The old saying,
“Any landing you walk away from is a good landing”
might be wrong.
I’m surprised that anyone survived this crash, but I am not surprised that this event happened. This was not an “if” but a “when.” This was a training issue that resulted in pilot error. Fast, no flare, they slammed into the runway. But if we don’t properly train pilots to land in strong winds, or how to identify when to go around, or how to do so, because that might cut into executives profit, then we failed these pilots.
Why has Nobody Interviewed the CEO Captain James Graham?
Substandard Training
In 2008 Delta and Northwest merged. In 2009 they formed a single operating certificate. In 2010, I experienced my first Delta training checkride, where the instructor did not give the federally required oral. He sat in the back of the simulator and texted instead of paying attention to the “new to” A330 pilots. He did not even give a debrief. He falsified training records. Why? Because as he said, “At Delta we have the power to do what we want.” He soon became a line check airman.
Meanwhile, in another Delta simulator a different instructor is telling Delta pilots, “Stop asking questions, be the monkey, hit the lever, get the banana.” Delta even provides answers to the written tests, computerized now, for rote memorization. To pass the test however, sometimes you have to answer incorrectly, because the test is wrong. Their training manuals for years said the Airbus A330 had a stick shaker. It does not.
Pilots who flow up to mainline Delta and cannot pass this training are allowed to return to their same captain position, at Endeavor. While I can only attest to facts of Delta’s substandard training to first-hand experience and trial testimony, I only have hearsay as to how bad Endeavor’s training is. The FAA will have to investigate that. But there is the problem.
Effort to Improve Safety
In 2014 I returned to school to earn a doctoral degree in aviation focused on Safety to figure out what the hell was going on at Delta. I learned of SMS and realized that Delta’s processes were violating Federal Regulations, and that substandard training led to the lack of understanding that resulted in accidents. During my defense, a professor said, “What do you think they will do now?” as a result of my findings. “They” being management and the FAA. But the FAA already knew, and management refused to invest in training and the FAA looked the other way.
In 2015 I heard Delta’s CEO, Richard Anderson at the time, speak on safety and reporting that conflicted with the Delta culture. Therefore, I requested a meeting with senior executives, Captain Steve Dickson and Captain James Graham to discuss my concerns. In 2015, Graham put in writing that he planned to send me into a psychiatric evaluation after our meeting went through. In 2016, four months later, Graham and Dickson met with me. Two months after that, they enacted the hit to have me removed, in the exact manner Graham had said that he would.
Safety Concerns
During trial, March 20, 2019, Captain James Graham, Delta’s SVP of flight operations at the time, not only perjured himself on multiple accounts during trial, but he proudly testified, “And Flight Operations, specifically, our ASAP program now has, for the year 2018, we were just over 25,000 reports that were brought forward from our pilot group!” That is not a metric to be proud of.
In my report to captains Dickson and Graham, I expressed my deep concern that pilots could not fly based upon what Captain Dempsey, Delta’s Chair, Human Factors Working Group, told me. He had departed an airport heading to Atlanta, but he lost his auto flight system on takeoff. Dempsey continued to fly to Atlanta, but requested a block altitude, meaning the pilot is unable to fly a specific altitude so they need more airspace. He also flew into RVSM airspace, an altitude that requires an autopilot due to close separation of 1000 feet from other traffic. Upon arrival, Dempsey declared an emergency because ATC refused to provide a block altitude for their arrival phase. He used the emergency card for something that was not an emergency. The Training Department used this as an example of “workload management” and created a training video telling pilots to declare an emergency if they, too, lose their auto flight system.
The problems with this video were many. The FAA and office of inspector general were working to convince pilots to hand fly due to an endemic loss of hand-flying skills. However, this training video stated that hand-flying was an emergency procedure. The worst part of all this was I reached out to Dempsey about this event, and he told me that, “Delta as a group, cannot fly Level 0, nor can we fly Level 4, so says ASAP.” Level 0 is when there’s no automation engaged, complete manual flight, and that would be no flight director, auto thrust, autopilot. Level 4 is a fully automated aircraft. Delta did not train their pilots but suggested they declare an emergency if they lost their autopilot.
