambulance helicopter crashed in Wichita Falls, TX, killing the patient and injuring the pilot and both flight nurses.

20141004.. United Regional Health, helipad and reported accident siteNews reports indicate that the Bell 206 helicopter, based in Duncan, OK, had been dispatched to move a 26-yr-old man who had been shot in the Waurika, OK area. Google maps indicates a ground ambulance would have been a fairly direct drive, 38-miles in just forty minutes, to get to the hospital in Wichita Falls.

Here is a clip from an online satellite view. The crash location (red circle) is roughly one block from the helipad (smaller orange circle) at United Regional Health Care System.

Weather appears to have not been a factor. The METAR sequence at [KSPS] shows clear skies, calm winds, good visibility, termperature 51.

The Air Evac Lifeteam website describes the company as the largest independently owned and operated air ambulance company in the U.S. Based in O’Fallon, MO, it serves 15 states with more than 110 helicopters, operating primarily out of rural bases in the Midwest and South.

The company’s recent accident history includes (click on dates to view NTSB report):

Note that nearly all of this company’s fatal accidents have occurred in the middle of the night, in darkness. The only fatal accident in the daytime was due to a mechanical failure (a defective rotor disintegrated, in a mid-day flight). Fatigue may be an issue, too; the pilots are routinely assigned 12-hour shifts.

Why fly at these dangerous hours? Most likely, for the ‘golden trout’ profits. A 2009 news posting at EMSflightCrew.com had this quote:

…A typical HEMS flight can generate a payment of $20,000 or more. To garner these payments, operators have an implicitly built-in incentive to fly — despite such proven deadly factors as marginal weather at night. One HEMS pilot described every patient as a golden trout. “We need to go get these trout,” he said, because of the generous Medicare reimbursement….

This needs to change, and we depend on FAA to make this change happen.


See also:

Helicopters: the Wrong Way to see Grand Canyon

Five days ago, a pilot employed by Papillon was killed when his/her helicopter rolled over while being repositioned on the floor of Grand Canyon. [article] The air tour passengers had already been off-loaded, so none of them were injured when the fatal accident happened. In the five days since, there has been no new information; neither FAA nor NTSB has released the gender, age or name of the pilot, nor have any weather conditions or other pertinent facts been presented to the Public. We are left to wonder why this tragedy happened, and could it happen again.

There have been many fatal air tour crashes around Grand Canyon. In fact, a careful analysis of news stories and the NTSB accident database reveals thirty significant accidents since 1980, some fatal and some non-fatal. A few were horrific, killing six, ten, and as many as twenty-five. Even the minor accidents hint at air tour practices that add unnecessary risk:

  • crowding too many helicopters together at remote landing spots,
  • parking helicopters too close to picnic tables,
  • worker fatigue, due to long workdays for the pilots and mechanics,
  • lack of maintenance oversight,
  • lack of FAA safety oversight, etc.

Here is a link to a list with short summaries for each of the thirty accidents. Each dated event has further links to online news articles and NTSB reports.

Passenger photo taken minutes prior to the 9/20/2003 crash. (NTSB)

Passenger photo taken minutes prior to the 9/20/2003 crash that killed seven. Analysis of this and other photos showed reckless flying and endangerment by the pilot. (source: NTSB Report)

One accident that really stands out happened in August 2001. A tour group from New York filled twelve seats in two Papillon helicopters. The flights had flown outbound from Las Vegas, spent around an hour in the canyon area, and they had taken off from Grand Canyon West Airport for the flight back to Las Vegas. Just a few miles west of their last departure point, the helicopters crossed Grand Wash Cliffs at roughly 5,500 feet, then quickly descended a thousand feet into the space below the tall cliffs. One of the helicopters crashed, and six were killed. The one survivor lost her husband and both legs, and eventually won a $38 Million settlement. A subsequent NTSB report noted there were no local recorded weather observations. In fact, the nearest official weather reporting station is nearly fifty miles south of Grand Canyon West Airport, and is not adjacent to the canyon; the only known weather fact is that it was a very hot day, around 106 degrees Fahrenheit.

