Ethiopia Flight 409-Pilot Error or something More?

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    Regarding Boeings New Generation Take on Old (Persistent?) Problems. Maybe. Maybe not.

    George’s Point of View

    The 787: Dreamliner test flight suffered from extensive smoke, fire and structural damage originating in the P100′ electrical panel, a key component that distributes power from the left generator to power vital systems

    The 777: United electrical panel set the nearby insulation blankets on fire. This was initially reported as smoke. Thus no reason for the FAA to go there. And the full narrative said only “electrical fire” but did not elucidate beyond “electrical fire” to explain the electrical panel set the nearby insulation blankets on fire.

    The AAIB conclusions 4,5, and 6, were:

    • “The RGCB and Right Bus Tie Breaker (RBTB) suffered from severe internal arcing and short circuits which generated temperatures in excess of 1,000°C, and resulted in uncontained failures. The RGCB was probably the first to fail.”
    • “ Molten copper and silver droplets from the failed contactors dropped down through the open base of the P200 panel and ignited the insulation blankets below.”
    • “The insulation blanket fire spread underneath a floor panel to the opposite P205 power panel, causing heat and fire damage to structure, cooling ducts and wiring.”

    The three requirements for a fire: oxygen, ignition source and fuel.

    From 2000 to 2008, over 22 ADs are directed at insulation blankets that burn. Before that, from 1988 to 2010, 8 FAA Tech Center reports and 2 FAA Safety Conference Papers are directed at electrical induced fires or the insulation blankets that give fuel to the fire.

    When was the latest AD ?
    2008-23-09. REMOVE PET (AN-26). Boeing Model 727-200s, 737-200s, 737-300s, and 737-400, 747s, 757s, 767s Series Airplanes.from the fuselage. Such insulation blankets could ignite and propagate a fire that is the result of electrical arcing or sparking.
    DATES; Issued Oct 24, 2008 -effective Dec 15, 2008 – Comply by
    2014. If you read the AD, you can note that the compliance date is actually set beyond the affected planes anticipated passenger service-life. Compliance is put off until the planes will likely be converted from passenger to cargo.

    2002 FAA ASTRAC Conference Conclusions

    • 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.
    • It is impossible to predict the relative risk of serious fires occurring in Hidden Areas or Locations.

    Without being too critical or belaboring the obvious, I do have to say that the 2002 conclusions are overly obvious and simplistic. These same points will probably be as true in 2002 and 2011 as in 3011. Point by point? Consider this:

    • In-flight fires are a risk to safety, whether they’re hidden or not. Certainly if one doesn’t know where they are, they have more time to be destructive before they are found. And as for being predictable-there probably is a random statistical probability that can come pretty close; but translating theory back to real life situations perfectly only happens on tv.
    • Electrical problems are certainly a broad umbrella-one might even say the current problems with rogue batteries to be a form of electrical problem.
    • Non compliance regarding safety is hardly an issue when a plane is in the testing phase; in fact, that is when the manufacturer is are troubleshooting to get rid of potential safety issues. The 777 electrical panel issue may or may not have a common cause; and if it does have a common cause, then, isn’t that splendid for Boeing? The detective job (i.e. finding the cause) is half of the problem already solved. What luck! But in real life, are the causes that easy to find? And in practice, how many times are non-compliance with Safety Regulations due to poor operator maintenance versus to unsafe parts?
    • Fire Safety Improvements are an ongoing process. It’s the nature of the beast.

    So here is the problem as it should possibly be stated:

    -We need compliance now because people are on these planes now, not at some random future date. Pushing back solutions puts more people are at risk. We need feasible compliance that doesn’t put good companies out of business but still maintains the highest possible safety standards NOT the lowest possible cost. Putting off compliance over a combustible insulation blanket until 2014? Really? How is this safe?

    -The lowest common denominator should not be lowest possible cost-to-the- industry. It should be the highest possible safety for the passenger. These things are not always mutually exclusive.

    -If the root problem is less than ideal materials used across many manufacturer and model applications, then quit pussyfooting around.
    If the boy is going to cry wolf, let it be for a real wolf. If the wolf is real, then act. If inadequate materials, composites, etc are the problem, then don’t point the finger and do nothing. Questionable materials have no place in an industry that lives under guidelines advocating and promoting safety over all.

    Like Yoda said, “Do or do not. There is no try.”

    Raise the standards.

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  • FAA: The New Iceberg

    George’s Point of View

    There’s a lot that is said in the world about gatekeepers. If you haven’t heard about them, you’ve run into them. They’re the low level filter that keeps the riff raff out, in positions that look plebeian but which wield far more authority than their level on the hierarchy would suggest. That’s the guy at the door who won’t let you in. If you’re hitting the trendy night spot, he’s the one whose thumbs up — or thumbs down–decides your fate. It’s the secretary that let’s your call go through. It’s the one at the ticket office who lets you in on the really good seats to the fight. Those are the gatekeepers you see.