Dempsey emailed me that a Delta Boeing 737 on final in ATL in IMC, meaning they were in the clouds, and at 700 feet the pilots decide to go around but hit the auto throttle button instead of go-around button and the flight director stayed in approach mode. Neither pilot noticed that the pitch was 3 degrees and power was at 56% N1 power, those were not the pitch and power settings for a go around. They should have been approximately 12 degrees up and 90% power. Dempsey said that they didn’t even have the situational awareness to look beyond the flight director and recognize something was wrong. They got to 186 feet, with over 2,000 feet per minute descent, before going around, as the warning systems wailed in the background. Passengers on that flight came within seconds of dying.
Did these pilots attempt a go-around and push the wrong button? That might explain why they did not flare. I am not saying this is what happened, but the thought occurred to me rewriting this event. The NTSB will hopefully answer that question.
The Safety Presentation
Captain James Graham invited me to give a safety presentation as part of his ploy to have me removed, despite already having removed me for mental health concerns because I reported safety. I explained to Captain John Tovani, the director of training, at that presentation, that 90% of my concerns were training related. Yet Delta did nothing but pay a doctor $74,000 to diagnose me as bipolar. The short version of how this ended can be read in the Seattle Times article.
While Dickson was the FAA administrator, awaiting Delta’s appeal, the file regarding Delta’s violation of order for violating duty times regulations disappeared. I have the FOIA response that it existed, but the FAA sanitized Delta’s culpability. Dickson resigned within days of Delta losing their appeal.
Captain James Graham Credibility Assessment by ALJ Judge Morris:
“The Tribunal further questions the candor of Captain Graham’s testimony at various points and occasionally found his testimony to be incredible. In particular, the Tribunal gives little credit to his statements that Complainant’s safety report had no bearing on his decision to refer Complainant for a Section 15 evaluation.” (Decision and Order pg. 71).
“Tribunal accepts as proven—the many inconsistencies in his testimony between his deposition and his hearing testimony. Compl. Br. at 40-42. The sequence of events left the Tribunal with the impression that Captain Graham harbored little if any tolerance for criticism of the organization he ran, especially criticism from a line pilot like Complainant.” (Decision and Order pg. 71).
“The two key actors involved here are Captain Graham and Mr. Puckett. They were the parties moving the pieces in the chess game in which Complainant found herself an unwitting player.” (Decision and Order pg. 99)
Endeavor Air CEO, Captain James Graham
Please answer the question.
How is it possible that Captain James Graham could possibly become Endeavor Air’s, Delta’s wholly owned subsidiary, CEO?
Pilot training under his leadership at Delta was substandard, and when a pilot tried to speak out, with an internal safety report, he violated federal regulations and retaliated. I never lost my first class medial, despite a bipolar diagnosis, but Dr. Altman forfeiting his medical license. Beating Delta in trial and appeal, Dickson retired early from the FAA. Yet how is Captain Graham allowed to be the CEO of Endeavor Air as a result of his actions?
No, I am not surprised that this Delta plane crashed in Toronto. I’m simply surprised that an accident has not happened sooner. The FAA is allowing Delta and Endeavor to do whatever they want to save money; training be damned. These pilots, while their error caused the crash, are every bit a victim to FAA approved substandard training. The CEO, Captain James Graham, and FAA are fully responsible.
Impacting Change Where we Can
In that the FAA never enacted change, despite what we learned in my doctoral research I wrote the book, Normalization of Deviance, a Threat to Aviation Safety to educate the public of what is happening worldwide.
In that nobody was held accountable at Delta for their retaliatory actions, despite their loss in federal court, including Graham, Dickson and the Delta CEO, Ed Bastian, I wrote a book to help encourage employees to safely report, and how to use the law to protect themselves, Delta’s Debacle, Legal Lessons Learned and Shared to Save your Career and Improve Safety. Safety is contingent upon employees reporting safety concerns.
I’m uncertain what else I can do, but enough is enough. If substandard training worldwide is not improved, then we will see more of these accidents. This time we got lucky, but safety should not be based upon luck.
27 Comments
You are an amazing and brave bastion of truth in the swamp of corporate money over safety. We see it in politicians and now in healthcare.
Humanity and integrity lost.
I love your books.
Thank you Wendy! Healthcare worldwide is definitely as bad. I’m so glad you love my books! There are more coming. Thank you!
Thank you Wendy!! I really appreciate it. Oh… the health care is equally as bad and they do not like people to voice their concerns there either.
It appears that there is a world wide phenomenon within civil airlines irrespective of the flags of origin, of compromise between commercial considerations overriding aircrew training standards and thereby flight safety.