The NTSB compiled a detailed investigative report, which included the following insight into the helicopter air tour industry:

  • Investigators interviewed many, including the Papillon manager at the South Rim (Tusayan), who told NTSB: “The mechanics said that Kevin was the only pilot that they felt comfortable with on test flights.” (underline emphasis added)
  • The report suggested that pilots may be motivated to add more ‘thrill’ to the flight to earn larger tips.
  • One passenger from an earlier air tour flight with the same pilot shared her concerns, and backed them up with a copy of her air tour video. She described what air tour pilots call the ‘Thelma & Louise Descent’, in which the pilot crests low over the top of a ridge, then dives into the empty space on the other side. In her testimony, the passenger said her pilot did the ‘Thelma & Louise Descent’ at Grand Wash Cliffs, a classic location for this maneuver. She testified the pilot asked them if they wanted to do the descent, and they all said ‘no’, yet he did it anyway.

There are many professional aviators who have no love for those who make money using aircraft as a form of ‘thrill ride’. For example, the Sundance helicopter pilot who crashed into a canyon wall in September 2003 (killing all seven on board) was known by the name ‘Kamikaze’, and pilots interviewed in that NTSB investigation expressed many concerns about his long history of risk-taking. There is even an online pilot discussion, where a British tourist seeks feedback, with the title: Helicopter over Grand Canyon – which company won’t kill me?

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

Grand Canyon is an extraordinary place, but it is certainly not an appropriate venue for aerial thrill rides. We can only hope that the latest tragic fatality will precipitate reform and bring an end to this dangerous form of flying.
GCNP Grandview Trail hike pic

What should YOU do if you are coming to Grand Canyon?

One of the facts gleaned while reviewing more than thirty years of air tour accidents is that very many of the fatalities are from Asia, Europe, and other parts of the world. It appears that Grand Canyon vacations are planned to be very special trips. It also appears these tourists may have been sold the idea that an air tour is necessary to experience Grand Canyon.

In fact, this is completely wrong. Just your first view of Grand Canyon will amaze you.

And, frankly, the helicopter ride is thrilling and scary when you first take off, but after that it is mostly just a lot of monotonous flying. And the noise you have to hear while crammed in the helicopter cabin…? Yeah, all air tour passengers are issued headsets, to help block out the loud noise. Too bad for those in the park below, as the ‘thump-thump-thump’ noise carries everywhere, for many miles.

So, please DO NOT book an air tour before you embark on your vacation. Please wait until AFTER you arrive and see the place, to confirm if you really want to give so much of your money to an air tour operator. And even then, please ask yourself one more time, ‘do I really want to make this noise that diminishes the experience for so many other visitors?’

GettingAroundGCNPMake it your first priority to stand at the edge of the Canyon and see how incredible it is, right there. Then, check with the Grand Canyon National Park maps and just walk some of the miles of flat rim trails (or hike below the rim, if you are more adventurous). The views will amaze you. Ride the free shuttle buses, and get out and find your own quiet vista point while enjoying the sunshine and fresh air. Spend a few bucks and enjoy tea or a beer or a pleasant meal at a lodge on the South Rim, while gazing at the view. The experience is so much more rewarding without the noisy helicopter, the stuffy cabin air, and the bouts of flight-induced nausea.

<< <> <<>> <> >>
…if you would like a quick video tour, please see page two of this
Post, which has embedded links to four different videos….

Aviation vs. Railroads: Why is FAA so much slower than FRA to address personal electronics distractions?

Last week, FAA posted in the Federal Register their Final Rule, Prohibition on Personal Use of Electronic Devices on the Flight Deck. Essentially, the new rule declares the obvious … that texting (or computer games or sharing pictures of your cute kids or porn files or whatever) is dangerous, distracting, and must cease immediately …or at least once the rule goes into effect on 4/14/14.

A discussion then developed at FlightAware.com. While most of the discussion participants were pilots and all had a keen interest in aviation, some of the participants were U.S. railroad professionals. They made a very interesting point: specifically, that very similar accident histories have produced very different outcomes by the Federal Railroad Administration (FRA) vs. the Federal Aviation Administration (FAA).

In short, here is the comparison:

Rescue workers in front of the Metrolink locomotive lying on its side after penetrating the lead passenger car (left). (photo from Wiki)

FRA: On 9/12/08, a head-on collision at Chatsworth, CA killed 25, injured 135, and caused $7.1 Million in damages. The NTSB investigation revealed the locomotive engineer was texting and missed a safety signal. Twenty months later, on 5/18/10, FRA issued an NPRM rule proposal via the Federal Register. Fifteen comments were received. The Final Rule was posted to the Federal Register on 9/27/10, and went into effect on 3/27/11.

