One Mangalore Crash Question: The Wreckage

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    All In The Family

    George’s Point of View

    Maintenance abroad, no matter how good the mechanics are; monitoring; who does it; how good is it?

    • If something terrible should happen, our hands are tied in the courts.
    • If the person at fault is in, subject to, and adjudicated in a foreign country, the laws may be antiquated, inadequate, indefensible or unenforceable.
    • In the U.S., suing a company from a foreign country does not guarantee that a court here will hear the case. The injured or the victim families suffer unrequited consequences.

    Let’s keep our U.S. planes serviced right here in the U.S.

    Scene: Back to the future


    Doc Brown
    No wonder this circuit failed.
    It says “Made in China”.
    Marty McFly
    What do you mean, Doc?
    All the best stuff is made in Japan.
    Doc Brown
    Unbelievable.

    What is the quality of imported products? It all depends on the decade. The appetite, desire and need for imported spices impelled the development of trade, forced Columbus to hop in the Nina, Pinta and Santa Maria and go looking for a trade route, and we all know that he found, instead, the American continent.

    Spices, fruits and veggies out of season, products are all imported.

    So should airlines based in the US be exporting their maintenance outside of the country? Aside from ridiculous logistics, I think the problem here is regulation. How can standards of regulation be upgraded to optimum levels if our maintenance is shipped out of the country? Aside from that, it is impractical and somewhat silly. Think about it–when our bathroom faucet springs a leak, do we send the house to China? Do we uproot the bathroom and send it to China? Do we even send the part? No, we have maintenance–the plumber, ubiquitous panty line notwithstanding–comes IN and with his expensive clock ticking away, replaces the part and saves the day.

    That’s not to say that Mohammed must always come to the mountain. But in the wake of proliferating engine shutdowns, defective parts, structural design issues and hull failure, maybe we need to rethink sending our maintenance out of the country. Maybe it is cheaper, but is it better?

    Let’s look at the big picture, where relying on non-US standards takes us: Look at the fiasco of Chinese drywall–where families across the country are suffering with degrading, stinking, sulphur infested drywall as their home values and quality of life plummets. Look at the ongoing stream toy recalls, as warnings of children’s toys covered by lead paint, or lead components are broadcast daily. Look at the massive pet food recall of 2007, where 17,000 complaints and over 2000 pet deaths were related to melamine in dog food with chinese rice components containing melamine.

    Until every outside resource is going to have the quality rating of Quantas, do we really want to export our maintenance? Not only does it not make sense…well face it, it just does not make sense. Maintenance and the maintainers should reside under the umbrella–and the sharp teeth–of our legal system. Under our own US regulatory system, we need to hone the edge of our own country’s in-house maintenance, exercise the craft that once made “Made in the USA” the top of the line INTERNATIONAL standard, and frankly, let our corporate dollars feed—not bleed—our own job-hungry nation.

    SEE: http://www.wbur.org/news/npr/113942431

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    When Lady Luck Turns Away

    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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    Anniversary of Air France 447-Personal Consequences of Death on the Flying Brick

    Elie Wiesal said “Because I remember, I despair. Because I remember, I have the duty to reject despair.”

    It is not time to despair. It is time to remember. We are remembering Air France 447, and the families whose lives have forever changed. Families left behind have to deal with carrying on.

    Experts say that there are five steps (called the Kubler-Ross model) of grief: denial, anger, bargaining, depression and acceptance.

    After a year, or two, or three one might be able to say that families with tragedies to process have come to acceptance; but the model is not a hard truth. Those suffering grief may hopscotch between stages, or get stuck at any of them. And just as smells tend to refresh memory, so too can dates. And June 1 for Air France 447 families is one of those dates.

    Maybe it is a blessing that everything changes. Maybe it is a blessing that the first moment of finding you have lost a loved one in a plane crash is not frozen in amber, to be felt always at the original intensity. It is inevitable that the depth of grief will fluctuate.

    In the beginning, the deaths of those aboard the plane were shrouded in mystery. A black hole of mystery, in fact, one that swallowed up the craziest theories, from abductions, to terrorism, to aliens. The investigation marched on, to the tune of millions of dollars, and hundreds of investigators and professionals marched to that tune, working to uncover the puzzle pieces and put them together to shed light on what really happened. At least now, with the black boxes recovered, there are facts to deal with rather than crazy speculation.

    But even facts will not change the reality. Those gone are still gone. At whatever stage you are experiencing it, the grief you feel is real. I have no advice for you. Anyway, advice comes across as condescending. But we all have suffered pain and grief and loss, and I can only hope for the families that you remember.

    Remember the good things.

    Remember mornings across your breakfast tables, the rush to begin the day, the slow times after the day is done.

    Remember the moments spent together. Remember the depths as well as the peaks. Remember the places you went together, and when you revisit the places, you will revisit your loved ones.

    The heart is not buried along with the victim. The heart goes on.

