When Lady Luck Turns Away

Thursday, April 17, 2014
By John King

Incidents and Accidents.

Behind every accident, there are many incidents. Accidents may be defined as involving fatalities and incidents as those many smaller events seemingly unconnected from any others. The importance of incidents has gotten little respect but for two obscure references. The industry recognized Heinrich Pyramid says “…. for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries.”

A 2005 Rand Report drawing attention to NTSB databases said “…(there is) poor control of information, part of resolving more complex accidents depends upon a thorough knowledge of prior incidents, the number of major airline incidents the FAA reported in 1997 was ten times the number of major accidents, (there is) neither oversight nor an emphasis on accuracy in the collection and maintenance of NTSB records, as a result, the accuracy of most of the NTSB data sources was rated as “poor” and although the NTSB does examine a significant number of major incidents, only a small portion of the NTSB’s aviation resources are focused on incident events.”

Rand report Link >
http://www.rand.org/content/dam/rand/pubs/monograph_reports/2005/MR1122.pdf

See page 38 –40.

Key Public Databases – NTSB and FAA. Gaps Compromising Safety Assessments.

The NTSB’s most public source of records is the accident/incident database.

It is cited in the FAA Accident/Incident Data System (AIDS), Airworthiness Directives (ADs), risk/analysis studies, and in DOT/GAO Reports to congress.

In my various surveys along major safety issues (uncontained engine explosions, un-commanded rudder movements, shutdowns due to engine main bearing failures, or smoke/fire incidents, the NTSB data contains about 20 % of what is found in SDR data or other counterpart investigative agencies.

Gaps in NTSB data are further compounded by similar gaps in SDR data. From
1992 to 2002 four NTSB Safety Reccommendation Letters and the GAO had complained of such gaps. In 2010 and regarding data on windshield fires, an article said the “FAA said it was aware of 11 cases of fires in the planes over the past 20 years. However, Boeing has said it is aware of 29 incidents involving fire or smoke over the past eight years.’ Source link >
http://www.news24.com/World/News/FAA-orders-Boeing-inspection-20100710 – bottom of article.

1994. In 1994, The Department of Transportation Inspector General reported that between “46 and 98 percent of the data fields of inflight ‘service difficulty’ records are missing data.” From GAO/AIMD-95-27. 02/08/95. Data
Problems Threaten FAA Strides on Safety Analysis
Source Link >
http://www.gao.gov/archive/1995/ai9527.pdf

From the House Hearing Electrical Safety. (Ref report 106-112, Thursday, October 5, 2000, Testimony of Alexis M. Stefani, assistant IG for auditing), said; “Third, of most concern to us is the health of this SDR system, itself. While the new rule (coding for wire issues) was intended to improve the data in the system, FAA must also insure that the reports that are provided to it are timely, and follow the guidance. We found, however, that the SDR system is not robust, and over the years, it has suffered from budget cuts with staffing going from twelve full-time to three full-time people. Weakness in this system reduces the reliability and usefulness of the data, and can impact FAA’s ability to do trend analysis.”
Source Link >
http://commdocs.house.gov/committees/Trans/hpw106-112.000/hpw106-112_1.HTM
Page 47

From a June 8, 2006 U.S./Europe International Aviation Safety Conference, FAA’s Flight Standards Service, Jim Ballough.spoke of “FAA’s growing concern over numerous reports of smoke/fumes in cockpit/cabin and that FAA data analysis indicates numerous events not being reported.” Source Link >
http://www.faa.gov/news/conferences/2006_us_europe_conference/ See ‘Presentation
’ by Jim Ballough.
650 Records Of “Smoke In The Cockpit” A Lack of Concern.

Gary Stoller at USA Today did a good piece on “smoke in the cockpit”
reports. Of some 650 records, the FAA/NTSB has but a fraction. The story highlights included; (that the) “issue happens roughly four times a month.

Some experts say the problem is under-reported. FAA says there is “no safety benefit” to requiring systems to remove cockpit smoke. Smoke in a plane’s cockpit from electrical or other failures is reported an average of four times each month, a USA TODAY analysis finds.” Further that “In-flight fires left unattended “may lead to catastrophic failure and have resulted in the complete loss of airplanes,” the FAA warned. A flight crew “may have as few as 15-20 minutes to get an aircraft on the ground if the crew allows a hidden fire to progress without intervention.” USA Today

Source http://www.usatoday.com/story/news/nation/2013/10/30/cockpit-smoke-airline-faa/3316429/

33 records Of Insulation Blankets Fires. – How They Start.

From my catalog of 78 Records of fire from 1983 to 2012 sourced from the NTSB, AAIB (Danish & UK), French BEA, FAA’s SDR databases, and a few media reports of records of accidents and incidents of fire. There is no central repository. There are 33 records where acoustic insulation (blankets) were specifically mentioned are listed. The issues of self-igniting and flammable wire insulations and of flammable blankets were now are co-mingled.