    The ones to watch out for, though, are higher on the feeding chain. They’re the ones who appoint the gatekeepers. Usually they have some kind of agenda, but you’re not going to see them, or their agendas, because the main thing about them is that they’re the part of the iceberg that you don’t see. They’re very good at staying underground, until something comes along like the Titanic.

    So picture this:

    Your job is inspecting planes. You’re sort of the gatekeeper for the plane. IF you say yes, it flies, then, well…it flies. If you say no, the plane goes back to the drawing board. Your whole purpose is to be discriminating–to keep out the riff raff. You keep the “plane” bakers from serving the planes before they’re “done.” You catch what problems there be, so there won’t be a disaster down the road. Imagine if you report a problem with a plane, and instead of getting commendations from the powers that be for your superlative discernment, you get shunted off to a desk, and the powers that be rule in favor of the airline. And then a year later, the plane you had issues with causes a disaster which you may have been able to prevent.

    This is all under investigation, and it may all be smoke and mirrors and finger pointing.

    It may be something more.

    I’m talking about inspector Christopher J. Monteleon whose story is in the New York Times.

    Monteleon got moved to a desk for doing his job. The situation seems to have been the catalyst for a whole lot of professional trouble for him. What if someone had paid attention to his concerns? Would the Bombardier Dash 8 Q400 been given more refinements? Would changes have been made that could have made it safer?

    Then, Monteleon complained that the Office of Runway Safety “was using skewed methodology to understate the severity of safety concerns.” He wasn’t monitoring a flight that was subjected to dangerous icing that was being flown by a poorly trained and exhausted pilot. But maybe his is the kind of eye that would have made someone somewhere insert an extra page in the manual to cover the situation that would have saved 49 lives.

    Maybe his contribution would have made no difference at all to the tragic Colgan/Buffalo NY flight.

    But I’m looking past Monteleon and this particular incident to the bigger picture. I’m looking at his superiors who for some reason discounted the advice of their own expert. His bosses may not have liked the squeaky wheel, but his JOB was to do the squeaking. Apparently they wanted him to shut up, and stop getting in the way of the airline business. Apparently someone in the FAA forgot that the FAA does not work FOR the airlines. Their directive is to regulate civil aviation to promote safety–NOT commerce.

    I am wondering if there is a part of the FAA iceberg that needs to be brought into the light. I suspect that Mr. Monteleon agrees with me.

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  • Foreign Aviation Tragedies, Thoughts on Compensation

    Lives have value. It doesn’t matter if a man makes $10,000 a day, or 10 cents. If he dies in a plane crash, he’s irreplaceable. Maybe his boss can put a dollar figure on what it would cost him to lose that worker; maybe his banker can come up a specific value to subtract from the family’s credit rating.

    But to his wife
    to his son
    to his daughter
    to his parents
    to his friends
    to all those his life touched daily—
    he’s irreplaceable.

    His loss leaves a hole in a family that money can never fill.

    And then the attorneys for insurance companies will “try” to get by with compensation offers that are equal amounts for each passenger, that in some cases, equal to “peanuts” — I don’t see that too much, but ‘they’ try, especially if the laws in the country have established maximum low-values for the loss of life in aviation accidents. Even with Warsaw and Montreal the compensation I’ve seen is seldom governed by the caps provided for in these treaties.

    Instead, the compensation is based on the profile of the decedent. Age, Occupation, Family, etc. With this said, each seat on that plane is occupied by an individual and the family of the victim should be compensated accordingly, and in addition, the family should be paid non-pecuniary damages for pain and suffering, etc. In a perfect case, that’s how it works.

    Whether he makes $10,000 a day, or 10 cents will not affect a man’s pain and suffering. In fact, his pain may be worse, knowing his ten cents is all that lies between his family and ruin.

    PEANUTS is not acceptable.

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  • What Will EASA do?

    IF the European Aviation Safety Agency is going to uphold its own mission “to promote the highest common standards of safety and environmental protection in civil aviation,” it must take strong action when it receives the French Accident Investigators first results.

    There’s so much speculation out there regarding what this account will be that it just seems better to wait and see what it says before second-guessing it. Regardless of the details, you know the report is going to talk about 1. lightning and weather 2. pitot tubes; they may also talk about computer issues, composites and the stabilizer/tail fin/rudder also. I doubt they’ll tackle Airbus’s fly-by-wire technology.

