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Never Forget

Lives have been shattered by the events I record.

I know you could drive a mid-seventies Cadillac Fleetwood through the gaps in these records, but that is partly because I generally write about an event only once, partly because my content is based on a couple of randomly gathered secondhand observations, partly because I do not follow up, and partly because I am not an expert. (I never claim to be an expert in anything but my own life experience.) How could I be? The actual investigations take years, and are based on combined expert opinions of a whole boatload of bona fide experts. I am only a bystander, a bystander of second-hand bystanders, in fact. The reporters who inform me frequently misstate, interpret or misinterpret the facts, or add little imaginary flourishes. I still do my best to get the facts out as accurately as I can.

Official final reports are the result of the combined knowledge and experience of experts (some of whom have agendas and bias) in “air traffic control, operations, meteorology, human performance, structures, systems, powerplants, maintenance records, survival factors, aircraft performance, cockpit voice recorder, flight data recorder, and material factors,” interviewers, rescue observers and specialists as needed. Sometimes the reports are obfuscated by agenda, bias or politics.

I am just another pair of eyes, and untrained eyes, at that.

I never, or hardly ever, write about what happens in the seats. Ironically, this is what I write now as I sit in one of those seats myself. Picture me in the cabin of a flight to Argentina. A young family is also on this flight, with hyperactive children running up and down the aisle whenever possible. Picture an infant or two, their safety seats empty as their mothers rock them to still their tears, to the relief of the couple across the aisle, and the irritation of one of the flight attendants. Picture a couple of newlyweds off on their honeymoon, and another couple of newlyweds returning from their honeymoon. Students flying home for the holidays, others returning after. Vacationers in Hawaiianwear. Nearer to me, an assortment of business people in summer suits appropriate for Argentina in July. This accidental ensemble of humankind is engaged in various activities: thumbing through magazines, cloud gazing through the windows, watching movies, listening to music, reading, studying paperwork, connecting intimately in intense whispers (or avoiding) a seatmate, sleeping.

Just as all around me are engaged in making it through the flight, in a moment precisely like this one, other lives were interrupted. Maybe it was an instant, maybe a four minute fall. Maybe there was no time to process what was happening, or enough time to feel horrible bone-deep terror, and to endure for long moments the fight-flight reflex while belted into a seat. The detail of each event through individual eyes is simultaneously unique and identical.

I don’t write about these moments. It is too horrible to contemplate except in cases like when Chesley Burnett Sullenberger is making a miracle happen.

Out of the generous experiences of the decades of a whole, full life, families want to remember their loved ones in their entirety. They don’t want or need to be haunted by the torment of that single moment of horror, a final dark exclamation point.

So when I write about these terrible crashes, I talk about system failures, or spatial disorientation, ATC schedules, fumes, pressurization, sleepy pilots, malfunctioning radar, stick shakers or a couple hundred other possible causes I have seen frequently enough for them to become familiar even to a layman like me.
But it is not about the machine. It is about those who boarded that flight in perfect trust, expecting to disembark and fill more decades with passion and life. It is always and only about the passenger.

I don’t mention them.

But not an article is written, not a character is typed that I forget that the only matter is the passenger and the family.

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    American Traveling Public Says ‘There Has to Be a Better Way’ to Conduct Air Travel Security Screening

    Overwhelming Majority Support a Trusted Traveler Program That Could Help Spur $84.6 Billion in More Travel

    Blue Ribbon Panel of Experts Convened By U.S. Travel Association to Make Recommendations in Coming Weeks

    WASHINGTON, Dec. 21, 2010 — As airports begin welcoming passengers during one of the busiest air travel periods of the year, a new survey reveals three in four air travelers believe “there has to be a better way” to conduct air travel security screening. Eight in 10 support a trusted traveler program that would provide alternative screening measures for American citizens who submit to a background check and meet other risk criteria. Respondents would take an average of two to three more trips per year if the hassle involved in flying could be reduced without compromising security. Those additional trips would add $84.6 billion in travel spending and support 888,000 additional jobs, according to research from the U.S. Travel Association.

