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Flying Magazine published an article by Stephen Pope, Fighting Pilot Fatigue: New Views on Staying Alert.The 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…
Shortly 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.
News 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:
This needs to change, and we depend on FAA to make this change happen.
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.
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?“
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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.
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?’
Make 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.
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…if you would like a quick video tour, please see page two of this
Post, which has embedded links to four different videos….
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:
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.
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 ensureCockpit 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.his audience would not be blinded by technical jargon. He talked about the aviation data sources including the
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.
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:
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 * 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.happen 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,
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…
NTSB’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.
…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.]
…This report contains the definitive summary of ATC performance. It includes the interview summaries for three ATC personnel: Marty Theobold (FAA CERAP/radar controller) at pg.13; Kurt Mayo (contract tower controller), at pg.17; and Sherie Ewert (manager at the contract tower). Signed by Richard Wentworth, Chairman of the ATC Group for the NTSB Investigation.
…FAA’s Operational Support Directorate made this 14-page presentation at the KAL801 Public Hearing, in Honolulu. The aim was to explain MSAW. At page 12, it states that on “…October 3, 1997, FAA established a method for strict configuration management of MSAW.”
…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.
…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.
Fatal Air Crash
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.
- 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.
- 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.* FAA’s radar includes a
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.
- * 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.
…YouTube video, with updated info, followed by answering press questions.
…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.
…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.
…Check out the comments in this 8/16/13 Flying magazine article. The comments by Jim Underwood are especially worth reading.
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…
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:
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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:
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 …
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. 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). 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 in the early years, and Korean Air 801 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.