Root Cause Analysis
Last week I wrote a post attributing blame to the FAA, as the root cause of the midair in DCA. Some people, perhaps without knowledge of this concept, did not understand. Root cause analysis is the core of any safety management system. We must look at the human, physical and organizational issues and figure out why the events occurred. In the midair accident all three were involved. Yet, the accident was not the event that should have triggered this analysis. The near misses were. As you critically think, ask yourself who was responsible to regulate and fix all three of those areas to create a safe environment for passenger travel?
A ROOT CAUSE:
Back in the day when a military pilot raised his gear instead of flaps, if we simply blamed the pilot nothing would get fixed. Human factors got involved and identified that both the gear and the flap handles looked like the same lever. A ball on the handle, and they were too close to each other. The root cause of this human error was due to the similarity in shape of the handles and proximity. They fixed that problem.
If your doctor says you have a high white cell count but makes no effort to find out why, you could die from cancer. Death would not be from too many white cells, that symptom told you there was an underlying problem in the body. If you do nothing you die. If you don’t address the symptom, and ignore the warnings in your body you may not survive. Not from the symptoms, but from the root cause of those symptoms.
In the American Eagle Blackhawk accident, the symptoms were multiple mid-airs. Warnings came from those operating in the environment. The FAA did not address the underlying cause of those symptoms, and the two aircraft collided, killing everyone onboard. Had the FAA done a root cause analysis of why the near misses in that airport—control tower constraints, operational constraints, runway 33 issues, human error realities with military pilot training, and had done anything about the impact, this accident would not have happened. Doing nothing when there is a concern eventually will lead to death. This is why I say, “It’s not if, but when.”
INDIVIDUAL CONCERNS:
But the helicopter hit the plane! It’s their fault!
If a car manufacturer sold you a car with a known problem and you drove it and killed someone because of that issue, who is to blame? Yes, you drove the car and did the hitting, but only because you were put into a situation that should not have been. This area was a known issue to be problematic, and the FAA allowed training operations, with knowledge that pilots make errors as part of being human. The industry has worked to ensure human error don’t manifest into an accident. Except at this airport.
Wait for the accident investigation!
If families are telling the city that they need a stop light at the crosswalk for the kids because of all the close calls over the years, and nothing is done because the county doesn’t want to spend the money or inconvenience the high value property owners who travel through that area. Then a group of kids get hit in the crosswalk, do you really need an accident investigation to determine why that happened?
The Tower should never have put the plane on runway 33!
You’re right, in a perfect world they would not have offered it. But this is a high efficiency airport with supervisors watching the ability of a controller to manage the operation. Put American on 33 and we can get another plane out on time, off of runway 01. Look how great this works! This happens all the time at all airports. And, in this area, it has been a known operation and yet the FAA has done nothing to mitigate the risk of the potential problems.
The American pilots should never have taken runway 33!
You’re right. But then, why wouldn’t they if they had the ability? Perhaps these pilots lacked knowledge to the unsafe environment. A retired Captain reached out and said he avoided that airport during his career because it was unsafe, but still had to fly there over 200 times, and never would accept runway 33. Endeavor Air has it in their operations specs that their pilots are prohibited from landing on runway 33. It’s unsafe. Why didn’t these pilots know this? Because we lead them to believe they are safe.
Over reliance on a safe environment
Our new generation of pilots are buying the FAA and Airline propaganda that “Safety is our top priority” that we have “the safest airspace” and we have a special regulation called SMS that ensures the airline and FAA have mitigated the risk to our operation, and pilots… YOU ARE SAFE. They offer runway 33, it must be safe. The new kids in the sky are not like those old timers being forced to retire, who mitigated risk on their own (avoid or don’t take the runway) because when they flew it wasn’t proposed safe. We learned to always believe safety was our responsibility and not to rely on controllers or the system. More on this to come.
Today, I believe pilots operate, unknowingly, in a fantasy bubble blown by the regulators and airline management that they are protected, but all it takes is a pin to pop that safety bubble and the accident happens. Those pilots landing on 33 did not know it was unsafe. Did not know that retired captains avoided that runway. Did not know that some airline prohibits it. Or those pilots would never have accepted that runway. They were given a false sense of security. This is an issue with today’s aviation. Something needs to be done.
10 Comments
Your comments were right on – are there no regs about helicopters flying under an approach used by commercial airlines? It seems the helicopter max altitude of 200 feet with the glide scope to 33 intersecting st about 325 feet is WAY too close. 125 feet!!
Is this acceptable to the FAA? Has the NTSB reviewed or recommended this approach? Shouldn’t they? Thanks Kevin Brady
Kevin, those are great questions. Check this out: Part §91.119 – Minimum safe altitudes: General.
Helicopters are able to fly below the minimums of airplanes provided that “each person operating the helicopter complies with any routes or altitudes specifically prescribed for helicopters by the FAA.”
If there are not any specific restrictions by the FAA, a helicopter may descent to any altitude as long as the pilot in command deems it safe.
Apparently they had permission to fly down the river. But the sad part is, the FAA knew this was unsafe and should have prevented it. Now they’ll do something since people died. We need to change this.