    “Americans are clamoring for a better way, and it should be a wake-up call for our leaders in Washington,” said Roger Dow, president and CEO of the U.S. Travel Association, which commissioned the survey. “An efficient air travel security screening system that streamlines the process for trusted travelers can strengthen our security and economy. Let’s get to work building the system Americans crave.”

    A majority of those surveyed believe Congress should make air travel security a top priority in the new term that begins in January.

    According to the Consensus Research Group, which conducted the survey, “Travelers’ frustration with the system is not limited to just one or two security measures. It is across the board and includes a range of issues.”
    Among the survey findings:

    The U.S. Travel Association has convened a Blue Ribbon Panel for Frictionless Aviation Security comprised of industry and security experts and former government officials. The panel will recommend how to improve air travel security in a way that maximizes security and minimizes the burden on travelers. The panel is expected to issue its report in early 2011.

    The survey was conducted online by Consensus Research Group on behalf of the U.S. Travel Association between November 29 and December 10. The survey includes a nationally representative sample of 1,000 business and leisure air travelers who have flown during the past two years, are aged 25 or older, and who reside in the U.S.

    • Having to remove shoes before going through a metal detector received a higher negative response from those surveyed than newly implemented pat-down body searches by Transportation Security Administration (TSA) personnel.
    • Nearly 9 in 10 respondents believe it is possible to achieve an air travel screening system that is both secure and efficient, while virtually the same number believe if we can put a man on the moon, we can create a passenger security system that doesn’t frighten or inconvenience travelers.
    • Three in four air travelers support recruiting more professional security personnel who are trained to use personal observation, dogs and sophisticated computer analyses that have proven to be effective screening techniques in the past.

    One page summary of the survey:

    Travelers Frustrated with National Air Security System Public Believes “There Has To Be a Better Way”
    Three in four American travelers (75%) believe there has to be a better way to provide air travel security than the procedures used today.
    • Two-thirds of air travelers (66%) believe air travel security is a complicated problem and will not accept heavy-handed procedures unless they are more effective and efficient – 72% of business travelers agree.
    • Eight in ten (82%) agree that if we can put a man on the moon, we can create a passenger screening system that doesn’t frighten or inconvenience air travel passengers.
    More travelers describe the current passenger screening process as “inconsistent,” “stressful,” or “embarrassing” than describe it as being “fair” or “effective.”
    •
    Top ten words air travelers use to describe today’s screening procedures:
    o Inconsistent 64% o Stressful 58% o Embarrassing 41% o Intimidating 40% o Intrusive 39%
    o Fair 30% o Ineffective 29% o Effective 23% o Rude 22% o Frightening 16%
    More would travel by air if the screening process was improved – and the economy would benefit.
    • Nearly two in every three air travelers (64%) said they would fly more if security procedures remained as effective but were less intrusive and less time-consuming.
    • Travelers would take an average of two to three more trips a year (2.48/year) if the hassle could be reduced without compromising security effectiveness. These additional trips could add $84.6 billion in spending and 888,000 more jobs.
    • 80% agree there should be alternative screening measures for American citizens who submit to a background check and meet other risk criteria. In fact, half (50%) of those who have traveled recently “strongly agree” with this.
    • Three in four air travelers (74%) support recruiting more professional security personnel who are trained to use personal observation, dogs and sophisticated computer analyses.
    • A majority of air travelers support common-sense measures such as creating a special security lane for frequent travelers (60%) and a special screening lane for families, infrequent travelers and people who need boarding assistance (58%).
    American travelers believe fixing air travel security should be a top priority in the 112th Congress.
    • A majority of air travelers (54%) believe Congress should make air travel security a top priority in the new term that begins in January.

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    Cerritos: Aeromexico Shattered Lives

    In George’s Point of View

    It is a strange, sad phenomenon how tragedies live on.

    On August 31, 1986, a Piper and a Douglas DC-9-32 collided over Cerritos California. The Piper, carrying the pilot and two passengers was going from Torrence to Big Bear. They departed Torrence at 11:46. The DC-9 from Mexico City was approaching Los Angeles with 58 passengers and 6 crew aboard. At 11:52 am, the DC-9’s left horizontal stabilizer sheared through the Piper’s cockpit like a can-opener.

