Dumb Luck

Although the FAA would have everyone believe that “We are currently in the safest period in commercial aviation history” (Statement of Lynn Osmus, Acting Administrator, Federal Aviation Administration, on the FAA Reauthorization Act of 2009, Before the House Committee on Transportation and Infrastructure, Subcommittee on Aviation, February 11, 2009), it’s only because there hasn’t been a big body count from an airline crash in the United States; not because there haven’t been any crashes; nor because of any methodical or measured approach to flying safety.

A crash in Amsterdam on February 25, 2009 highlights what is a foolhardy and dangerous approach to correcting problems with aviation safety.

Dutch investigators have determined that the Turkish Airlines Boeing 737-800 flight that crashed was operating on autopilot, and that at 1,950 feet altitude, the pilot’s radar (radio) altimeter (the one the autopilot was using) errantly indicated that the airplane was just a few feet above the ground, which caused the autopilot to reduce power to idle, believing the airplane was about to touchdown and land.

Instead the airplane lost flying speed, and at about 490 feet stalled and plummeted to the ground killing 9 (including the pilot and co-pilot) and severely injuring another 26.

The problem is that this wasn’t the first time the left altimeter had failed in this aircraft.  It had failed twice before in 8 previous flights leading up to the accident.

Obviously there was faulty (or no) maintenance performed on the altimeter.  The airline itself is at fault for this problem (more on that issue later).

However, ultimately the blame for the accident rests on the flight crew, who failed to notice the disparity between the two radar altimeters on the plane, one of which was obviously malfunctioning.

Boeing’s solution was simply to advise the flight crews that they needed to notice the faulty altimeter and then manually switch the autopilot to use the other functioning altimeter. Um, duh…

But in this case the crew didn’t notice the altimeter was broken and the plane crashed.

Why, in an aircraft with a glass cockpit and highly automated flight systems (like the B737-800),  isn’t there some indication when the redundant systems are seriously out of whack with each other, to ensure that the flight crews don’t miss that fact?

B737-800 Cockpit
B737-800 Cockpit

Don’t get me wrong: obviously the crew should have noticed the discrepancy; it’s part of their job.  But they didn’t.

This accident is another human factors case study.  The flight crew didn’t notice a problem and the plane crashed.  Many aviation accidents are caused by the crews failing to notice and correct a problem (and in some cases many problems).

However, telling the crews not to make mistakes isn’t a real fix for those sorts of accidents.

A real fix for the problem would be to have some sort of alert/warning for the disparate altimeters that would sound until a human intervened.  (There are all sorts of cockpit alarm/warning systems on modern airlines; just not one in this case.)

Boeing’s fix is like the old joke:

Patient:  “Doctor, it hurts when I do this!”

Doctor:  “Then, don’t do that!”

As an air traffic controller I know that I’m the one who’s going to blamed when something goes wrong in the sector too, because ultimately I’m the one who has the responsibility to see and correct problems.  The human being in the loop in both airplanes and behind the radar scope is ultimately the one who’s going to be blamed when a mistake is missed and not corrected.

But simply telling people to not make mistakes does nothing to address the problem.  Human beings make human errors.  Telling them not to make human errors doesn’t make those errors disappear.

On January 17, 2008 a British Airways Boeing 777 landed short of the runway at London’s Heathrow Airport with 136 passengers and 16 crew on board.  Amazingly, while the accident destroyed the aircraft only 13 were injured.

The resulting investigation theorized that icing in the fuel delivery system prevented fuel from reaching the engines so that when the throttles were increased the engines didn’t receive enough fuel.

Then on November 6, 2008 a Delta Boeing 777 at 39,000 feet flying over Montana lost power in a single engine.  The crew handled the problem without further incident.

After the Delta Airlines incident the National Transportation Safety Board (NTSB) made an “urgent” recommendation to the FAA that the parts involved be redesigned to prevent repeat occurrences, with its acting chairman stating, <snip>”we believe that there is a high probability of something similar happening again.

However (from CNN),

The Federal Aviation Administration recently ordered operators of Boeing 777s that use the Rolls Royce engines to revise flight manuals to give pilots procedures to follow in certain cold weather conditions, outlining steps they should take if their jets experience a reduction of power.

It’s the same approach that Boeing offered in the B737 incident.  Train the flight crews better so that when there is a problem they can recognize it and deal with it.

Forget about actually fixing the problem itself.

I call this the “workaround” fix approach.  It’s not really a fix at all, but simply involves telling those who work with the faulty equipment how to ignore or cope with the problem.

FAA management loves the “workaround” approach when it comes to the equipment and procedures air traffic controllers use, because then they don’t have to really do anything of note other than write a memo.  If things go wrong they can still blame the controllers (just like blaming the B737 crew at Amsterdam).  Forget about actually spending time and/or money to fix the root of the problem.

It’s just disappointing that the FAA, the U.S. government agency tasked with safety oversight and regulations has taken such a laissez-faire attitude towards safety issues.

There is a reason there is a government agency that has been tasked with safety oversight of the airlines.

Check out this article from 2002 entitled “Do low-cost airlines cut corners on safety as well as sandwiches?“.  In it there is the following quote:

Fortunately, evidence to the contrary can easily be found in the skies above the United States. At a typical moment on a typical day, about 200 Boeing 737s are flying the drab colours of Southwest Airlines across America. The orange and brown stripes belong to the safest airline in the world.