Thus, for an FRA rail safety failure related to a major accident, it took thirty months from accident to effective rule change.

FAA: On 8/27/06, Comair Flight 5191 took off from the wrong runway at Lexington, KY, then crashed, killing 49. The tower controller had failed to specify the runway and the pilots, evidently fatigued from a short night’s sleep, failed to notice they were on the wrong runway. The controller had nearly a full minute to look out the window and see the problem and ‘save’ the situation with a timely radio transmission. The tower controller failed and the accident happened. Seventy-seven months later (!!), on 1/15/13, FAA issued an NPRM rule proposal via the Federal Register. Sixty-three comments were received. The Final Rule was posted to the Federal Register on 2/12/14, and will go into effect on 4/14/14.

Thus, for an FAA aviation safety failure related to a major accident, it took ninety-two months from accident to effective rule change. Ninety-two months; yes, nearly eight years!

So, in summary, a railroad safety rule by FRA takes 30-months, while an essentially identical aviation safety rule by FAA takes 92-months.

Why does it take FAA so much longer to pass the new safety rules? Most likely, the delay is directly related to FAA (and industry) efforts to protect their financial bottom line: mistakes happen, people die, and those who might have saved the tragedy feel compelled to obscure their culpability, to protect their own interests. So, they maneuver to maximize distance from any risk/liability exposure. In other words, a conscious effort is made by aviation professionals — including some very highly paid FAA officials — to guarantee no accountability for system failures.

The aiREPORT: [2013Q3, week-10]

aiREPORT is a weekly collection of notes and links to news items relevant to aviation impacts and FAA reform. It is provided as a research tool…

Third Quarter, Week #10: September 1 — September 7, 2013

summary:

Top AvNews story: A Judge has rejected airline arguments that the testimony of FAA Whistleblower Christopher Monteleon and the Report compiled by consultant (and former FAA official) Nick Sabatini are irrelevant in trials related to the Colgan 3407 crash in Buffalo. Attorneys representing families of the deceased will have access to these resources. … Also, many more news releases appeared, with elected officials grandstanding about the FAA/AIP money coming home for their constituents. And, lots of what appears to be early maneuvering, to get Congress to exempt FAA from a repeat of last Spring’s sequester debacle…

QUICKlooks:

  • 9/3/13: Helicopter Association International president Matt Zuccaro said HAI is evaluating its legal and political options in the wake of a federal court decision upholding the authority of the FAA to mandate the “North Shore Route” for helicopters transiting New York’s Long Island. [link]
  • 9/4/13: FAA has issued a Notice of Proposed Rulemaking (NPRM) to make it legal for some pilots to fly down to 100′ above the touchdown zone elevation without seeing the airport, before they must execute a missed approach. The current is 200′ (generally). The new standard would apply to crews using enhanced forward vision systems (EFVS) using a real-time image of the flight environment while flying on straight-in precision approaches. [link]

Airports in the News:

  • Cedar Rapids, IA (The Eastern Iowa Airport [KCID]): FAA has announced a $5.2M AIP award for construction of a new taxiway. The new ‘Taxiway Echo’ will parallel the north end of crosswind Runway 13/31, along the east side, and will replace a portion of current Taxiway Delta. The airport averages 153 operations/day (four takeoffs per hour of ATC service), with roughly 30 daily commercial passenger departures. Airport operations have declined 33% since the peak in 1999. News articles from earlier this year expressed concern the project would be delayed by the FAA budget sequester.
  • Telluride, CO (Telluride Regional Airport [KTEX]): A new ATC aircraft tracking system has been activated, which will allow controllers at the center in Longmont to ‘see’ flights below 12,000′, all the way to the ground. The system uses ground-based and satellite-based technologies, and should substantially reduce delays during heavy traffic periods in the ski seasons ahead. [link]
  • Butler, PA (Butler County Airport, Scholter Field [KBTP]): $1M in FAA and state funds will be used to acquire 4 acres and widen the taxiway. This airport is home for roughly 100 GA aircraft, has no control tower, and averages 200 operations per day. Nearby airports include Pittsburgh (KPIT), Alleghany (KAGC), Beaver (KBVI) and Zelienople (KPJC), and are all substantially underutilized. [link]
  • Louisville, MS (Louisville Winston County Airport [KLMS]): FAA will pay 90% of the $734K needed for construction of a new terminal building. This airport has twelve based aircraft and averages 21 operations per day. It is midway between Tupelo and Meridian, both of which have control towers at very slow airports (averaging 150 ops/day). [link]
  • Fort Meyers, FL (Southwest Florida International Airport [KRSW]): A coooerative effort aimed at reducing residential noise impacts began on 8/1/13. The preferred runway for the hours of 10PM to 6AM changed from Runway 6 to Runway 24. The tower closes at 10PM. [link]