    The Piper crashed in the Cerritos Elementary School playground; the DC-9 in a Cerritos neighborhood destroying five houses, damaging seven more and killing an additional 15 on the ground.

    Descriptions of the collision still fill me with horror.

    The accident predates some of the precautionary measures we have now. Now, the Piper would have a Mode C transponder, which would indicate that it was too high, breeching LAX Terminal Control area; LAX was not at that time equipped with automatic warning systems.

    It has been twenty-five years since that accident happened. A memorial ceremony now is being held commemorating the tragedy in the Cerritos Sculpture Garden, and another in Loreto, Mexico. The tragedy is being remembered by at least 30 US families, 20 Mexican families, in at least one home in Colombia, and one in El Salvador. It is being remembered in the neighborhood the wreckage demolished, where families neither need nor want a plaque to remind them of their loss.

    There is a reminder of this crash in every light plane, and every jet. In fact, everyone who flies now, everyone who has flown and not died in a crash owes a debt to the victims of this senseless tragedy, because this was the event that spurred the FAA to require “Mode C” transponders that could report three-dimensional positioning on light aircraft. This was the event that spurred the FAA to require TCAS on airliners.

    I still live to breathe the smoggy air of Los Angeles. And as long as I still have the breath of life, I will remember the day when these 82 souls breathed their last.

    Aviation tragedies shatters lives like broken glass, and there is no lawsuit, no settlement, no “all the kings horses, nor all the kings men” who can ever put families back together again.

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    Testimony: Colgan Air

    Statement of Peggy Gilligan, Associate Administrator for Aviation Safety

    Before the Senate Committee on Commerce, Science, and Transportation, Subcommittee on Aviation Operations, Safety, and Security on Aviation Safety: One Year After The Crash of Flight 3407

    Chairman Dorgan, Senator DeMint, Members of the Subcommittee:

    Thank you for inviting me here today to provide you with an update on the Federal Aviation Administration’s (FAA’s) Call to Action on airline safety and pilot training. There is no question that the FAA’s job is to ensure that we have the safest aviation system in the world. The aviation safety record in the United States reflects the dedication of safety-minded aviation professionals in all parts of our industry, including the FAA’s inspector workforce. In an agency dedicated to aviation safety, any failure in the system, especially one that causes loss of life, is keenly felt. When accidents do happen, they reveal risks, including the tragic Colgan Air accident. Consequently, it is incumbent on all parties in the system to identify the risks in order to eliminate or mitigate them. As Administrator Babbitt noted when he appeared before you in December, history has shown that we are able to implement safety improvements far more quickly and effectively when the FAA, industry, and labor work together on agreed upon solutions. The fastest way to implement a solution is for it to be done voluntarily, and that is what the Call to Action was intended to facilitate. On January 27, the FAA issued a report that describes the progress made toward fulfilling commitments made in the Call to Action and offers recommendations for additional steps to enhance aviation safety. I would like to use this opportunity to review the issues the Administrator identified in December and let you know where we stand on them.

    Pilot Flight Time, Rest and Fatigue: When Administrator Babbitt was last here he told you that the aviation rulemaking committee (ARC) he convened for the purpose of making recommendations on flight time, rest and fatigue, consisting of representatives from the FAA, industry and labor organizations, provided him with recommendations for a science-based approach to fatigue management in early September. While we were extremely pleased with the product provided, the ARC did not reach a consensus agreement on all areas and was not charged with doing any type of economic analysis. Consequently, in spite of the Administrator’s direction for a very aggressive timeline in which to develop a Notice of Proposed Rulemaking (NPRM), his hope that a rulemaking proposal could be issued by the end of last year was not realized. The complexities involved with these issues are part of the reason why the FAA has struggled to finalize proposed regulations on fatigue and duty time that were issued in the mid-1990s. However, with the Administrator’s continued emphasis on this topic, we hope to issue an NPRM this spring. Although this is slightly later that we originally hoped, it is still an extremely expedited schedule, and I can assure you the FAA team working on this is committed to meeting the target.