The Federal Aviation Administration’s rules are said to be written in blood. After 50 plus years of active flying I have been waiting for a year to get a special issuance 3rd class medical that my AME says I qualify for. Ask a question, get a response in 3 months. Discipline always was a point of pride for me, and professionalism means training and proficiency at the highest level. Lawyers shouldn’t have anything to do with the pursuit of higher standards.
Wayne, this system is hypocritical. We are still writing regulations in blood, but now the FAA is looking the other way when airlines do bad. They actually don’t do anything anymore but exert their power over the medical, when doctors should be in charge. Hang in there, right does win out in the long run.
Flight attendant safety training is substandard compared to the way it used to be years ago. We are easily and fast replaced if we were to complain too much.
I’m not surprised at the degradation of training. I see it in the pilot ranks too. Retaliation for speaking out is sad, and all too often a standard occurrence. I started the AIR21 book to explain the law, then I decided to teach people how to use it so the company cannot replace you when you complain. We need everyone to speak out. We just need to learn how to do it properly. Check out AIR21 Delta’s Debacle, this will help with this dilemma. Should be in every flight attendants bag. AIR 21 Delta’s Debacle
I wish that I had this book in 2022 I wish that I had this book in 2022 before I was unlawfully terminated. They paid me to shut up & go away like everyone else because I had an incompetent bar card attorney. The system is rigged against us & it’s all about lining pockets of attorney’s & judges….Nobody wins in Article I court systems today. Corruption is rampant in the legal systems today. I just ordered this book & will pass it on to my friends. Thank you so much!
Leah, yes… corruption is strong. We just have to be stronger. And the quote about getting justice in the next life, but today we have the law could not be more profound. You probably understand and will enjoy Flight For Revenge. When there is no justice…there is revenge. In fiction, it’s fun and legal!
Really interesting article Karlene, came across your account when doing some digging on the crash and what you say is a real eye opener. Not even remotely surprised that his happens in US Avaition as we’ve seen plenty of misses preceding this accident, I can only hope over here in Europe there’s more scruples but to learn otherwise wouldn’t shock me. I must get to reading your literature it sounds truly interesting, keep up the good work!
Simon, I was so surprised that ICAO adopted SMS in the Annexes in 1980. The US did not require SMS compliance until 2018. I think we are a little behind the curve. If we don’t improve training, but more so mandate safety culture, then sadly this may not be an isolated case.
I’m not surprised either. Just surprised nobody died.
Great article Karlene, I’m also concerned about the lack of training and experience on the flight deck. Unlike when you and I came up through the ranks. Many of the new hires today are flying with captains that are new hires.
Kevin
Kevin, that is so true. Delta is known to place a new hire in the left seat. In 1997 NWA would not even allow a new hire to fly right seat in a widebody. We all need to gain experience and that comes with the experience from the left seat. The next level of concern is a management pilot who flies a desk. This captain was terminated from Delta in 2022 because he failed training as a first officer, and was sent back to Endeavor. This is a deep concern. We are forcing pilots out at 65, when we need to retain them.
Thank you Kevin. You’ve seen it, you know.
Karlene, Congrats on the new website.
For the others who have commented I’ll repeat and then add to what I said on your blog.
What you always dreaded, what you have been speaking out about so courageously, is coming to pass! How is this possible in the USA? The birthplace of the airline industry? And, goodness, everyone was so lucky to survive.
Does US Society as a whole accept this? Or do people just move on, thinking “Won’t happen to me!” I’ve got news for them, Fate is still out Hunting, we’ve had a midair between two small a/c even since the YYZ crash.
I’d say you, Karlene, are the person to to advise and guide your new President, he’s the one person who can change everything overnight. Jis performance on the day of the DC midair was not encouraging though!!!
Keep up your great work.
I’ll add – The more detail you post about the qualifications and experience of the Endeavor Captain’s and FO’s qualifications, the more I see writ large all the scenarios about which you have been warning us, including the “Good Old Boys” running Delta, Endeavor, and the FAA.
Will Donald Trump bring big change or more mayhem?
I hope here in the UK we have a better separation between airlines and regulators, the airline sector is tiny compared with the USA, but still Capt Mike Simkins has had a nightmare similar to Karlene’s. Please read Mike’s book “Pulling Wings from Butterflies”, a second is ready to publish I believe.