Links to Articles:

9-6-2013FAA Cuts the Red Tape to Let UAS Work Yosemite Wildfire
An FAA News Release putting a positive spin on their working with the Department of Defense and the California National Guard to quickly approve use of a drone to aid in monitoring the fires at Yosemite National Park.
9-4-2013It’s a bird; it’s a plane; no, it’s another annoying helicopter
Some good background information on the long history of helicopter noise impact (and safety concerns) related to helicopters in the Hudson River area. Discusses an 8/27/13 symposium held at Teterboro Airport, attended by Senator Menendez, Congressman Sires, and many other local officials. Some say it the problem is beyond tourist helicopters, which supposedly cease at 7PM. The problem is said to be later traffic using the Paulus Hook Heliport and the repair facility at Kearny. A quote: “The quality of life of our residents has suffered due to the constant noise being generated by these aircraft, and we are all concerned about the frequency and dangerously low altitudes at which these helicopters are flying over our neighborhoods.”
9-3-2013Judge grants access to internal review, FAA inspector in advance of trial in 2009 plane crash
Fifty people died when Colgan Flight 3407 (flying as Continental Connection) crashed into a house in Buffalo in 2009. The accident investigation unveiled very troubling details about pilot pay, pilot fatigue, FAA blocking of Whistleblower concerns, etc. The airlines used a bankruptcy to delay the release of critical records. OF 40 filed lawsuits, all but eight have been settled through mediation. A trial is set to start on 3/4/14. Shortly after the crash, Colgan hired Nick Sabatini (FAA’s Associate Administrator for Aviation Safety, who had just retired on 1/3/09) to look at their operations and draft a confidential report. The airlines did not want to share the report, and claimed the report was irrelevant because the work culture at Colgan had changed. U.S. District Judge William Skretny disagreed;  he said the report was potentially relevant because it was unlikely that the culture at Colgan had significantly changed in the weeks after the crash. Additionally, the Judge approved testimony by FAA inspector Christopher Monteleon, a Whistleblower who had warned of Colgan problems prior to the crash. Judge Skretny agreed with attorneys for the passengers’ families, who said Monteleon may have information that is either new or fills gaps in other witnesses’ testimony.
9-2-2013Alabama and Tennessee team for effort to land 1 of 6 FAA drone test sites
FAA holds the authority to decide which six locations will be designated for drone development, research. (Perhaps this authority should be reassigned, for drone activities below a low altitude such as 1,000′ and at least five miles from airports, so that FAA is no longer in the loop?)
9-2-2013FAA deferring ERAM functionality as money runs out
The program, En Route Automation Modernization, replaces the 4 decades old high altitude radar tracking system known as Host; currently, ERAM is operational either full- or part-time at 16 of 20 air route traffic control centers. FAA officials told  auditors that sequestration will significantly impact ERAM implementation, although the report doesn’t say if they anticipate missing the 2014 deadline.
9-1-2013AIN Blog: Torqued: What If Aviation CEOs Were Held Accountable for Employee Safety Violations?
John Goglia (former NTSB member) with yet another interesting blog. This time, he discusses a recent court action that held former New Jersey Governor and Senator Jon Corzine accountable for the malfeasances of a subordinate employee that resulted in massive financial losses for investors. Goglia then suggests: why not extend accountability for aviation blunders up to the levels of management, especially when management creates the culture and pressure that often precipitates errors, accidents, and other system failures?
9-1-2013FAA’s 2014 Budget Remains Unresolved
An AIN article by Paul Lowe, noting that Congress went on their summer break with no evident progress toward resolving the sequester threat. Looks like another round of primetime sequester reactions coming soon…
9-1-2013Industry Lobby Groups Prepared To Take On FAA
A review of the growing distrust of FAA officials, as expressed a month ago at Oshkosh. The opening paragraph: “The alphabets are angry. Reflecting the growing frustration of their members, presidents of the trade associations tasked with representing general aviation interests showed up at this year’s EAA AirVenture with both barrels loaded full of criticism for the FAA and for the congressional oversight of the agency. The rhetoric was a marked shift from the traditional message of cooperation with the FAA. Other than controllers and their supervisors, top FAAofficials, including agency Administrator Michael Huerta, were conspicuously absent from this year’s AirVenture, allegedly because of federal budget sequestration. It was the first time an FAA Administrator has skipped the event in many years.”