    One of the issues contributing to fatigue that I know is of interest to many of you is that of pilots who commute by air to their job. I would like to describe some of the emails and letters the Administrator has been receiving on the issue of commuting from pilots who choose to commute by air to their job. As you can imagine, those pilots who commute responsibly are understandably concerned that they could be forced to relocate because of the irresponsible actions of a few. Should some sort of hard and fast commuting rule be imposed, it could result in families being separated, people being forced to sell homes at a loss, or even people being forced to violate child custody agreements. It is important to keep in mind these personal accounts because, to people not familiar with the airline industry, the issue of living in one city and working hundreds of miles away in another does not make sense. But in the airline industry, this is not only a common practice, it is one airline employees have come to rely on. So we want to emphasize these issues are complex and, depending on how they are addressed, could have significant impacts on people’s lives.

    Focused Inspection Initiative: From June 24, 2009 to September 30, 2009, FAA inspectors conducted a two-part, focused review of air carrier flight crewmember training, qualification, and management practices. The FAA inspected 85 air carriers to determine if they had systems to provide remedial training for pilots. The FAA did not inspect the 14 carriers that have FAA-approved Advanced Qualification Programs (AQP) because AQP includes such a system. Seventy-six air carriers, including AQP carriers, have remedial training programs. An additional 15 air carriers had some part of a remedial training program. There were eight air carriers that lacked any component of a remedial training program that received additional scrutiny and have since instituted some component of a remedial training system. Since we started, all carriers have implemented some component of a remedial training program. The FAA inspectors also observed 2,419 training and checking events during the evaluation. In the few instances we observed regulatory non-compliance, we took corrective action.

    Training Program Review Guidance: Based on the information from last summer’s inspections, the FAA is drafting a Safety Alert for Operators (SAFO) with guidance material on how to conduct a comprehensive training program review in the context of a safety management system (SMS). A complementary Notice to FAA inspectors will provide guidance on how to conduct surveillance. SMS aims to integrate modern safety risk management and safety assurance concepts into repeatable, proactive systems. SMS programs emphasize safety management as a fundamental business process in the same manner as other aspects of business management. Now that we have completed our data evaluation and drafting, both guidance documents are in internal coordination.

    Obtain Air Carriers’ Commitment to Most Effective Practices: To solidify oral commitments made at the Call to Action, Administrator Babbitt sent a letter to all part 121 operators and their unions and requested written commitments to adhere to the highest professional standards. Many airlines are now taking steps to promote the larger airline’s most effective safety practices at their smaller partner airlines. The Air Transport Association’s Safety Council is now including safety directors from the National Air Carrier Association and the Regional Airline Association in their quarterly meetings. Several large air carriers are conducting periodic meetings with those with whom they have contract agreements to review safety information and we are encouraged by these efforts.

    In addition, I am pleased to say that since July 2009, after the Call to Action, the FAA approved 12 new Flight Operations Quality Assurance (FOQA) programs. Three air carriers that had no Aviation Safety Action Programs (ASAP) have now established them. Four more air carriers have established new ASAP programs for additional employee groups. All of this supports the contention that the Call to Action did make a difference.

    Professionalism and Mentoring: Last week, the FAA met with labor organizations to discuss further developing and improving professionalism and transfer of pilot experience. In the interim, these organizations have answered the Call to Action and support the establishment or professional standards and ethics committees, a code of ethics, and safety risk management meetings between the FAA and major and regional air carriers. We also believe that labor organizations can explore some of the ideas raised in the Call to Action road shows, such as establishing joint strategic councils within a “family of carriers,” use of professional standards committee safety conferences, and mentoring possibilities between air carriers and university aviation programs, with the goal of coming up with concrete ideas on mentoring. These ideas merit further discussion and the FAA looks forward to continuing to work with these organizations on these concepts.

    Crew Training Requirements: As the Administrator explained during his last appearance before this Committee, the FAA issued a rulemaking proposal in January 2009 to enhance training programs by requiring the use of simulation devices for pilots. More than 3,000 pages of comments were received. The FAA is now developing a supplemental proposal that will be issued in the coming months to allow the public to comment on the revisions that were made based on the comments that were submitted.

