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‘Most Wanted’ List Updated to Account for Reality

Fuel tank safety has been removed from its “Most Wanted” list of improvements and emergency medical service operations have been added to the National Transportation Safety Board’s (NTSB) list based on continued crashes of medical helicopters and the fair prospect that many recent fatal accidents would have been avoided if the Federal Aviation Administration (FAA) had acted with alacrity.

Recently added to the NTSB’s ‘Most Wanted’ list of aviation safety improvements is this 2006 recommendation, which has not yet been implemented.

 But, then, the FAA’s failure to act smartly and comprehensively is exemplified by the fuel tank issue just removed from the “Most Wanted” list. After being on the list about 12 years, the NTSB has pronounced the FAA’s actions satisfactory, when in fact they are of very limited application and provide only partial protection against a fuel tank explosion of the type that downed TWA flight 800 in 1996 – the genesis of the NTSB’s recommended corrective actions. However, the FAA’s actions would not have prevented the fuel tank explosion of a Transmile B727 at Bangalore, India, in 2006, which involved an aircraft not covered by the FAA’s recent ruling.

What is discouraging is the amount of time most initiatives remain on the “Most Wanted” list, and how the FAA response is either to ignore them or to take only partial steps to redress the safety deficiencies identified.

Indeed, traditional NTSB protests over unsatisfactory outcomes have now apparently transmogrified into a mutual admiration society of self-congratulatory endorsed compromise. In many cases, problems seem to have been consigned to the “fixed” bin (that is, “made to go away” amidst much laudatory and unwarranted fanfare). In many cases, those “fixed bins” are destined to become what is forensically known as “Cold Cases.” The lids come off those cold cases only when repeat accidents disclose that a serial killer is still on the loose. The recent case of a Spanair MD-83 crashing on take-off in Madrid due to inbuilt flaws in that airplane model’s Take-off Warning Systems (TOWS) comes to mind as just the latest example of a killer left loose. The earlier compromise – after a Northwest Airlines DC-9 crash on take-off in 1987 – was a non-mandatory exhortation that airlines should check their aircraft TOWS once a day. (See Aviation Safety & Security Digest, ‘Previous Events Foreshadowed Spanair Crash,’ archive.)

The history of the “Most Wanted” list is one of late, partial or ineffective FAA reaction to what are really basic problems of air safety.

The Excessive Risk in Air Rescue

Like the rest of the country, I was deeply saddened by the fatal crash of an emergency medical services (EMS) Eurocopter Dauphin II helicopter on September 28 in Maryland which killed four and left another in critical condition.  But as a former Chairman of the National Transportation Safety Board, this trend is anything but shocking.

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Amid Proud Declarations, No Answer About Accountability for Safety

The airlines are complying with airworthiness directives (ADs) 98% of the time, according to the Federal Aviation Administration (FAA). In other words, all is well. But before accepting this declaration, consider a few factors, not the least of which is that the FAA conducted an audit of itself that lacks the test of independence.

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Opening The Book on Leadership Dysfunction

 The Federal Aviation Administration issued a press release on 5 September 2008 titled “FAA Announces Results of Compliance Audits, Updates Safety Commitments.”  After reviewing what the FAA spin masters have released, this document should be titled, “Oh What A Tangled Web We Weave.”

 

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Twelve Years of Half Measures

While Canada’s Transportation Safety Board (TSB) has achieved only about a 20% acceptance rate for its Swissair flight 111 recommendations, the U.S. National Transportation Safety Board (NTSB) may not have fared much better in its TWA flight 800 recommendations, even though a general comparison indicated a 40% acceptance rate.

 

Congress Asks For Assurance That Aircraft Are Safe

Aircraft wiring and fire safety is a concern in Congress, as evidenced by a recent letter that wants detailed answers from the Federal Aviation Administration (FAA).
 
The 2 July 2008 letter from Rep. Bart Gordon (D-TN), Chairman of the House Science and Technology Committee, to FAA acting administrator Robert Sturgell, harkens back to the crashes of TWA flight 800 and Swissair flight 111 of a decade ago and asks tough questions about what has been done since the twin tragedies to improve safety. Gordon wants answers by 9 September 2008.
 

Significant Regulatory & Related Activity

For the second time this year the Federal Aviation Administration (FAA) has rejected the notion of installing cameras in transport category airplanes, thereby missing an opportunity to enhance both safety and security.

The first rejection was last May, when the FAA said the matter of image recorders in the cockpit was “unsettled” and it would not require them to augment cockpit voice recorders (CVRs) or be used in lieu of CVRs on those airplanes not requiring them.

The second rejection came 28 October, when the FAA dismissed closed circuit television (CCTV) on transport category aircraft to enhance security, claiming there are privacy concerns. These concerns may be overblown, as Jet Blue Airways has deployed CCTV to cover the cabins of its airliners, and the picture is fed to the cockpit. A noted security expert recommended a system of external and internal cameras on future airliners to “create a situation where cockpit crews have full views of the passenger cabin and the exterior of the aircraft … without having to leave the cockpit.”

Other recent regulatory action shows the FAA being very tardy on needed safety improvements. On 16 October it recommended improved training to enable Bombardier CL-600 crews to better detect ice on the wings before take-off. The idea here is to prevent uncommanded roll, or worse, on take off. One wonders if this tendency of an iced wing was uncovered during certification flight testing and why training is only now being required.

The FAA also continues to issue airworthiness directives to prevent ignition sources in fuel tanks, the most recent being for B727s on 7 October. The action comes years after the FAA ordered a review of fuel tank safety and allows up to 5 years for the B727 to be flown without corrective action.