The aiReport …a link to the full report…

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.
JAY REEVES — AP Photo

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

Christine Negroni’s articles about HEMS

One of the most informative aviation-related blogs online today is ‘Flying Lessons’, by Christine Negroni.

Started in late 2009, ‘Flying Lessons’ covers all sorts of aviation content, from light/fun/curious travel details, to very serious air safety issues. The latter has included numerous articles about the profit/risk imbalance (and lack of adequate regulation) in the helicopter EMS industry. If you are concerned about the HEMS problem, be sure to read these posts.

An 11/16/10 article has the title Helicopter Ambulances:  The better-safe-than-sorry scare tactic. Ms. Negroni notes that the rate of HEMS accidents is so high that, comparatively, it would be equal to an airline disaster every day … and yet this level of carnage is accepted as the cost of doing business. She also provides a clear example of how HEMS fees appear to be at the root of the problem; how the profits gleaned from exorbitant billings are causing safety failures (her example includes a billing, for an unnecessary night-time helicopter transport, charging a $12,150 base rate and an additional $135 per mile flown). Here is a copy of the bulk of her article…

…I’m talking about the business of medical transport and the price paid by patients who are moved by air.

Last week, Nanci Wilson of KXAN in Austin, Texas reported on the case of Oscar Vaz. His 12-year old daughter bumped her head at summer camp in June. Now that’s not news; everyone knows that bumps, bruises and bug bites are part of the camp experience like campfires and ghost stories. Only in this case the camp called for an ambulance, and it wasn’t the four-wheeled variety that showed up it was a helicopter. After a brief visit to the hospital, the girl was released back to camp with a clean bill of health and not long after that, Oscar Vaz received a bill for $16,000.

What the better-safe-than-sorry philosophy costs

Oscar is one smart daddy and he started to wonder just what motivated such a drastic response to a simple bump on the noggin. What factors led to the decision to bundle the child into a helicopter and on to Dell Children’s Medical Center?

Critical attention from a doctor couldn’t have been the issue since the helicopter flew right past two hospitals located closer to the camp. And there was no stated need for some highly sophisticated medical technology only available at the medical center in Austin. Oscar was mystified.

“If it is important enough to call an air ambulance, then why not go to the hospital that’s 30 minutes away?” he asked me rhetorically when he called this summer.

I didn’t know Oscar then. He came across some of the many articles I’ve written on this subject when he started researching air ambulances. He got in touch because he was trying to understand the money machine that is today’s for-profit air ambulance business.

But Oscar didn’t need much from me. He was already asking the right questions. When the bill arrived, Oscar asked why the 9-11 dispatchers called – then cancelled – Starflight, the Travis County public service helicopter, a taxpayer-supported service which would have cost considerably less, and instead dispatched the for-profit air ambulance Air Evac? If speed was the issue, why did it take the 90 minutes to get the child to the Austin hospital which is only a 50 minute drive from the camp?

Surely, Oscar thought, there must be some standard operating procedure used for determining when an air ambulance is needed and when it is not especially considering that medical helicopters are themselves, not particularly safe.

What Oscar didn’t know – and if you ask me, it’s a good thing for his peace of mind that he did not – is that the period of time in which his daughter was flown; the hours between 10 pm and 6 am or what’s called backside of the clock are the most dangerous hours to fly by helicopter medivac. Nearly half of all the EMS helicopter crashes take place during this time and they are almost four times more likely to result in fatalities than helicopter accidents occurring during the day. So Oscar and his daughter had two things to be thankful for; No medical problems and no unhappy landing.

But there is that whopping bill from Air Evac. And I think that Oscar, and others who have been transported by air unnecessarily feel companies like Air Evac are playing them for fools.

Their complaints, however, always get reduced to the argument that they are better-safe-than-sorry, that air transport is worth the cost because, after all, a life is on the line. This is the bread and butter scare tactic used by the helicopter ambulance industry and you don’t have to go farther than the comment section on this blog to read the endless varieties on that theme.