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    Air Maintenance in Crisis

    George’s Point of View

    Oversight is one of those words in the English language that bothers me because it means the opposite of itself.

    An oversight is something that was missed. Something that is over-looked is something that was not seen. That smudge on my windshield after a car wash–that is an oversight. The Christmas bicycle that came without it’s assembly manual–that is an oversight.

    Oversight means the unintentional failure to notice. It’s an “oops.”

    But–oversight also means the act of supervision. It is frequently mentioned in terms of aircraft; the FAA and the NTSB are responsible for Aviation oversight. But when I read that, I read two completely opposite sentences. The FAA and the NTSB are responsible for supervising aviation. AND the FAA and the NTSB are responsible for what they missed.

    When I read the usage of “oversight” (meaning supervision) I am waiting for the other shoe. What have they overlooked (missed) now? What’s the oversight (supervisor) oversight (missed)?

    And now I see the oversight (missed) is the licensing of aircraft mechanics.

    Apparently the procedure to qualify aircraft mechanics is poorly administered. Hundreds of aircraft mechanics may have been improperly licensed

    The crisis comes down to faulty testing by FAA examiners who profit from testing in “diploma mills.” Apparently the FAA does not keep employment histories on the mechanics they license. There have even been programs where testing was delayed; and when the program was discontinued, the untested mechanics kept working.

    So where do we look when there’s an accident like the Indonesian Air Force Lockheed L-100-30(P) Hercules whose wing fell off in flight on May 20th 2009? (Granted that this is NOT a US plane–but there are US incidents. This is just a recent one.) Did the pilot cause that wing to fall off? Of course not. The pilot climbed into that plane in good faith, with complete trust in the mechanics whose job it is to keep the plane in safe running order. The pilot relies on the integrity of the mechanics to maintain the integrity of the plane. As do we all.

    Fortunately, integrity is a word in the English language that always means what it means:
    The quality of being honest and having strong moral principles; moral uprightness; the state of being whole and undivided; the condition of being unified, unimpaired, sound in construction : the structural integrity; lack of corruption.

    Is it too much to ask of our FAA to require integrity in our mechanics and the planes they maintain? Integrity is not an oversight; but lack of integrity in oversight is.

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    India: Civil Aviation Safety Advisory Council

    Air India Airlines did not single-handedly inspire the newly formed Indian separate body to investigate air accidents, but as the committee was formed immediately after the Air India Express crash in Mangalore that claimed 158 lives, it certainly was a major catalyst. It remains to be seen if the new investigatory committee will be as efficient or reliable as the US’s NTSB/FAA which investigates all major air events in the US and some outside of the US (when requested by foreign agencies or when American pilots, citizens, service or goods are involved).

    Certainly the DGCA needs help. We have already pointed out in a prior editorial that the DGCA’s report on the Mangalore crash is overdue. The Times of India quoted the DGCA’s own statutes:

    According to Civil Aviation Requirement (CAR) Section 5 (Air Safety), Series C, Part I issued on 13 October 2006, “preliminary report by the inspector of accidents/inquiry officer should be finalized within 10 days of the accident.

    We have also located a source that claims that * all of Air India Express managerial positions are “part-time.” Does this mean that the company was deliberately set up to have no key personnel who can be targeted as decision-makers? Though why should that matter? Air India Express is the budget branch of a larger company; Air India Express is a wholly owned subsidiary of Air India which is now part of National Aviation Company of India Limited (a merger between Air India and Indian Airlines.) Someone is in control.

    Those who fly India and have high expectations of the new safety committee being effective may be in for a let down while the newly formed body finds its footing. The new, separate Civil Aviation Safety Advisory Council which has been set up to handle air crashes has no experts from Air Traffic Control (ATC) nor expert pilots. Along with the Directorate General of Civil Aviation (DGCA) chief, Dr Nasim Zaidi, the 28 member body includes Aviation CEOs including Air India Chairman Arvind Jadav, Spicejet CEO Sanjay Aggarwal, managing editor of Centre for Asia Pacific Aviation, Kapil Kaul.

    If you take a look at how the NTSB handles an investigation, you will see that a team of experts are engaged and all interested parties, including pilots, are represented, including some you might not expect. Without such input, investigation is a waste of time.

    The NTSB team of investigators handle individual aspects of the individual investigation, allocated by expertise. Each expert is responsible for a specific and sometimes overlapping portion of the investigation. Specialization like this helps develop and apply expertise in each area and prevents key points from being overlooked. Also, bear in mind that the experts involved in investigating each crash will differ, depending on the parties involved; and most of these parties are on site within hours of the crash.

