Pulling A Slater

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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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  • Aviation’s New Ride-Em Cowboy Poster-Child

    George’s Point of View

    Americans are always looking for new anti-heroes, and Steven Slater has slipped into that role for a number of groups, especially those who have to deal with a surly public, who always have to be polite for the sake of their jobs and bite back their equally surly response.

    With the job shortage being what it is, people are feeling the weight of their bills and putting up with their need to take this job and shove it

    But in a more specific sense, he also stands as a symbol of problems in the aviation industry, inside and out. Air travel means discomfort, the bother, the fuss, and a hundred goading needling annoyances: the rude attendant or passenger, hot plane, lost luggage, uncomfortable airline seat, on top of putting up with being too hot, too cold, too miserable. Steven Slater has a whole world of people out there who applaud him for not being “too polite.”

    Slater is one cowboy who would have never had his ten seconds of fame if Jet Blue had provided what every cowboy needs: a side kick. Where was the in-house support? While you’re on that plane, what an airline attendant says is law. (Just ask the Feds.) If the machine had been working properly, it would be that unruly passenger who would be behind bars. Whoever should have been backing up Slater, wasn’t. Instead of one lone cowboy taking it on the chin, Jet Blue needs to step forward and take care of their own.

    When Steven Slater decided he just wasn’t going to take it any more, and slid off the Jet Blue plane with a couple of beers, he became the poster child for dissatisfied people everywhere, who suddenly put themselves in his rebellious shoes and liked the feeling.

    What is more American than the pursuit of happiness?

    After all, we’re all cowboys.

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    Remembering AirBlue Flight 202

    On July 28, Air Blue Flight 202 crashed in the Margalla Hills north of Islamabad. It was the last flight ever for 146 passengers and six crew. The accident happened during a July rainstorm six years ago, I believe the people aboard should be remembered.

    The only survivors were the family members. No one aboard lived.

    That means that the families of 152 people have had to learn to live with the memories of their loved ones. Most of them have probably traveled to the memorial to see their loved ones names written in stone. Stone will remember what people may forget.

    The accident has been labeled pilot error, but those are just words. Some called the fatal flaw CRM, which is an acronym referring to how well the crew inter-managed resources, i.e. themselves. The final report has been completed and filed and put away.

    And the victims are still dead. I could wish for a world of magic reality where the investigation would solve some thing, and somehow put the passengers back in their lives. Or even better, change the events of the past so that the flight never happened.

    But magic reality does not exist. All that exists is the truth of what happened, the lessons of the past, and the hope that the aviation industry learned whatever it could to prevent such accidents in the future.

    The tragedy is a stain on 2010, and forever a wound in the hearts of the families of those whose lives were pointlessly lost. Families, please know that even if the accident is no longer in the global eye, we are so sorry for your loss. No one can say it better than John Donne:

    Any man’s death diminishes me,
    Because I am involved in mankind,
    And therefore never send to know for whom the bell tolls;
    It tolls for thee.

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  • 6 Years of Unsupervised Supervision=65000 Flights of Chaos

    They say about real estate that the three most important things are location, location, location. And that makes sense, because the key factor about real estate is its lack of portability. Whether you’re in Calabasas or Timbuktu, where you are ultimately is where you are. The fact that it is where it is is what makes it what it is. Intrinsic value, and all that.

    One could argue what the most important thing about travel is. You could make a strong argument for getting there, being there, or smelling the roses along the way. If we narrow the question to the single most important thing about air travel, the most important thing is probably getting there in one piece–mostly because it seems that getting there safely and completely without incident is an ever more dubious proposition, a perception which is being emphasized now more than ever due to NASA’s Aviation Safety Reporting System. When record keeping changes, it is difficult to say if some underlying factor has changed, or if the reporting is the only change. At any given time, it looks like the odds of getting there in one piece–on a plane that is 100% airworthy–are starting to look slim. And that is important whether the a plane is landing at LAX, (third busiest US Airport)

    NASA’s Aviation Safety Reporting System allows crew members to phone in anonymous reports, a whistle-blower’s hotline as it were. So there’s a record of blunders, errors, faults, and slip-ups, like improper repairs, substandard repairs, unqualified mechanics and maintenance deficits that might otherwise have slipped by or gotten swept under the rug.

