More on the Delta Crash in Toronto
While nobody wants to believe that pilots can crash a perfectly good aircraft, this might be what happened. There is always more to the story. A picture is worth a thousand words and these pilots did not flare, as identified by the video seconds from impact. Yet, don’t blame the female first officer who was flying the aircraft in strong crosswinds. This is not a DEI issue. This is a negative Safety Culture issue buried deep within the Delta Air Lines corporate culture annihilating any FAA approved SMS with management’s complete disregard for risk mitigation. This is what I told them would happen.
I’ve been asking the media why hasn’t anyone been questioning Delta as to the experience of these pilots. Crickets. Sadly, Delta spends far to many advertising dollars for any of the networks to report the truth. The saying around Delta is “they are a marketing company that flies airplanes.” Now, as the story behind the flight crew emerges, we can create the picture of this puzzling accident and ask Endeavor’s CEO, Captain James Graham, what happened. But he is deep in hiding.
The Pilots
Captain James Henneman has flown for Endeavor for over 17 years. Yet, he flowed up from Endeavor to Delta in 2022, but he was unable to pass his first officer training. He failed, so they sent him back to Endeavor. Not to start over. Not to get retrained. Not to gain experience. But he stepped back into his old position as a captain. We cannot blame him, he did not create the rules.
Henneman was a management pilot. He was also in charge of the ASAP program. A recent video asserts he was a simulator instructor, but I’m uncertain about that or he would have been flying that plane and/or guiding the first officer through the landing. He was also a FOQA manager and had worked for Mesaba/Colgan. This captain should have been the very person who had “seen it all” with FOQA data and ASAP reports, and knew the risks. He should have known the threat of this flight.
Regardless as to the reason why he was not actively flying, he flew this trip for currency. Yet we must ask if he’s out getting current, why did he allow his newly minted first officer to fly in such conditions? Henneman earned his ATP January 15, 2013.
Then we have first officer Kendal Swanson. She had just received an ATP on January 9, 2025. Yes, this year! But that is more than likely they re issued her license when her restrictions were removed. She did not have 1500 hours and therefore held an FAA restricted certificate. She was a graduate of UND. A flight supervisor. She had also been an instructor, and in 2023 even received instructor of the month award. Highly accomplished with all indications of being an excellent pilot. But these planes are not single pilot operations. We expect the pilot in the left seat to be the pilot in command.
The Perfect Storm
A new pilot without experience is paired with captain who doesn’t fly and failed a first officer checkout, flying into windy conditions. Anyone looking at this could identify this was a high-risk operation.
This is a culture issue with Delta and their refusal to mitigate risk for profit. How many other airlines are in the same boat? An accident like this was known to happen, because despite federal violations, the FAA has yet to enforce change at Delta. Does the media fear losing Delta dollars, so they remain quiet? Delta owns lobbyists. They control the pilot union, ALPA. I would hope someone would look into what is really happening within the walls of this company.
Did you know two Delta pilots fell asleep on final and the gear warning horn awoke the first officer seconds before impact? No media coverage. Delta came within seconds from impacting the ground in Atlanta, because the pilots failed to push the go-around button and accidentally disengaged the autopilot. Seconds from death. No media coverage. Delta had an overhead laptop fire and did not divert, but pressed on to destination. No media. Delta even flew to destination after hitting another aircraft before departure. The events are too numerous to name in one citing, but the is no media coverage, therefore the public doesn’t know. Nothing changes. No accountability. The FAA looks the other way.
Endeavor should never have allowed a captain who flies a desk to be paired with a new, low time pilot to retain his currency. There are so many holes in this Swiss Cheese that aligned to open the door for a crash, that could stand alone, even if the crash never occurred something should still be done. Do we have to kill people to create change? Apparently yes, as proven when the Blackhawk hit American Eagle this year.
If you haven’t read the culture issues that I believe lead to this accident, please read the Miracle in Toronto.
41 Comments
Hey Karlene, Delta issued this about the time you posted this. I hope you apologize. Please check the responses to your tweets. This is highly unprofessional of you.