    One of the things that the Call Action has shone a light on is the issue of varying pilot experience. The FAA is attempting to address this issue with an Advanced Notice of Proposed Rulemaking (ANPRM) in which we can consider possible alternative requirements, such as an endorsement on a commercial license to indicate specific qualifications. We know some people believe that simply increasing the minimum number of hours required for a pilot to fly in commercial aviation is appropriate. As Administrator Babbitt has stated repeatedly, he does not believe that simply raising quantity – the total number of hours of flying time or experience – without regard to the quality and nature of that time and experience – is an appropriate method by which to improve a pilot’s proficiency in commercial operations.

    The ANPRM requests recommendations from the public to improve pilot performance and professionalism; specifically on whether existing flight crew eligibility, training and qualification requirements should be increased for commercial pilots engaged in part 121 operations. The FAA is requesting comments and recommendations on four concepts for the purpose of reviewing current pilot certification regulations. The four concepts are: (1) requirement for all pilots employed in part 121 air carrier operations to hold an Airline Transport Pilot (ATP) certificate with the appropriate aircraft category, class and type rating, or meet the aeronautical experience requirements of an ATP certificate; (2) academic training as a substitute for flight hours experience; (3) endorsement for air carrier operations; and, (4) new additional authorization on an existing pilot certificate. The FAA has also asked for recommendations from industry and the public on any other concepts they may wish to offer. The ANPRM was published in the Federal Register on February 8.

    Pilot Records: While Congress is working to amend the Pilot Records Improvement Act of 1996 and the FAA amends its guidance to airlines, Administrator Babbitt asked that air carriers immediately implement a policy of asking pilot applicants to voluntarily disclose FAA records, including notices of disapproval for evaluation events. The airlines agreed to use this best practice for pilot record checks to allow for a more expansive review of records created over the course a pilot’s career. The expanded review would include all the records the FAA maintains on pilots in addition to the records airlines already receive from past employers. Of the 80 air carriers that responded to the FAA on this issue, 53 air carriers, or 66 percent, reported that they already require full disclosure of a pilot applicant’s FAA records. Another 15 percent reported that they plan to implement the same policy.

    As the Administrator stated when he appeared before you in December, the core of many of the issues facing the air carrier industry today is professionalism. It is the duty of the flight crew to arrive for work rested and ready to perform their jobs, regardless of whether they live down the street from the airport or a thousand miles away. Professionalism is not something we can regulate, but it is something to which we must encourage and urge pilots and flight crews to aspire. The conversations we have been having, in part because of the Call to Action, help emphasize the importance of professionalism in aviation safety.

    In conclusion, our efforts will not stop or even slow down just because the final report on the Call to Action was issued. We have been gratified with the response to this effort. We believe that the collective efforts of FAA, the airlines, labor unions and, of course, Congress, will continue to result in implementing best practices, transferring pilot experience, and achieving an overall improvement in safety. Safety is at the core of the FAA’s mission, and we will always strive to make a safe system safer.

    Mr. Chairman, Senator DeMint, Members of the Subcommittee, this concludes my prepared remarks. I would be happy to answer any questions that you might have.

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  • Politics and the Art and Science of Crash Investigation

    Should art be mentioned here? Art is the expression or application of human creative skill and imagination. Surely this applies to investigation. It is only through imagining the sequence of what happened that what actually happened can be determined. Theoretically, scientific experimentation takes place in a vacuum, or at least in a neutral area where the laws of nature can be observed to run in a natural fashion, after which, conclusions are drawn. Attempts are made for the hypothesis to be untainted by factors such as “opinion,” “bias,” and “prejudice.” But it could not exist without human imagination.

    But imagination is far from “imaginary.” Accident investigation is not scientific experimentation, but it is supposed to be based, like science, on handling conclusions based on neutrally observed but hard facts. The problem of course, is that the accidents being investigated do not occur in the careful measured neutrality of a lab, but in the messy, busy, interactivity of the real world. The search for the truth is a crucial thing, one of interest not only to the victims or families of the victims, but also the insurance companies, banks, aircraft manufacturers, airlines, future airline passengers…the list grows. The climate in which investigations take place is far from neutral, in spite of attempts for investigators to be professional.