    Honestly, what I see on these reports makes me seriously anxious. I’ll be facing more white-knuckled flights, just knowing that in the past six years, 65,000 flights have taken off in less than airworthy condition in conditions of deferred maintenance, or sporting less than stellar repairs farmed out to contract shops. 65,000 flights is a lot of flights, even if it is spread out over 6 years and 63 million flights. And do I believe that ALL of the other planes were in perfect running order? No.

    Some of the mechanical problems that down planes can be linked back to tiny repairs, or perhaps I should say involving small but very important parts. If a plane can go down because a single screw is loose, or the threads are worn, then acute attention to maintenance is exponentially more important. I wouldn’t set foot in a golf cart in the condition some of these planes are in. But as a commercial passenger, I would never know if repairs on my flight were deferred. I would not know if a plane were outsourced to a sub-standard repair facility by mechanics without repair manuals, proper tools or correct parts. Outsourcing repairs to other countries not only removes shops from proper supervision, it also opens up the possibility of security risk. But I digress from what is my primary concern right now.

    A sense of proportion and common sense should be applied here. Lights over a passenger seat are not as crucial as a screw assembly on the tail that provides pitch control.

    I’m just saying:

    We need more qualified supervised aviation repair facilities on U.S. soil.
    We need airlines to stop deferring repairs.
    We need airlines to maintain high standards.
    We need the FAA and the NTSB to do their jobs.

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    Chinese Pilots Flying with False Records

    George’s Point of View

    Apparently false flying records are part of a known underground Chinese pilot subculture. All Chinese pilots know about it. Now the CAA does too. Just google this phrase: false pilot certification surname Xu

    192 Chinese pilots with falsified flight records are now under the eye of China’s Civil Aviation Authority; some of them have conditionally been allowed to continue flying pending re-application for pilot certificates after undergoing additional training under strict supervision. Some of the pilots involved had their licenses revoked. Here’s the big question that hit me, and the reason I posted this as an editorial and not just news:

    Should the pilots be allowed to earn their certification after falsifying their records?

    The US FDA would never let Chinese goods pass uninspected, especially since recent history has proven that if Chinese imports can somehow be adulterated (by melamine, or toxins in drywall, hook or crook, shame, fines, bribery, guilt, flattery or whatever), then it will be. So products are not to be trusted but must be inspected. This is not the sole dominion of Chinese exports, but all of all countries products.

    But what of the long-standing Chinese obsession with honor? Has honor decayed in the face of rapid economic and social change?

    The honor thing in China is very real. Zheng Xiaoyu, head of the Chinese FDA from 1998 to 2005, approved untested medicine in exchange for cash. In punishment, China executed him.

    Should China, which for centuries has set high standards for honor, now let these values erode because of a pilot shortage? Shouldn’t the ethics, honor and sense of responsibility of someone who is daily responsible for hundreds of lives be impeccable? Is someone who is willing to falsify their flying history an individual of impeccable honor, one responsible enough to bear the burden of all of those lives? Perhaps I should not bring this up, as the oriental concept of honor is not identical to the non-oriental perception. Perhaps saving face in this case is a matter of equating “honor” with the “Soprano-like” keeping of the false-paper pilot cult secret. Even so, the issue is not only the question of how one can be solidly qualified if the foundation of ones qualification is a tissue of lies, but also if a pilot is shady and unreliable enough to pretend to be qualified, how can that so-called pilot actually be reliable enough, trained enough, expert enough to safeguard the lives of planeloads of passengers who trust there is solid experience in the cockpit? It is a violation of the public trust.