    SomeAreas of investigation/investigators

    • Structures investigators (who also usually takes responsibility for the crash site, ensuring that all the wreckage (e.g. wings, fuselage, and undercarriage) is accounted for and that proper trails of evidence are followed)
    • Engines investigators
    • Systems investigators such as flight controls
    • Airline’s Operations investigators (also studying crews’ training and suitability)
    • Black box investigators
    • Accident flight’s relationship with air traffic controllers
    • Meteorologists who analyze the weather at the time of the crash to determine if it had a bearing on the accident.
    • Metallurgists who analyze the condition of the plane’s metal and the forces on it
    • Sound specialists (for eg, identifying sounds on black box tapes)
    • Fire and Explosions experts
    • Simulation experts who reproduce the events
    • Flight survival experts who analyze the forces the passengers were subjected to. (These are the people who can tell you the safest place to sit on a plane.)
    • Maintenance experts who analyze the plane’s condition–and how it got that way
    • Psychologists may examine procedures to determine if airline practices exist that cause the pilot to make mistakes, like flying different types of planes. (e.g. Different types of cockpit controls make switching planes an unsafe practice.)
    • Manufacturers representatives who study and analyze their product’s performance
    • Pilots (representatives from the pilots’ union) may be attached to many or all groups; just as…
    • Labor Unions such as the International Association of Aircraft Machinists may attach representatives to multiple groups.
    • Cooperating “foreign specialists” in wreckage reconstruction, black box decoding or interpretation. (Countries who develop special expertise in various fields are often called to join the investigation, just as the NTSB is frequently asked to join foreign investigations.)

      Plane manufacturers have their own investigative teams experienced in this type of analysis, and they stand ready to work on any event that needs their expertise. And the investigation is networked so that if and when they need additional specialists, they can tap into their own company resources.

      One should note that in the case of the Mangalore Crash investigation, the wreckage sat out in the elements for 50+ days before being collected and warehoused. In my opinion, this is carelessness; and furthermore, this carelessness is just one visible aspect demonstrating where the existing procedures are obviously not up to par. While I am sure that experts combed the wreckage, including Boeing, (they always dispatch a team when one of their planes is in a crash,) leaving the wreckage out in the elements is not a best practice for conservation/preservation of evidence. One can only wonder how all other aspects of procedure including those behind closed doors-stand up to Aviation Industry’s internationally expected best practices.

      The industry calls this massive joint investigation the “party system.”

      The parties involved include all parties affected. The more parties involved, the faster the investigation may go.

      Chairmen of each group make their report; and any groups who discover any failures or unusual effects of machinery make note in the final report given to the primary investigator. The investigator invites the individual groups to provide their angle on what caused the crash and how it might be prevented.

      If all the probable causes line up neatly, then it is a simple thing to complete the final report. When theories conflict, the final report takes longer, and tension develops.

      All of this information is supposed to remain confidential until the final report is published.

      In this “party system,” the various opposing parties tend to keep each other “honest”. Unfounded attempts at blame by one party will be met with rebuttal by another–so it is obvious that if there is no pilot representation in this new committee, pilots may end up the “dumping ground.” Let’s say, for example, that a pilot in a crash went in with bad input like an outdated map. Is this committee set up to pursue the investigation to the source of the bad input? A pilot’s association representative would be instrumental in getting to the cause, whether it might be inadequate training, or materials.

      The international community and the people of India are waiting to see how this new committee manages to regulate and oversee all aspects of civil aviation in India, and whether it helps keep India’s DGCA and the safety of India’s aviation systems on track.

      * Need separate body to probe air crashes: Patel; Economic Times, The (India), May 25, 2010

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    Southwest Airlines: Hole in fuselage


    Click to view full size photo at Airliners.net
    Contact Photographer Tim Perkins

    What: Southwest Airlines 737 en route from Nashville to Baltimore
    Where: Charleston’s Yeager Airport
    When: 6:30 p.m Monday July 13
    Who: 126 passengers and five crew
    Why: While en route, the cabin depressurized when a hole (metal fatigue?) approximately the size of a football appeared in the fuselage. The plane managed to land safely in Charleston West Virginia. The NTSB is investigating.

    (News photos don’t look football sized, but it is sure big enough to see plenty of daylight through.)

    George’s Point of View

    The 737 is a true workhorse, built to land and takeoff almost without too much delay except to load and unload passengers.

    I fly Southwest to Las Vegas all the time. It’s a short hop.

    I must admit, that every time I fly in one of these planes I have begun to worry about the age and/or the fatigue of the structure. A trip like one from LA to Vegas, most times, is a beating on the passengers and the plane itself. My guess is that 4 out of 5 of these short trips encounter turbulence, sometimes bad turbulence. This beats up the plane. In this case, the plane being beaten up was manufactured in 1994. That’s a lot of years of turbulence abuse. Metal fatigue in these conditions is not surprising, and neither is it completely unexpected. An inspection on this plane last January revealed eight cracks in the frame that required repairs.

    I’m just glad it was a BOEING, and that the pilot remained in control of the aircraft. And of course, it’s a good thing that Southwest is now inspecting all of their planes for fatigue. Last year Southwest was fined $7.5 million for overdue inspections. I hope this is not going to be a repeat of last year. All the timely inspections in the world aren’t going to make this plane any younger. Maybe it’s time to put this particular plane out to pasture.

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