Information about Endeavor Air 4819 flight crew
Endeavor Air and Delta are correcting disinformation in social media containing false and misleading assertions about the flight crew of Endeavor Air 4819.
• Captain: Mesaba Airlines, a progenitor company of Endeavor Air, hired the captain in October
2007. He has served both as an active duty Captain and in pilot training and flight safety capacities. Assertions that he failed training events are false. Assertions that he failed to flow into a pilot position at Delta Air Lines due to training failures are also false.
• First Officer: Hired in January 2024 by Endeavor Air and completed training in April.
She has been flying for Endeavor since that time. Her flight experience exceeded the minimum requirements set by U.S. Federal regulations. Assertions that she failed training events are false.
Hi Karlene
This is a very concerning read, and ties up with my experience of aircraft maintenance.
A serious aviation accident is long overdue—not because of chance, but because of systemic human factors issues that have been ignored for too long. The industry’s approach to pilot fatigue, operational pressures to minimise aircraft maintenance down time and regulatory oversight has created an environment where risk is increasing rather than being mitigated.
Fatigue remains a major concern, with pilots frequently pushed to the limits of duty time regulations that fail to account for real-world fatigue science. Meanwhile, commercial pressures force airlines to cut corners, placing additional stress on flight crews who are already operating in a highly complex and unforgiving environment.
Aircraft Maintenance is being carried out in ever shorter and shorter windows of time, most often conducted at the worst possible time for human circadian rhythm.
Regulatory bodies, rather than proactively addressing these risks, often take a reactive stance—only making meaningful changes after a tragedy occurs. The absence of recent major accidents isn’t evidence of safety; it’s evidence of luck. And luck runs out, and this is precisely what we are seeing.
Until human factors are taken as seriously as technical failures, we are playing a dangerous game with aviation safety. The industry needs to act before statistics catch up with reality.
Hi Karen ,until the primarily or even the final report declared, Thank you for this articulated analysis through which, it well clear that organisational factors are totally accused.
People engaged in training active line pilots or Abintios in the simulator, need to undergo a line route check on the actual Aircraft before undertaking a passenger flight.
And as a responsible Airline pilot no one will undertake such a flight without self realisation even if it is kept underwraps by Airline management.
Karlene,
Thanks. I’m seeing the picture more clearly, and the picture I see is Ed Bastian and his Delta gang getting themselves in deeper and deeper, and all the time endangering the flying public, and their own pilots and flight attendants.
The name of Colgan I still find chilling! RIP all those poor folks, who died at Buffalo, including the pilots, way out of their depth, fatigued, unaware of the hazard they posed themselves, their pax and fellow crew-members, and the people on the ground.
Time for the reset in USA civil aviation; yes it’s the USA, maybe you need a spell on the ICAO Blacklist! How would Mr President react to that? Withdraw our funding!
There’s one of you Foundational Problems, the way USA Society views itself.
After the Zenith of Flight Safety Culture across the globe in 1979, one of the leaders being Captain Al Frink of Pan Am, what a terrible terrible decade for Pan Am; did the slide start almost immediately with airline deregulation in the USA? Then Ronald Reagan sacking the Air Traffic Controllers?
Time for a civil aviation rest in the USA.
Time for a reset for Delta.
Time for a reset for the FAA.
Time for a reset for ALPA.
Time for a reset for the Flight Safety Foundation (I know a board members, I’d better have a full and frank discussion with her), all that Jerome Lederer worked to prevent is happening!
Keep up the great work Karlene, Whistleblower to the World!
Ken
Thank you Ken, The entire industry needs a reset!!! And the anger of some… for asserting there was no flare, is deeply concerning.
Thank you for your comment!!
All of your original assertions were debunked. I hope the crew sues you because for libel and slander.
There was no debunking. Delta has the Voice recorder. They have the vertical speed, the position of the controls… Why is nothing released? Delta said the captain never “failed training”… but you answer this, if he flowed up and did not qualify, and resigned to return, what would you call that? Success?
I don’t blame these pilots. I empathize with them.