But one thing aviation does well is the cost benefit analysis and this better-safe-than-sorry argument doesn’t hold up to that scrutiny. So before Americans go any farther embracing the booming business of air ambulances, its critically important to analyze how the industry got cross-wise with safety and study the programs that seem to be doing things right….

Another article, posted 10/18/11, has the title And the (woomph, woomph, woomph) Beat Goes On. It describes a powerful safety presentation by former air ambulance pilot Randy Mains, crusading for effective safety regulation in the HEMS industry. Here is an excerpt:

…What’s unambiguous is the fact that patients and medical workers have been killed in these helicopters by the score.

Randy+mains.jpgAnd here to help you visualize that is former air ambulance pilot, Randy Mains who spent this morning bringing the truth on home at the Air Medical Transport Conference in St. Louis. First he distributed to the audience hundreds of envelopes telling the medical aviators to just hang on, they could open them shortly.

Randy is on a mission making speeches and writing about how to make HEMS operations safer.

“I have watched in despair for over 32 years as the HEMS system in the U.S. has become more and more dangerous to where it is now officially the most dangerous job in America .”

Finally, the people in the audience with envelopes were asked to stand, 346 of them, about half of people in the room. Inside each envelope was the name of someone who died in a medical helicopter crash.

Randy’s wife Kaye described what happened next. “All you could hear was the tearing of envelopes. People really were in the moment and looking around, absorbing it. It was about two minutes with people standing. There was an overwhelming feeling.”

“It was very satisfying, “ Randy said, describing the stunt – a bit of dramatics intended to energize the people who do not want to imagine their own names on such a slip of paper in the future.

“We must design our programs in the States like they do it in Europe and Canada where they have excellent safety records,” he said ticking off the requirements outside of the United States; two pilots with current instrument-ratings and night vision goggles, in twin-engine aircraft. “Aviation safety doesn’t care about egos, bottom lines or competition. It only works if it is done right.”

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

Use this link HEMS articles at ‘Flying Lessons’ to see Christine Negroni’s other HEMS posts.

“…please don’t call the casualties “heroes” or “fallen angels”. Call them evidence that the public has been bamboozled into believing we need to be flying around by air even when the injury is not life threatening, just in case. And call them victims of an industry that’s off-the-radar, fueled with cash and powerfully incentivized to keep on doing it just this way.”

– from a 7/23/10 post, at ‘Flying Lessons’

 

ANALYSIS: The Boeing Battery Fires

“We do not expect to see fire
events onboard aircraft.
This is a very serious air-safety concern.”

-NTSB Chair Debra Hersman,
at a 1-24-13 press conference

The following analysis concerns the lithium ion battery fires that caused FAA to eventually declare an Emergency Airworthiness Directive (AD), grounding Boeing’s new Dreamliner.

There are four key players in this analysis:

Boeingis the largest commercial aircraft manufacturer in the world. Founded in 1916, they currently have roughly 174,000 employees worldwide. Revenues in 2011 were $69 Billion.
* *
Boeing’s 787
Dreamliner
built mostly from composites, flew its maiden flight in late 2009 and began commercial service in late 2011. A total of 49 had been delivered by the end of 2012. Another 800+ of this $206 Million (+/-) jet are on order. In mid-January of 2013, there was a rapid series of problems: a windscreen crack, two battery fires (one with an emergency landing and evacuation), and a fourth incident (again related to batteries).
* *
FAAhas formally existed since 1958, and today has an annual budget of roughly $16 Billion. FAA has grown to 47,000+ permanent employees, but there are many thousands of other ‘contract’ employees; in fact, many of these are ‘double-dippers’, collecting their FAA retirement pension while also drawing FAA contractor wages. FAA has promoted the growth of the U.S. aviation industry, while also managing the safety of the U.S. aviation industry. Sometimes (actually, many times) these two functions have become confused. One of the most alarming examples in recent years was when the congressional hearings on 4/3/08 revealed that FAA managers were overriding the work of their inspectors and enabling airlines to fly aircraft years past due for required safety repairs. The hearings drew sharp criticism from members of Congress,link and pressure on FAA to abandon their Customer Service Initiative’.link That original ‘CSI’, begun in late 2003, had FAA trying to act like a business and help out their airline customers), and rename it as Consistency and Standards Initiative’. I kid you not…
* *
NTSB established in 1967, has roughly 400 employees responsible for investigating not just aviation but ALL transportation accidents: aviation, marine, highway, rail, and pipeline. With an annual budget of roughly $80 Million, NTSB is also charged with producing hundreds of safety recommendations. Nearly all accident investigations are related to aviation; roughly half of the safety recommendations are aviation-related (the others have to do with highway, rail, etc.). FAA routinely either ignores or fails to acceptably resolve a very large percentage of NTSB’s safety recommendations, which become closed by NTSB with a marking of ‘unacceptable status’.