I’m assuming this reporter’s declaration that Southwest was the “safest airline” in the world was due to its accident record; not necessarily to its exceptional maintenance procedures.  (Note:  although Southwest has yet to have had a fatality involving anyone on its aircraft, on December 8, 2005 at Chicago Midway a Southwest B737 ran off the runway and struck a car killing a 6 year old boy.)

Unfortunately there’s a huge difference between an intentional measured approach to aviation safety and just lucking out.

Notably in 2008:

The Federal Aviation Administration on Thursday issued a $10.2 million fine — the largest in its history — against Southwest Airlines.

The FAA said it will seek the fine from Southwest for flying 46 jets during nine months in 2006 and 2007 without performing required inspections for cracks in the fuselage.

So much for an intentional measured approach to safety…

In the absence of strong independent oversight (what the FAA is supposed to be doing), airlines will cut corners on maintenance to save money (and probably more-so in tough economic times).

That’s why the airlines and manufacturers don’t get to do their own safety inspections.  They’re (allegedly) supposed to be overseen by the FAA to ensure that they meet flight standards.

Unfortunately the last few years the FAA had a “customer service initiative” where it decided its customers were the airlines and got cozy with them, giving them a pass when it came to many safety issues.  FAA safety inspectors were threatened with the loss of their jobs when they complained to their managers about safety violations they had witnessed.

Instead of providing the safety oversight they should have, the FAA morphed into an organization driven by a partisan agenda rather than a safety oriented one.

Just before the FAA whistleblowers stories made it into the mainstream media, suddenly American Airlines and Delta Airlines canceled many of their flights to perform safety inspections that obviously hadn’t been done previously.  Why the change of heart?

It was simply because those airlines saw that the “new” FAA that had been buddying up with them suddenly was under fire for not doing a good job with safety oversight and was reversing course on their relationship and threatening fines.  Talk about fickle: first FAA managers threaten its own safety inspectors with firings should they not relax their safety standards, then they fine Southwest for violating safety standards!

“The Customer Service Initiative, to me, is clearly intended to say, ‘We are not going to regulate, really. You are our customers, and we wouldn’t want you to be upset with our scrutiny,’ ” said Rep. Peter DeFazio, D-Ore., a member of the transportation committee.

The FAA has clearly lost its way.  It failed to make consistent proper decisions with respect to safety, and has failed its real customers, the flying public.

But are they now correcting their approach?

The fact is that there have been two significant major air carrier incidents in the U.S. in the last few months.

On December 20, 2008 a Continental Airlines Boeing 737 veered off the runway during takeoff  at Denver and crashed.  38 out of 115 people are injured but none seriously.

Then on January 15, 2009 a US Airways Airbus 320 lost both engines after striking a flock of birds and ditched in the Hudson River.  155 people on board survived, with the most serious injuries two broken legs to one person.

In both these accidents it was a miracle that no one died.  But they were significant accidents nonetheless.

And the fact that two passenger airliners crashed without loss of life doesn’t necessarily mean there is anything anyone is actually doing to improve aviation safety.

It just means the FAA and the airlines have been very, very lucky.

And luck won’t last forever, especially if the FAA continues to choose to use “workarounds” for problems instead of real fixes, and continues to believe that the airlines are their customers instead of the flying public.

In the meantime I’m sure we’ll continue to hear the FAA PR machine continuing to take credit for the “safest period in commercial aviation history”, even if it is just an accident (no pun intended).

Postscript:  On February 12, 2009, a Continental Express DASH8-Q400 crashed in Buffalo, New York killing 49 in the airplane and one on the ground.  But I’m guessing the FAA won’t “count it” as it wasn’t operated by a major air carrier.  But try telling that to the families of those on board.


  1. Justice For The Clarence Center 50 – FIRE FAA’s Lynne Osmus and Hank Krakowski
    Photos and biographies of the Flight #3407 aircrash victims, links, and this message, can be found at:

    America continues to learn that the victims of the Clarence Center aviation disaster were great people.

    But one example:
    The late “Dawn Monachino of Clarence typically drove 10 hours round-trip to Pennsylvania, every two weeks, to be with her mother, who has Alzheimer’s disease”.

    Dawn was a hero. So were her fellow passengers. They died to make our air travel safer. But they should not have been taken from us.

    Quiet Rockland extends thoughts, sympathies, and prayers to families and friends of the victims of the horrible airplane crash which occurred near Buffalo, New York in the nearby hamlet of Clarence Center, Continental (Connections) Flight #3407, on Thursday, February 12, 2009. The crash of Flight #3407 was but part of the legacy of harmful malfeasance rendered to us by now-exited failed Acting FAA Administrator Robert Allan (“Bobby”) Sturgell, now-exited failed FAA “Safety Officer” Nicholas Sabatini – and still-in-office FAA COO Hank Krakowski and Acting FAA Administrator Lynne A. (Dobler) Osmus.

    The victims of the Flight #3407 crash were kind and decent, with hopes and dreams. None of them deserved to die at the hands of malicious bureaucrats. We again call upon the President, USDOT Secretary LaHood, and Congress to immediately remove Lynne Osmus and Hank Krakowski from FAA and from all other government work permanently. We again call upon the President, USDOT Secretary LaHood, and Congress to now give FAA the top-to-bottom clean-out of other FAA personnel recommended by Congressman Oberstar last year, before Flight #3407 ever happened. If the clean-out of FAA had happened already, the crash of Flight #3407 may not have happened. Finally, we want a Congressional investigation into the circumstances of the timing of the hasty departure announcement by NTSB Member Steven R. Chealander, which announcement occurred but a week after he commenced work on the February 12 Flight #3407 crash. We want answers. We want justice. We want a new FAA.

    Quiet Rockland

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