“Failed training” is an ambiguous term. Training is typically not graded. A proficiency check? Not likely, since pilots complete a course of training before the checkride. If the captain did flow up to Delta Mainline but was rejected, perhaps it was due to a failed simulator assessment, or interview, or psychiatric evaluation that was conducted. Does anyone know?
And how can we fact-check the captain’s recency of experience before the accident flight?
As DO and chief pilot for almost 20 years, my small airline experienced several near-accidents when the crew were ‘trading legs’ and the captain allowed a new FO to make an approach / landing in adverse conditions. At that time, our culture led the FOs to have a sense of entitlement to be the pilot flying (PF) regardless of winds / runway length, width, conditions, etc. – and the captains sometimes made poor decisions by letting the FO make the landing.
Paul, Yes… he showed up for training and he was not successful. He did not complete it. But what made laugh is the reasons you gave that a pilot would not fulfill but till be able to go fly as captain at the other airline–did not pass a checkride (assessment) or a psychiatric evaluation. In this case, there was no interview, this was a given due to his position. You could fact check by Delta provide the facts. You must read what they don’t say. They have the CVR… why haven’t they released it? Yes, he went to Delta and could not pass with proficiency. Now… maybe that’s a better word choice. And.. the captain was an instructor. So even if the first officer was flying, any instructor should have been able to talk her down. I do know what you mean about being entitled … this is a US problem with new pilots. But… not allowed to fly because of it? EVERY pilot in the flight deck should be able to land. Who is ever most fit for the particular flight should do the job, be it new airport, level of fatigue, etc. However, what you just said is extremely concerning… “and the captains sometimes made poor decisions by letting the FO make the landing.”
The crew may have been experiencing flat light conditions and misjudged their height above touchdown.
Yeah, but the reason for two pilots and instruments telling them the height…
Shaming the crew? I hope you get your ass sued.
I certainly did not intend to shame the crew, and sorry you took it that way. I do not even blame the crew for the accident, because it could have been anyone in the same circumstances. This accident happened because I believe they were not given the tools and put in a position they should not have been placed.
And you wonder why everyone thinks you’re legitimately crazy. Why would you post this? I better never see you on one of my airplanes.
I know! It’s simply crazy to speak the truth in todays world, isn’t it.
This is a real Karen moment. She had issues with Delta and now it’s biased arm chair quarterbacking. If she was such a professional she wouldn’t be speaking until the TSB does their thing.
I am most certain when the first MAX crashed you did not want any speculation and did not want to ground the plane until the investigation was done there too. But then we did the same thing and killed a second airplane load of people! Oh… good thing we waited. Did you know that Delta had 14 events that took down AF447 and they and the FAA did nothing until after 228 people died? I’m sorry, I cannot and will not buy into the camp that we sit silent and kill people while we wait for a process. These pilots are alive and they have the CVR. The airline knows what happened. So… why are they not sharing? Perhaps you don’t really understand the gravity of the overal situation.
Are you sure that photo is of James Henneman? TinEye Reverse Image shows 5 results dating back to 2013 and iidentifies it as a stock photo of an Asian or Indian man.
99% sure! The pilot who gave me the photo was hyperlinked to his LinkedIn profile, of which he removed the photo. Those links last forever.
I think it was a hard landing. Whoever were flying… nose wheel also touched simultaneously. Maybe glideslope had sent a wrong signal due aircraft parked. Pretty undortunate …
Yes, that’s what it looked like to me too. Maybe they needed more training? It is unfortunate.
Please notice in the FAA airman registry that the FO’s ATP and CFI certificates were issued the same day (January 9, 2025). Most likely this indicates a name change or address change and not the original issuance of the ATP certificate. Just wanted to make that point of clarification.
Absolutely! I suspect a re-issuance when her restriction was removed and she received an ATP with no restrictions.
I know the CA. Everything youve stated about his flow is factually incorrect and demonstrably false. I hope you get sued for libel.
M Qindy, he was at Endeavor and never flowed up to Delta and resigned to return? And he never worked in the ASAP program? I don’t believe there is much more than I said. If he did not go to Delta and the training records are false, please advise.