 

Aviation has always been incredibly harsh and unforgiving

There are more than a few true professionals in aviation. For generations, a lot of careful effort has gone toward improving safety. Mechanical systems have become so reliable, we practically take them for granted. Overall, the present commercial aviation system tends to be reliable and racks up impressive safety statistics. But, on an individual flight, if anything starts to go wrong, there is always the potential that it can rapidly escalate into a full catastrophe. When you really get down to the details, today’s commercial aviation accidents appear to stem from two primary causes: complacency, or technical ignorance. We have modern technologies that layer so much automation into formerly manual processes, it becomes too easy for pilots and controllers to let down their guard. These are people, after all. Give them nothing to do for hours and they will sleep, check out the laptop (maybe watch a movie?), text or otherwise not pay attention. The problem, of course, is that these same systems are not foolproof, and if/when they do fail, the people sitting at the controls may not be able to figure out the problem, let alone recover. In aviation, there often is not enough time.

Here are three recent examples …

Air France, over the Atlantic, on 6/1/09. Nearly four hours after departing Rio for Paris, it’s the middle of the night and they are cruising at 38,000’, in  normal flight conditions. For reasons unknown, key portions of the autopilot disengage. Erroneous readings confuse the pilots who apply corrections which bring the aircraft into a stall. Eventually, they are nose up 35-degrees while descending toward the ocean at nearly 11,000 feet per minute. Four minutes after the disengage, the Airbus A330 impacts the ocean surface, killing 228 people.link
Colgan at Buffalo, on 2/12/09. Two fatigued commuter pilots, both with low experience, encountered icing on an otherwise routine flight from Newark to Buffalo. They commented to each other about the icing but failed to take corrective actions. At 10:17pm, while setting up for a final approach, they lost control and dove into a house. There were 50 fatalities.link
Comair at Lexington, on 8/27/06. At 6:05am on a Sunday morning, a commuter jet was cleared to depart but took the wrong runway. Fifty seconds later, the takeoff roll commenced, at 6:06:05.0. The aircraft needed a speed of 138kts to rotate and safely takeoff. At 6:06:24.2, the captain called out “one hundred knots”, to alert the first officer he would soon call for rotation. Seven seconds later, at 6:06:31.2, the captain called out “Vee one rotate.” Flight data later showed this call was made early, at 131kts, as they ran out of runway. Both pilots pulled back on the controls to rotate, but tire marks show continued ground contact beyond the runway. A berm was impacted seconds later, and the aircraft went temporarily airborne, before eventually crashing into trees. The sound of the first impact was recorded at 6:06:33, and the recording ended at 6:06:36.2. Forty seconds later, the lone FAA controller in the tower (who was working no other aircraft at the time) observed the fire. He picked up the crash phone at 6:07:17, almost exactly two minutes after he had issued the takeoff clearance. While working in the tower, he had failed to notice that Comair was NOT at Runway 22 when ready to depart, and that Comair then took the wrong runway. He evidently did NOT look at Comair for the next minute, losing his opportunity to save the mistake. The controller also did NOT notice that he had failed to specify the runway number in the takeoff clearance. This oversight was critical due to confusion caused by both the runway/taxiway configuration and an ongoing construction project. There were 49 fatalities; the copilot was the sole survivor.link

 

NTSB is the smaller/Better aviation safety advocate

So, the two key federal entities in U.S. aviation safety are FAA and NTSB. The larger of the two has 120-times as many permanent employees, and 200-times the annual budget ($16 Billion vs. $80 Million).

FAA has a proven track record: an ever-growing budget, hundreds of cases where managers and regulated airlines are NOT held accountable, a very high percentage of NTSB Safety Recommendations that are NOT complied with or are ‘closed, unacceptable’, and as compared to other federal agencies, an inordinately large number of damaged whistleblowers. FAA also has a huge amount of clout with members of Congress, by virtue of FAA money doled out each year to projects within all the congressional districts (the largest such fund, drawn primarily as a tax on airline passengers, is the Airport Improvement Fund that distributes nearly $4 Billion annually).