There was a near-miss the night before, at that very airport. It was averted by TCAS on both jets. On the next night, the Blackhawk had its ADS-B turned off, however, I still find fault with the controller who, like so many in the domestic theaters, relied on the pilots to call traffic in sight then required them to maintain visual separation. Ever since a captain I know was violated for calling the wrong traffic in sight and then getting too close to the one he should have kept distance from, I have never accepted that clearance. Each time, the controller would give me a snippy answer, taking me on a detour, keeping me low, punishing me. One even said, “that’s unbelievable, he’s right in front of you”, to which I replied, “I’m not calling him”. Controllers should be reminded that they are trained to separate jets and props, while we are trained to fly them. Every pilot I have talked with since this horrible collision happened mentions KPHX airport, where the tower asks you, “do you have departing traffic in sight?” before issuing a takeoff clearance attached to a “maintain visual separation” order. I must be the only person who ever refused that clearance, sending the controller into a palpable rage. He was not happy and was going to punish me. He did clear my 767 for takeoff, but restricted us to 3000′ and a heading away from our course. I was not affected by that clearance, but instead, relieved that he was actually doing his job. The DCA controller could have vectored the helicopter to maintain separation. THAT, again, is on the controller. When I watched the press conference, the NTSB Official became visibly choked up when he bemoaned the lack of action by the FAA at the MANY recommendations made by the NTSB. Maybe it’s time for the NTSB to have the authority to effect procedural changes, instead of the corrupt FAA.”
Brigitte, excellent points and thanks for the info on the recent near miss. I think these controllers are allowed to pass the buck and they do it to focus elsewhere. The system is broken and the FAA needs to mandate rules so they can not do that. So, I don’t blame that controller, every day, every airport, this is ongoing. You are not the only pilot who refuses a clearance. I know many of the old school pilots who challenge, because they understand. This is the difference of being able to think, versus becoming a puppet in the industry. Having courage to speak out like you do. Unfortunately we are training monkeys to push the buttons and get the banana. But that extends to the plane, because they stop asking questions, even when the question is… “should I take this clearance or turn it down?” Thanks for your comment!
He had more than 3x the flight hours of the military pilots combined. You owe us and his memory an apology
Mrs. Lilley, I cried for your son and all those on board. I have given my life and my career to ensure these things don’t happen. That helicopter hit that plane because they were at the wrong altitude. There are many ifs.. but that life. I think about the movement for automation to replace pilots. But if automation had been flying that plane, it, too, would have taken the other runway and still been hit. This was a horrible accident that the FAA saw coming due to high risk. They did nothing. There is no blame to your son. I am fighting to ensure this doesn’t happen again. I have been fighting to ensure your son’s accident would not happen. But instead of doing anything to fix the problem, they tried to silence me. Maybe if the FAA listened to the problems he would still be alive.
In the brief moment it took me to read what wrote twice, you called my son inexperienced, a monkey and a puppet. He was a fine pilot, respected and loved by any that had the pleasure of flying with him.
Mrs. Lilley, please read again. I only said that a Delta instructor told a Delta captain learning a new plane to be the monkey and do what he said without question to pass training. This was testimony in a trial to a judge in a public record. There was no learning involved. I would never call anyone a monkey and it bothers me that this this statement was ever made. Because if we don’t provide the best to our pilots and ensure they have full understanding accidents will happen.
Hi Karlene, first of all I agree completely with your assessment of the crash. We know indeed that the Blackhawk pilot was flying above altitude – but isn’t it a bit crazy that the FAA even permitted a flight path that passed so close beneath the glideslope at a major international airport in the first place…? I find it really hard to fault the pilots here. I’m not a pilot, I’ve only played sims, but to me allowing a training exercise to pass so close to the glideslope in the first place seems like playing with fire.
If you’ll pardon me for polluting your comment section with something a little bit off-topic: about the FAA, after the recent incidents this year, recently I’ve been looking into the aftermath of Swissair Flight 111 that crashed off Nova Scotia in 1998. The cause was found to be faulty wiring for the in-flight entertainment system that arced, igniting flammable metallic Mylar-covered (MPET) insulation above the cockpit. I remember seeing the news report on TV as a child and what a terrible tragedy it was, and one that’s still remembered here in Canada.
The documents are dense reading for a non-specialist, but the overall impression I got from looking through the TSB report and then the FAA assessment and ADs in turn was that the FAA is at least as much an industry group as it is a regulator.
Some things I found particularly disturbing about the FAA’s actions (and manufacturer, maybe you could say by extension?) before and after Swissair 111:
– The FAA had a completely inadequate test for insulation that involved holding a piece of it over a Bunsen burner for a few seconds, and had actually approved the insulation that caused the fire
– Aircraft insulation was supposed to self-extinguish once sources of ignition had been shut off, but in the early 1990s several MD planes had insulation fires that self-perpetuated. MD tested the MPET again and found it was highly dangerous, but in 1997 only a service bulletin was issued, not an AD
– the aisle lights and emergency lights on many MD (Boeing after 1998) planes were found to overheat to over 300 degrees Celsius and damage the insulation, but the FAA didn’t test them; they allowed Boeing and the lighting manufacturer to run a test and took their word that they were safe
– similar fires had happened in the early 1990s on Boeing planes built with an insulation called AN-26, but it wasn’t until 2008 that the FAA issued an AD calling for its replacement, and gave airlines fully 96 months to complete the work
– In 2000 the FAA issued a series of ADs addressing manufacturing defects in the breaker boxes on many MD planes, whereby circuits were unprotected and could cause fires – major defects that had previously escaped the FAA’s notice
…and it seems to me that the wording of the FAA ADs that were issued in response to the crash betrays an attitude might explain why the TSB didn’t consider its main recommendations to have been fully addressed until 2020 – they always start with “To prevent possible…” and end with “…potential problems.”
It seems to me that when something has caused a plane to catch fire and crash in the ocean, it would be better to call it a definite problem that really exists. And the main takeaway is that the FAA and McDonnell Douglas already knew the insulation would not self-extinguish as required, but the FAA didn’t issue an AD that would cost the airlines and the manufacturer money…
Yours is an interesting blog, thanks for caring about aviation safety.
Dear Gemma, you completely understand. Someone (FAA) is not doing their job. Send me an email…this needs a post of its own. Thank you for sharing.