    One of these falsely certified pilots was manning the Henan Airlines jet crash. His fake credentials and lack of experience caused the deaths of more than 40 people. How much more of a wake-up call does China need?

    But it is not unreasonable to allow testing to verify qualifications. It is more humane than applying the Chinese FDA solution. Perhaps the very existence of 192 known falsifications indicates some need of a fast-track solution for former military pilots who wanted to transition into commercial positions.

    I have personally flown within China in their planes. I felt safe. The flights had no incidents, and believe me, unlike many passengers whose lives do not revolve around aviation, I am always on the lookout.  So, let’s not put down the many for the few who have taken the course of this criminal act. Let us, rather, respect that China ferreted out the falsified records, and are proceeding in a modern and reasonable fashion to make amends. I personally love China, and travel there often. I will continue to do so, even if it is on a Chinese plane.

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  • Getting Past Indifference

    In George’s Point of View

    When we are working on a case trying to get compensation for victims of a crash, we find that the court relies on friends and family to paint a picture of who the victim was, and how they used to fit in the world. Of course we all know that every human being is priceless; but it is the court’s duty oftentimes to put a numeric value on a person for the sake of compensation. Some courts can be remarkably indifferent to individuals. I was reminded of that truism when reading the word-pictures rendered by the boyfriend of one of the Kazan Airport Crash victims, Yana Baranova …” an incredibly focused and mature businesswoman. Her colleagues describe her as a “rising star” of their industry, and her drive would have doubtless carried her beyond her own expectations….” He barely glances over this description of her, but in his words, we do see the snapshot of a vital young woman lost in her prime.

    Yana’s boyfriend is unaccustomed to dealing with the Russian bureaucracy, and refers to “indifference and a lack of surprise boarding on apathy” and officials who write off that attitude with “This is Russia.” As this young man notes, my experience too has been that Russian courts that can be apathetic.

    It is true that the opposite of love is not hate; it is apathy. Elie Wiesel said that, and it is true. Apathy is the callus that has formed—like a healed blister over an injury— thickened, hardened, insensitive tissue formed over a wound to protect it. Over time, it may become expedient for an official not to stop and feel the pain, but it is a tragedy when that happens. Something of humanity is lost. When dealing with government and the courts, one has to remember that they have seen it all, not once but a hundred, a thousand times. Their souls are probably more blistered than your worst blistered feet in new shoes with no socks, worn day after day, in grueling conditions. No wonder they are calloused, insensitive, even hard. It is a grievous fact that too often robes of government, of jurisprudence, which should be worn to empower and embrace the rights of man and the rule of justice are often worn as shields and blades against the individual. For the law to work at its best, it should be objective, but never sacrifice sensitivity to the victims, or the families of the victims.

    Sometimes it is up to our lawyers to remind the courts that the best and brightest of the legal profession went into the field because they were idealists who love the law; who stepped into their professions because they wanted to spearhead change for good, rights of man; who probably had specific agendas where they wanted to affect change; who believed they would be more effective than they are; who ran into barrier after barrier and who may have given up; who may have substituted apathy for the appearance of objectivity.

    After consulting for forty years on a huge variety of cases, maybe I haven’t seen it all, but I’ve come pretty close. I can’t claim to have a crystal ball, but there’s not a whole lot that surprises me. I’ve developed a pretty good instinct about where and when courts go left instead of right.

    In the US, our “rights-based” ethics system means that we all have the right to be treated as equal to others. Other countries may have “utilitarian ethics based on “good outcomes” vs “bad outcomes”, often with the rights of the individual getting crunched somewhere under the wheels of the system.

    We can only hope to do our best to represent the individuals who were lost. We can only do our best to remind those who sit in judgement that underneath the armor and callouses we all wear to protect ourselves from being fragile in the face of all the storms of life, that we are all human, all deserving of hope, concern, and ethical treatment.

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