Three modes of ignition are seen here: wire shorting/arcing, molten metal sprayed from faulting electrical relays and heating tapes. Most reports lack necessary detail, but seven incidents were seen from wires shorting/arcing.
Some involved only a few wires; one powering coal closet lights. Molten Metal (spatter) comprised another 8. More importantly, within those reports were references to another 19 (but without details) and that the NTSB said; the relays involved were not “substantially different from the receptacles used on other transport-category airplanes.”

Ignition from faulting heating tapes/ribbons was seen in another 4 reports – but there were more. In a November 14, 2002 Letter to the FAA, the Canadian Transport Safety Board (TSB) advised that; “heater ribbons are used extensively in transport category aircraft, including Boeing 707, 727, 737, 747, 757 and 767 series and Boeing (Douglas) DC-9, DC-10, and MD-11 aircraft. ” From a TSB report of such fires on 747s and a 767, four other reports were disclosed. The TSB added; “The standard Boeing 767 incorporates 26 heater ribbons. Between June 1985 and June 2002, operators of Boeing aircraft made a total of 67 reports to Boeing of heater ribbon failures where thermal degradation was evident.” From one Delta MD-88 fire in 1999, the NTSB said; “DAL conducted a fleet wide examination of their MD-88/MD-90 fleet to ascertain the condition of their static port heaters. Eight heaters were found with evidence of thermal damage on their wires and or connectors.” There are 8 ADs, and 24 additional SDRs describing burn marks or fire damage. (ref King Survey ‘History Heater Blanket/Tape Fires’.)

In 2002, the FAA concluded that “in-flight Fires In Hidden Areas are a risk to aviation safety – most hidden fires are caused by electrical problems – non-compliance with Safety Regulations have been uncovered. Fire safety problems and improvements are in various stages of correction and study” and that “it is impossible to predict the relative risk of serious fires occurring in Hidden Areas or Locations”. Source Link >
http://www.caasd.org/atsrac/meeting_minutes/2002/2002_01_Fire-Safety-in-Hidden-Inaccessible-Areas.pdf

Dense, Continuous Smoke in the Cockpit.

In June 2013 a GAO Report to Congress cited but one record of ‘Dense, Continuous Smoke in the Cockpit’ (in 1973). The input came from the NTSB and the FAA. Contrary to that, a Specialist Paper by the Royal Aeronautical Society detailed seven. Only two were in the NTSB databases – but with no mention of ‘continuous smoke.’

Links > GAO-13-551R, Jun 4, 2013. FAA Oversight of Procedures and Technologies to Prevent and Mitigate the Effects of Dense, Continuous Smoke in the Cockpit.
http://www.gao.gov/products/GAO-13-551R

Link > Royal Aeronautical Society – Smoke, Fire and Fumes in Transport Aircraft. Second Edition 2013, Part 1, Past History, Current Risk, And Recommended Mitigations. A Specialist Paper prepared by the Flight
Operations Group of the Royal Aeronautical Society. March 2013

http://flightsafety.org/files/RAESSFF.pdf

In Lady Luck We Trust ? – Those ‘Lucky’ Ground Incidents.
Often heard whenever the safety of our air transportation system is questioned is that we have an enviable safety record due to the industry, the FAA and the NTSB’s efforts. That is true if only actual deaths are counted.

This boiler-plate response comes whenever issues of safety are raised, but something else is left unspoken: its conditional nature. It includes just the U.S. carriers, and is based on the records kept. However, there have been no less than 6 events where fires occurred on the ground and caused significant damage, or loss of the airframes. Fire departments intervened in five.

What if, instead, over 900 lives had been lost over the past 12 years ?
For example:

(1) Aug 8, 2000, AirTran DC-9-32 – fire and blistering of aircraft skin, 63 on board.

(2) Nov 29, 2000, a DC-9-32 by AirTran (97 on board).

(3) Same Day, Nov 29, 2000, a DC-9-82, American Airlines (66 on board) ,
blankets burned, emergency evacuation on taxiways – 97 on board”.

(4) June 28, 2008, ABX 767 freighter burned through the fuselage and was destroyed at the gate, (“The risk of an in-flight fire and the propagation of a fire in those areas is essentially the same whether the airplane is equipped to fly passengers or cargo” says the FAA). Approximate 767 capacity is 190 people.

(5) July 29 2011, Egypt Air 777, fire erupted and burned a cockpit-widow
sized hole through the fuselage. Emergency services put the fire out – 291 passengers were evacuated.

(6) On October 14, 2012, a Corendon Airlines 737-800 had “substantial damage” from fire in the cockpit on the gate. 196 on board were evacuated. Had these fires broken at altitude or during the trans-oceanic crossing, all on board may have been lost.

For the sum each of these fires found in the NTSB’s accident/incident database, over 900 lives were not lost. A more honest assessment and the credit for this remarkable safety record of no fatalities was not the FAA and industry abilities to manage and ‘mitigate risks’ – but rather the kindness of Lady Luck. But what can happen when lady Luck turns away ?

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