How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy

Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world?

Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:

Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the "Safety Investigation" by claiming that the "Common Good of the Traveling Public is at Risk!" Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of "What Happened" and "How do we keep this event from ever happening again?" are lost in the rush to "Who was at fault?" and "Who pays?"

Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap's recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.

Rule Three: Generate "Legal Uncertainty" using the term "Probable Cause" [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that "reasonable doubt" is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.

Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.

Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the "Traveling Public."

Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the "Parties To The Investigation" and those "Parties To the Investigation" without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the "inevitability of tragic human loss" in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.

Well, that about sums it up, no?

One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?

Could this be why in commercial aviation we observe the essentially "same disaster" or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn't this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?

Shouldn't the purpose of a Safety Investigation be to "find out what went wrong and take action to ensure that this event never happens again?" Isn't that what all of us do in life to keep from making the same mistake twice? Why wouldn't that same reasoning apply when we are talking about "Flying the Traveling Public Around the World in Our Commercial Aviation system?"

Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?

Or are we just stuck on Rules One through Six?

Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to "someone else?"

Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.

When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?

If so, their voices have yet to be heard.

This of course is my opinion.

Grim Safety Forecast for Air France

The recommendation is contained in the latest BEA accident report investigating the loss of the Air France Flight 447, a document that outlines 10 new safety recommendations, including improved pilot stall-awareness training, the inclusion of cockpit cameras, and adding angle-of-attack readouts in the cockpit.
But it's the inclusion of a call for mandatory data streaming technology that is sure to raise the biggest objections with airlines, who will have to pay for it.

This is a grim future for Air France if these are the BEA's main plan to prevent this event from reoccurring.
I can agree with the angle of attack recommendation. I can agree with the stall awareness training.
But did not having the cameras cause the mishap? Of course not; this is just someone trying to get the camera in the cockpit nnd using thes dead people to do it.
Did not having data streaming from the acft cause the mishap? No, in fact it was not having weather data streaming TO THE AIRCRAFT that was in great part responsible for the mishap.

So, it is my opinion that AF will have a string of these mishaps, more of the same!

AF447 again and again?

AF447 will undoubtedly reoccur again and again because the aircraft mishap investigation board failed to discover the cause of the mishap and instead blamed the mishap on the crew. Not only is this an inaccurate and unsubstantiated conclusion, it is also a conclusion that is misinformative. No airline reading this report will be able to use the report to take steps to prevent a similar mishap from occurring again. That is a very large error on the part of the company and the country.

The sole and critically important purpose of an aircraft mishap safety investigation is to determine the cause of the mishap. Period. By accurately determining the cause of the mishap, the safety investigation informs all of us on how to prevent this mishap from occurring again.

Instead, the board doing the investigation has chosen to take their license to do a safety investigation and use the investigation as a legal tool to attempt to lay legal blame for the mishap on flight crew. This is a total aberration of the legitimacy of the entire process of safety investigations.

While companies and countries have the right to do a legal investigation to protect their legal interests, it is not their place to take the safety investigation and abscond with it for their own legal purposes. The public deserves and the industry deserves an unbiased safety mishap investigation.
What has been publish so far is not that at all.

This is a terrible miscarriage of safety and a great example of why the fox should not be guarding the hen house.

Go Arounds, Missed Approaches and variations?

I would like to suggest that each reader spend a few minutes thinking about how many different procedures that their airline or aviation organization has for conducting a missed approach and/or a go around.

Your first reaction might be "Just one." But take another minute and consider the variations. Each aircraft type has a slightly different set of procedures. How about the case when an engine is inop? What if the weather is IMC and tower is using IFR procedures in the ATA?
What if the weather is VMC and tower is using VFR procedures in the ATA? How about the case of the flight executing a cleared IFR approach procedure, but when handed off to tower, the clearance reads, "Cleared for a visual approach to land?"
What if the terrain for the runway in use dictates immediate maneuvers, the weather is IMC and tower assumed that you would have broken out and is taken by surprise that you are going around and a large thunder storm is in the missed approach path?
Does your training program give line pilots training and sufficient sim practice to be superbly proficient in all types of MA/GA's?

What if the weather is so bad that the airframe is icing up with mixed clear and rime during the last 1000 feet and the previous aircraft has not cleared the runway and now tower orders a GA? Has the crew practiced and become proficient in this scenario?

I hope that each reader considers all of the variations on MA and GA for a while and feels free to post a comment on this subject.
Thanks and more to follow on this subject.

Safety Forecasts More AF Mishaps

Safety Forecasts and Plans has determined that since AF has devoted so many resources towards trying to prove that they were not legally at fault for the deaths of their AF 447 passengers, that AF has not devoted sufficient resources to preventing future mishaps of all kinds, and therefor should plan on more mishaps for the future.

The statistical review of the past 10 years shows that AF mishaps were preventable, yet AF took steps insufficient to prevent them. Since AF has seemingly now devoted enormous resources to the trying to defend themselves, such as spending as much as $35 million to recover a DFDR by submarine, when all that they had to do was to walk into their own dispatch office and witness supervisory personnel not taking preventative steps to advise line captains about weather hazards in their path.

Example? AF 358 flew into a thunderstorm upon landing. Was the thunderstorm present prior to approach? Did dispatch, flight ops or anyone at AF have a thunderstorm avoidance policy? Did the policy undergo scrutiny, study or in anyway become part of flight operations procedures subsequent to AF 447 departing?

It appears that the thunderstorm avoidance procedures at AF was not change after AF 358 crashed in Toronto. Remember that this crash happened in August of 2005.

AF 447 occurred June 2009. So four years occurred and AF 447 flew into a thunderstorm. So once again the same mishap occurred all over again. And Why?

Very simply because no one in AF, or Canada or any other body determined that the cause of the mishap was flying into a thunderstorm. Blame was placed legally at the hands of the flight crew. Legal blame, legal blame was the product of the Canada Aircraft Safety Mishap Board. In fact it appears that the board didn't complete the safety task at all.

Should not have the board instead of assigning blame, determined the cause to be an encounter with a thunderstorm? Who claims that the aircraft can fly in thunderstorms? Does the manufacturer? Who does?
And yet less than 4 years later, AF flies another aircraft into a thunderstorm and the various mishap boards are all focusing on the actions of the crew once inside the storm!!!!!!! How absolutely ridiculous and illogical can any attempt be?

The manufacturer of no commercial aircraft and the regulator of no civil aviation authority anywhere in the world builds or certifies any commercial aircraft to operate inside of a thunderstorm.

So why does AF continue to do so? Why does any board expect to find any differing result in the event of an encounter?

AF 447, Safety Forecasting and Planning

Did the AF dispatch office fail to fulfill their duty to look at satellite data?
Did AF flight ops management have a procedure to get the information about recent bad weather enroute passed to transoceanic flight crews, especially those transiting the tropical convergence zone?

When you who are safety managers look at these questions, do you wonder why this lack of procedure was allowed to occur when so many lives are at stake?

If you who are safety managers are able to see that this could be a problem for your airline, then you have created e forecast of things to come.

Did AF 447 use correct Turbulent Penetration Procedures?

The second issue seems to be flight crew training when in heavy turbulence and when the pitot-static system is not operating.
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.

Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.

The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.

I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?

Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.

Other procedures include all of the various heaters and engine ignition circuits should be placed on.

Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.

Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?