Greetings from the Philippines!
We met at ERAU when you were doing your PhD. Later, l bought your book 📚.
When l read this post l heard myself (Ex SIA corporate flight safely manager) talking. My subsequent time as a Boeing SFI & evaluator and KASA TRE/IRE for several Korean airlines would make even make your hair stand on end. Mainly re shameless Western SFIs who did not “hold the line”, and signed off dire incompetence as “ready for test” – a poisoned chalice for signing a licence. Needless to say, l had to refer many candidates for retraining. E.g. A captain going up half-way through an emergency descent. E.g. EFATO 90 degrees off heading. E.g. A captain flying into terrain, responding to “pull up” with “check radial”. A chief pilot evacuating with engines running, even on repeats. Etc. Most were retested without further training (my observations were simply “debriefed”). And no surprise that they all subsequently passed with “A”s for all exercises, and also no surprise that Boeing eventually removed me from further work, to placate the airlines complaint that l was racially prejudiced. When l asked for evidence of this – there was none. Yet plentiful evidence of incompetence in my meticulous failure reports. Needing no evidence (and ignoring unpalatable evidence) was no problem for Boeing then – as now.
I hear you saying, “Been there, done that!”
Glad to have caught up with you. 😊
Keep holding the line . . . !
Cheers,
Mike
Excellent analysis. When bottom line is all that matters, this is what happens. Starting with Boeing company, this dangerous trend needs to be put an end to.
Your bravery against all odds is to be commended. Here too in India, as the airlines keep expanding and the demand for pilots grow, the training standards are taking a big hit. Unfortunately every one is trying to put up false claims.
Really enjoyed reading this professional factual article which will be a small step in awakening the slumbering giant of US Aviation specifically Delta Airlines…. hopefully before the next big one happens. Please listen to this author. Capt Uday Kolhatkar CRMI and Flight Safety Instructor.
What are your sources for this nonsense? Does anybody take your words at face value? You are spreading lies. I used to side with you on your quips with Delta but after reading this it seems everything you have written should be called into question. Can you provide proof that Captain Henneman failed training at Delta?
Thanks
Ryan
Ryan, Email Ed and Jim and ask them if he ever flowed up and attended Delta training. Ask the right questions and you will get the answer. If they say no, email me their response and I will write a formal apology for asserting that he did. But when someone cannot pass training and allowed to resign, I’m going to probably call that failed training, despite of not allowing him to go for the check. Emails: Ed.Bastian@Delta.com And Jim.Graham@Delta.com
More blatant lies about these pilots based on hearsay.
You are aware, aren’t you, that the issue date on an ATP certificate refers only to when that pilot was issued their most recent certificate, right? So another type rating, the removal of a restriction from an R-ATP, etc – all these things will update the issue date of a certificate to a more recent date than the original issue. Delta has already published the actual facts about these pilots’ experience from their training and employment record which directly contradicts your misinformation.
You do not know how much or how little this captain was flying or how much experience the first officer had. You do not know the sum total of issues that contributed to this accident. Yet you continue to assign blame and spread falsehoods.
Please correct this misinformation in the name of professionalism, lest you begin to resemble those who misrepresented you those years ago at Delta.
Daniel, yes… I suspect this was the result of a reissued certificate after she got her 1500 hours. The piece of paper has nothing to do with the accident. As you should know that a sheet of paper does not identify or indicate the training she received. Don’t focus on the paper. Look at the not flaring. I with that Delta would release the CVR so we could hear the dialogue that the plane was not responding and she could not flare. But for some reason, that tell all is not being released. Delta just wanted to sweep this under the rug. But if training and processes were the reason, it should not be swept under the rug.
Accountability
I won’t trust such a combination with a kite.
Rules are meant to be followed and not merely for publication
Please keep the desk jockeys out of the cockpits.