By contrast, NTSB carries a slingshot to FAA’s flamethrower. But, the more important contrast is that NTSB is fit and vigorous and appears to be ethical, while FAA is one donut short of a coronary occlusion. In recent years, NTSB has become increasingly impatient with – and is speaking up more about – FAA’s failures. Thus, when Comair happened at Lexington, Hersman was a new NTSB member and met hundreds of grieving crash victim relatives. She had to stomach the careful construction of a report that could-not/must-not allow the FAA air traffic controller to tell his whole story. The controller knows what happened, and one of the less considered tragedies of Comair is that he now has to carry that fact concealed for the rest of his life. He deferred to the controllers union, NATCA, which quickly jumped in and took charge, representing ATC and working hand-in-glove with FAA to make sure the blame was nebulously reassigned. The official NTSB record declared the controller was distracted doing administrative duties. In truth, the counting of fourteen paper strips at the end of an ATC shift takes ten seconds, max. To her great credit, Hersman (and one other Board member, Higgins) submitted a ‘concurring’ opinion that effectively laid out the need to start adding FAA to the list of those held accountable. When Colgan happened, NTSB hammered home the need for FAA to quit delaying on fatigue issues, as they had for decades. Then, in early 2011, when a supervisor at Reagan National airport fell asleep around midnight and two commercial flights had to land without landing clearances, NTSB jumped forward and did a thorough investigation.link It seems highly likely, given the politics of Washington, that there were at least a few in FAA who cried ‘overreach’ at the time, and begged the White House or allies in Congress (yeah, the ones with ‘most-favored-grant-recipient status) to hold NTSB back. Why? Because NTSB was ‘doing well’ what FAA would have ‘well concealed’.

And what does FAA have to do with the burning batteries?

It comes down to a fear that FAA is not really performing its ‘certification’ duties. Patterns similar to the Dreamliner certification occurred a few years ago, with rushed certification of the Eclipse 500 VLJ (very light jet).link FAA Administrator Marion Blakey disregarded concerns raised by her certification employees, and helped accelerate the Eclipse into production, with a big certification media event at Oshkosh in 2006. Within two years, Eclipse was bankrupt, the limited fleet was experiencing dangerous incidents, and a 2008 Congressional hearing held by the House Aviation Subcommittee revealed just how far FAA had drifted from its core safety mission.

It is this simple…

Good people like Debra Hersman do not want to have to face crowds of people who have lost a loved one, people who sense (or even know, with the angry clarity that often appears where grief collides with bureaucratic coverup) that an effective FAA would have prevented this disaster. NTSB has given cover to FAA in the past (two that come to mind are Piedmont 22 link in the early years, and Korean Air 801 link in the 1990’s), but those were different times, and NTSB was just a young waterboy. Changes at FAA in the last two decades are forcing a new reality: NTSB must come of age. Through their long pattern of dereliction, FAA has relinquished the safety authority they should no longer have. So, let’s assign it to NTSB. Give Hersman and her team as much authority as they can handle. Give NTSB the full resources they need to manage air safety.

What others are saying:

“…outsourcing of the certification processes to the actual beneficiaries of the process is incompatible with the purpose and intent of testing and certification…”

“…the weasel words you will find in the history of the Eclipse certification debacle came from the same FAA administrators that ‘facilitated’ rather than thoroughly and independently examined the early stages of the 787 project…”

Ben Sandilands’ ‘Plane Talking’ blog, on 1-19-13

“… Now watch out because she’s looking at the Dreamliner problem not just as something that needs to be found, fixed and flown, but maybe even illustrative of a bigger problem of FAA oversight of airplane certification. But here’s a safety professional willing to see a potential safety problem and acknowledge it for what it might be without mincing around. What does it take to have more like her? …”

Christine Negroni’s ‘Flying Lessons’ blog, on 1-24-13

“… In a detailed Bloomberg news account, the NTSB chair also said the plane’s design should have prevented the spate of recent lithium-ion battery meltdowns that have grounded the Dream. Are Hersman and the NTSB second-guessing the Federal Aviation Administration’s approval of Boeing’s plan? If so, it could spell trouble for the 787. Rule of thumb when the NTSB and FAA clash? The NTSB wins. …”

Joe Copeland’s‘TheDailyTroll’ blog, on 1-24-13