    If you look at the Comoros crash you can see the effects of clashes between the governmental institutions of Comoros and France, replete with name-calling, bias, and politics. This is equally true in the Air France 447 case, where political pressures exert invisible pressures. Consider the stake the country has in Air France, and in Airbus. In any investigation, it may be that the lives and careers of some very powerful people hinge on how an investigation goes, and even more so when a country like France adds the aspect of criminal proceedings.

    The well-known world regulatory organizations over aviation industry trade groups (IATA, ICAO, AEA, ATA) have developed highly regulated procedures for investigation. We can only hope that the highly regulated and complex process of investigations can continue in as even a keel as possible, in spite of the turbulence coming from all interested parties. The world waits for answers, but politics inevitably set the stage, and like the observed but unseen air currents in weather, play a part, whether invisible or obvious. While there are some protections in place, (for example, NTSB reports can not be used as evidence lest the integrity investigation be compromised), we can never fully know what goes on behind the scenes.

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    The Ides of Germanwings: One Year Later

    There is a time to go about our daily business. There is a time to set everything else aside, and just remember. Now it is time to remember.

    Dusseldorf airport set aside a room for German family members of the 72 Germans who lost their lives on Flight 9525.

    Today in Barcelona, flags were at half-mast and 149 candles lit as people gathered at Barcelona Airport to recall the victims of the crash of Germanwings Flight 9525. On 24 March 2015, one year ago as of tomorrow, Flight 9525 was en route from Barcelona to Dusseldorf when it crashed in the French Alps, killing 144 passengers, two pilots, and four cabin crew. The tragedy was engineered by suicidal co-pilot Andreas Lubitz. Family members gathered here, as well as emergency workers and officials.

    There were fifty-one Spanish lost in the crash. Four countries (including the US) lost three victims; seven countries lost two victims, and five countries lost one. I hope that all the families, where ever they live, found comfort somewhere.

    On Thursday, the victims’ names will be read and remembered; flowers will be left at the Le Vernet cemetery which houses the accident’s unidentified remains. Six hundred Flight 9525 victim’s friends and family will have a commemoration ceremony in Le Vernet village in the French Alps not far from the crash site. Weather prevents a visit to the crash site.

    I was in Le Vernet last July when 149 balloons were released. I can’t help but feel that I should be there again to support the families. I have just returned from Barcelona, and barely unpacked my bags. I can only hope that the year of mourning and grieving has been cathartic, and that the families are finding a way to embrace life again.

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  • Criminal Regulation

    George’s Point of View

    The IATA ( Air Transport Association) is an association representing the world’s airlines commitment to excellence and safety in aviation. All of its 224 Member airlines live up to best practice standards in airline safety. 8 airlines lost membership due to failing a 2008 IOSA ( IATA Operational Safety Audit) audit.

    Airlines which fail the safety audit, or are otherwise unable to reach the safety standards are banned by the European Union. One of those banned airlines is Garuda Indonesia, the national airline of Indonesia. That’s the same airline which has been in the news for the recent sentencing of one of it’s pilots. Not that Garunda Indonesia even flies to Europe.

    Marwoto Komar who was piloting Garuda Indonesia Flight 200 , ignored warnings not to land the plane when he brought it in at twice the safe speed, resulting in the plane slamming into the runway, skidding off and bursting into flame, killing 21. While he did not get life in prison, he did get jail time.

    The pilot’s sentencing is really a symptom of what is going on with Garunda Indonesia, which is a lack of government supervision. In fact, aircrafts which would otherwise be considered safe, are NOT safe simply because of being part of GI’s under-supervised, under-inspected, under-maintained fleet. In fact, there is a $24 million Indonesian governmental program now in place to train Indonesian air safety inspectors, an ambitious program which may still take years to bring the airline up to acceptable safety standards.

    In the meantime, apparently the burden of safety rests on the shoulders of pilots, which in view of recent history, does not particularly appear to be a good thing. Furthermore, no one yet has made it public exactly why Marwoto Komar ignored air traffic control AND his instruments AND his co-pilot to attempt a landing at twice the safe speed, but perhaps while he is in jail, the Indonesian skies may be marginally safer. Not that it does any good for the 21 victims of Flight 200.

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