    The only thing I don’t understand is why Airbus 330’s have not already been grounded pending the results of the investigation. With several recorded incidents of Airbus 330’s suffering near-disasterous incidents and generating data similar to what was received from the AF447 flight, it makes more sense to ground these planes now before another accident occurs. Why are they letting people fly around in a plane that is an accident waiting to happen?

    Or are paying passengers the world over just guinea pigs for Airbus to test their craft on until they get it right?

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  • Airworthiness Directive: Life

    In an aviation disaster, what happened is never a true mystery. A true mystery is something that baffles understanding and cannot be explained. We know there’s an explanation. We know something tangible happened. There is a tangible explanation. We just don’t know what it is. What happened. Or in what sequence. Or if one or two of the events in the sequence didn’t happen, could the disaster have been prevented.

    Most aviation disasters live in a realm of tragic mystery. We are always walking around, picking up the pieces of the puzzle. In fact, there are usually few pieces of evidence to pick up–and the ones we do find crumble in our hands, or they’re inexplicable or perplexing. So when we put the puzzle pieces together, they may fit a multiplicity of ways. There may be huge gaps. Or there may be no way at all to fit together the disparate elements. Oh, sure, we come up with a thousand theories–perhaps a different theory for each time we consider, each time we try to take another perspective, each time we speak to another expert. These experts agree; those experts disagree. Perplexing, an enigma, a riddle the answer of which remains forever out of reach. The alleged mystery—the answered question— remains, all the more tantalizing because we know there is an answer.

    As troubling as it is for those of us who look for the answer to “how” it happened, families struggle with fathomless questions a thousand times harder to deal with: why my loved one? Of all the thousands of trips, why this particular flight, why this particular plane, why this January, why this Monday?

    Families play the questions back in their heads, rewind their lives and replay the events as if somehow in the thinking of it, they could reach back through time, stop their loved one from boarding that plane, or otherwise change a single factor–make the pilot leave his phone behind. Make the mechanic give that lug nut an extra turn. Bless that plane designer—or the parts designer—with something extra so that on that long ago day when he came up that design, it was flawless. The thing that if it had been done just a little differently, would have kept the tragedy from ever happening. That magic something that could undo what has been done with such conclusive finality. As if the moment could be rewound as in a movie, and come out differently. These are the questions which are beyond inscrutable, profound questions heavy with the weight of life, of love wrenched away before its time.

    The answer may be elusive.

    But there’s always rigid hard reality behind a crash. There’s always an actual sequence of events that instigated the tragic event.

    So any time I see an airline being proactive, I think of lives that will be saved.

    Alaska Airlines begun inspecting their 14 Boeing 737 jetliners because of the emergency airworthiness directive issued Friday. Severe vibration occurred in some European flights was due to “lug failure on an elevator control mechanism. The elevator controls the plane’s pitch.”

    There are mysteries hanging about 737s such as ITEK & PERM and recently Ethiopia. In the first two it was determined that it was human error.

    I have always believed that pilot error alone will not bring down a plane.

    This vibration opens a whole new window of possibility of answers to our unanswerable questions. In some of these past crashes where we have not found the answers, is it possible these tragic flights encountered turbulence which was exacerbated by this vibration? Could this flaw have been instrumental in the Aeroflot-Nord B735 crash at Perm on Sep 14th 2008? or to Itek Air B732 at Bishkek on Aug 24th 2008? Or more recently, to Ethiopian Airlines B738 in the Mediterranean Sea on Jan 25th 2010?

    So I am glad to hear that Alaska Airlines begun inspecting their 14 Boeing 737 jetliners. I am glad to hear that Alaska Airlines is committed to safety. They should be commended for wasting no time in ordering an inspection.

    If only all carriers were so diligent, there might be fewer grieving families. And that wouldn’t be a bad thing, would it?

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  • Thanksgiving Wishes

    Thanksgiving table served with turkey, decorated with bright autumn leaves
    It is time again for Thanksgiving. In my heart, I feel Thanksgiving every day, perhaps because in my business I am constant touch with families of victims. I work closely with people in all stages of loss. I have to admit, it takes a toll. Even the news of the day takes a toll-the deaths of children abroad in bombings, this bus crash in Tennessee, the latest crash: they all take a piece of me. There are so many times that I can bring hope or help; I can’t help but wish I could always do so. There are so many who have so much. I feel deeply for those who are struggling to get their lives on track, and those who have to scratch for meals wherever they may be.

    As this day of Thanksgiving approaches, I extend my condolences to all those who have suffered loss or deprivation. I pray that this season, everyone has everything they need, peace of heart, peace of mind, and tables full of blessings. At the same time, I give thanks for every moment, for my friends, family and health, and all the blessings of those close to me. Have a happy Thanksgiving.

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