If aviation safety and security are not keeping pace with threats, one has only to look at the FAA’s dilatory regulatory actions – which are either issued late or reject outright sound ideas.

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Study Shows Aircrew Errors Cause Most Fatal Accidents

Annual Number of Worldwide Fatal Accidents

There were six accidents in which more than 200 occupants were killed and 32 where the onboard fatality count was greater than 100.

Two-thirds of all aviation accidents involved flight crew error, according to an annual review of fatal airliner crashes done by the UK’s Civil Aviation Authority. Nonetheless, aviation safety is improving, at least as measured by the number of passengers and crew killed annually.

According to the study, some 8,500 passengers and aircrew were killed over the ten-year period, 1997-2006. That works out to an average death toll of some 850 per year, which is considerably lower than the 1,000 per year that were killed previously.

The big passenger jets achieved the safest record. Cargo operations remained hazardous, with an accident rate six times that for passenger flights. In addition, turboprop airliners crash at three times the rate for jets.

It is evident that technology can reduce accidents. The study found that TAWS (Terrain Awareness Warning Systems) can help prevent CFIT (Controlled Flight Into Terrain) accidents resulting from the flight crew’s “lack of positional awareness in air.”

An Ostensibly Minor Malfunction Escalates To An Accident

The electrical failure was so complete that the pilots were unable to shut off the engines after coming to a stop on the side of the runway at O’Hare International Airport (ORD).

 

Off the runway, scattering passengers – and plenty of questions.

What happened? While on a 22 September flight from Seattle to New York City with 185 passengers, the pilots received several advisory and status messages on the engine indicating and crew alert system (EICAS) and a caution light indicated that the standby power bus was off-line.  The crew looked at the quick reference handbook (QRH) for STANDBY BUS OFF and followed the directions therein, turning the standby power selector to the BAT (battery) position. The QRH informed the crew, “The battery will provide power for approximately 30 minutes.”

As one commentator noted, the incident involving an emergency landing of an American Airlines B757-200 reflects “a real tricky trap of thoughtless design, cascading failure modes and poor pilot training and education regarding aircraft systems.”

Sudden Pitch-Down Raises Questions About Computerized Flight Controls

 
 
On 7 October a Qantas A330-200 dropped about 1,000 feet while cruising at 37,000 feet, and numerous passengers were injured. Australian investigators are homing in on erroneous signals sent by one of the airplane's three Air Data Inertial Reference Units (ADIRUs). Apparently, this particular failure mode has never been seen before. One obvious question: why wasn't the fault in the wayward ADIRU screened out by comparison with the other two ADIRUs?
 
We are suddenly back to looking warily at software design standards for fly-by-wire aircraft, and whether they provide an adequate assurance of safety under all conditions.
 

Special Certification Review Comes Up Sort

The Federal Aviation Administration (FAA) conducted a Special Certification Review (SCR) of the Eclipse EA-500 that found no legal fault with the process by which the airplane received its type certificat but recommended a number of bland improvements to the process.
 
The SCR found no safety of flight issues, but it did not mention the June 2008 incident at Chicago's Midway where an EA-500, on landing, was unable to retard the thrust on the engines, forcing the crew into a bit of intelligent improvization to land the airplane.
 
The SCR team was shot through with conflicts of interest and the effort hardly merits the monicker "independent."
 
A truly independent review of EA-500 certification was conducted by the Inspector General of the Department of Transportation, which did a laudable job of documenting issues that the SCR studiously avoided. Indeed, one could argue that the IG's report and that of the SCR cannot exist in the same universe,  because they clearly do not observe the same phenomena.

 

Cumulative Toll of Helicopter Ambulance Crashes Tops $100 Million

The fatal crash 16 October of a medical evacuation helicopter in Aurora, IL, brings to 13 the number of such helicopters destoryed. If scheduled airliners were crashing at a rate of more than one per month there would be an enormous and anguished public outcry about the crisis in air safety. Meanwhile, the Federal Aviation Administration moves at a glacial pace on recommendations issued by the National Transportation Safety Board more than two years ago on air ambulance operations.

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Safety of Helicopter Ambulances Questioned by Maryland State Senators

In the wake of a deadly helicopter ambulance crash 28 September in Maryland, two state senators have sent a letter to officials responsible for the safety of such operations demanding a host of detailed answers. They have submitted a list of 35 questions, ranging from maintenance to operations, to which they want a "prompt response."
 
Their letter comes on the heels of a Legislative Audit Report in August that found serious shortcomings in maintenance of the helicopters. Those deficiencies included, but are not limited to, poor record keeping of maintenance performed on the helicopters and a shortage of spare parts.

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A Piece of Safety Equipment Wreaked Mayhem on Jet

A ruptured oxygen cylinder punched a hole in the fuselage and rattled around inside the aircraft causing additional damage, together with the sudden decompression of the airplane, forced an emergency landing of the Qantas jet in the Philippines, according to Australian investigators.

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A Decade of Minimal Action

Canadian safety officials say some limited progress has been made on recommendations coming out of the Swissair flight 111 disaster. Cut through the positive-sounding rhetoric, though, and it is apparent that only 21% of the recommendations have been fully implemented.

 
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Creative Interpretation’ of Fuel Loading Rules Rampant, Pilots Claim

Airline pilots are being pressured by their companies to minimize the amount of fuel reserves they pump aboard for a flight, resulting in more declarations of an emergency when the exigencies of weather, heavy traffic, and other factors produce approach and landing delays or even diversions.

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