Ken
Ken, Thank you for the comment. You have watched this journey and my fight to create a safer system. You understand. This is exactly what I said would happen, and while they have come close over the years for other catastrophic accidents, that the media has remained silent as well, this time they almost killed everyone on board. The others that were silenced in the media were events that would have been just as catastrophic, and no chance of survival, if not for the grace of God or luck. We can only hope that our new President will say “enough is enough” too.
Karlene you did a great job flying F/O with me on the A-330. You were great on the boxes (FMGEC). You correct me when I was making a mistake. And you flew a very good airplane. Yes your right. Training sometimes is a sleep at the wheel. As always training is a work in progress. One of our whale captains point your site out to me. Yeah I was on the whale too. Management had no right to do what they did to you. Thank You!
Thank you for the kind comment. I wasn’t the first person they did this to, I was just the first person who fought back and won. And, refused to sign an NDA so this won’t happen to others. I’m good that it happened to me, because we can prevent them from stealing others careers. Thank you so much for your comment!
I just wanted to thank you for what you’ve done to bring truth to light. It’s absolutely shocking that companies and the FAA could be so cavalier about training and safety.
Corporations in many industries are out of control, putting profit over health and safety.
As a retired Delta Captain, I can tell you that this woman has had an ax to grind with Delta for a very long time. I would take everything she says with a very large grain of salt. A lot of it sounds like pure fiction! If all of those problems actually existed, Delta would not have the outstanding safety record that it does. The accident in Toronto is definitely a one-off incident.
Jim, Happy retirement. I don’t have an ax for Delta, but for the condonation of such behavior. I will challenge your safety record by two points… that it’s only as good as it is by the grace of God and the many near catastrophic incidents. And if you believe this great record, check out the Aeroinside website and select Delta. This doesn’t even list those that Delta hid from the media. https://www.aeroinside.com/airline/delta-airlines
It’s frustrating to see misinformation blatantly published publicly as well as to have pilots and an entire organization blamed and decried before a formal investigation into this accident has even been carried out. This is premature and unprofessional.
I have personally experienced Endeavor’s training department to be a quality enterprise, pre- and post- Mr. Graham’s arrival. They have the enormous challenge of training many entrants with mostly GA or military experience into airline professionals, and they do so in a thorough, FAA-compliant, and safe manner. Their safety culture is robust, and their training is comprehensive from both the systems and indoctrination level all the way through the line and continuing qualification levels.
You have spread blatant lies about the Captain in this accident, who was well-qualified and had no prior issues in training. You have made assumptions about an accident as someone without an accident investigation background and prior to TC or the NTSB releasing a statement. It’s clear that you have an axe to grind against an organization that retaliated against you, but you are attacking ghosts of the past now. The industry continues to improve, and your attacks against Endeavor’s training standards are a blight on your professionalism as someone who calls themself an expert.
Please enjoy retirement, and employ your expert opinion only when you have real facts to back it up, not merely the hearsay that you so freely publish. You owe it to this crew and to the industry that you seek to better.
What lies are you talking about? Did he not try to flow up to Delta and had to resign and return? Did he not work on the ASAP program?
I’m super confused by the protection of the system of reduction of training. Most senior pilots have seen this and shaking their heads. I suppose, like pilot who don’t receive adequate training, you only know what you know. Best of luck in your career.
I see this issue problematic in South East Asia. Without identifying the airline, they will only have their lawyers get posting removed, they are an excellent worldwide marketing company that just happens to fly airliners. True it’s only my opinion, one would argue, but it is as a result of 20 years USA before the +15 years in Eastern Hemisphere. Thank you
Karlene,
I see the Good Old Boys are waking up! They should be thanking you for taking up the cause for them, I certainly thank you.
Interesting to see Pradeep’s post, Hi Pradeep.
I’ve been familiar with the airline sector in India since 1968 when I met my future father – in – law who was Director of Flight Ops at Air India.
At that time it was a tiny airline and very much a family.
As of December last year it had 344 Airbus a/c on order, and a further 185 from Boeing; to me that sounds like too big a task for the airline, and for the regulator.
I worry and see that people in India with a deep knowledge of the sector are troubled.
The obvious achievements of the last 40 should not fool anyone into thinking that we cannot return to the awful times of the 1970s.
I give Three Cheers and One Cheer More for Karlene and what she’s doing for us all.
Ken