I am so impressed with your knowledge Karlene, I am a physician (not a pilot). In medicine we have M&M (morbidity & mortality) conferences to discuss unexpected patient deaths. Often these will sadly involve a lot of bullying and threats from seniors to juniors so the learning environment can be compromised when doctors-in-training feel their career is on the line and they are getting publicly scrutinized in a large auditorium in front pf peers. My question to you, Karlene, is does the airline industry (or Delta) have the equivalent of M&M conferences where the entire department or team gets together to learn from these accidents? If so, is the environment safe so that people feel they can share the truth of their experiences?
Based on reading about you for the last two days (yes, I took a deep dive into your whistleblower story and even made a 3-minute video: https://www.idealmedicalcare.org/psycho-therapy-doc-gets-74k-to-label-whistleblower-bipolar/ I am thinking your answer to my question above is NO.
What is the best way to move forward to create a real safety culture at Delta (& other airlines)>
~ Pamela
Pamela, thank you for the insightful question. They have internal committees, but the output is typically how to make the FAA think they are doing something to satisfy an improvement and not spend the money. Sadly, those FAA positions who oversee the airlines are even questionable. Training is often the issue an there is nobody who understands learning to create effective programs. Perfect example: Colgan crashed because of pilot performance as a result of training. The FAA mandated the fix to change pilot hours requirement to 1500 hours. That had nothing to do with this crash. Then Delta learned from ASAP reports that pilots could not manually fly, and did not understand their technology. A plane came within seconds of impact because the pilot pushed the wrong button and disengage the autopilot, instead of the go-around button and did not recognize they were still heading to the ground and why it was happening. But, instead of teaching pilots how to fly, or understand the systems, another pilot declared an emergency because he lost his autopilot, and they produced a training video telling pilots to declare an emergency if they lost their automation not train them. The funniest response, and I say that with great sadness in my heart, the response to the pilots who fell asleep on final and where headed toward the ground, thank God the aircraft yelled at them because the gear was still up, and awoke them was a memo. The memo said, pilots need to “stand up, drink more coffee, and talk.” This was a result of a late flight and emergency divert. The pilots fatigued due to the hour and the adrenaline rush fueled them on the divert but drained them after. The fix to that issue should be a corporate change, replace the pilots when diverts happen in the middle of the night. But nothing happens. The concerning issue is the new generation of pilots arriving without… substance…put into substandard training, without proper regulatory oversight. Yes, we have a huge problem. Nobody is able to speak out. Sadly, those on the platform who attack me are those who either don’t understand, vying for a management job, or are part of the problem. I just watched your video. I love it!! THANK YOU!! You did do a deep dive!
Karlene is correct, after 9/11 airlines dramatically reduced their training footprint. Coupled with a change in the industy dynamics, many pilots dont have to cut their teeth in the night freight piston twin or military world anymore so the airline should supply the training to close the gap, but they really dont. To the airlines credit however, a pilot can say uncle and fatigue out. But, I would agree that the companies statement, Safety is Number one, isnt satisfactory in real life. Thanks Karlene
Thanks for the comment Ragnar. The challenge with that fatiguing out is that the pilot must have the confidence to do so. Pilots must have the ability and confidence to make that decision. But not unlike alcohol, fatigue alters our brains and how we think. Hopefully we can improve training.
Karlene,
I don’t think Delta is the only one with a training problem. I retired last September after 40.8 years as commercial pilot from United, most of which as a captain on heavy jets. The last 12 years on the B787. United has been hiring so much that they were allowing new hires into the right seat of the 787. In all the years as captain I never had to write a pilot up of for being unsafe; well that changed with one of the new hires. Quite frankly, I have no idea how she passed the training. When we got a clearance to do something, while she was flying, she would just sit there and do nothing, I would have to tell her what to do. Then on departure out of Brisbane she just started bringing the nose of the aircraft up when we needed to increase speed to bring the flaps up. Just totally unsafe, I wrote this all up and gave it to the chief pilot’s office, and made the comment, that I did not think new hires should be coming to the 787. Anyway, some of these new hires are basically being hired with very little experience, she told me she was a flight instructor and then worked at Skywest as copilot for one year, probably on reserve and didn’t fly much. Another gal who flew as IRO on my flight, so I didn’t see her fly, came right from Emery Riddle from being flight instructor. Scott Kirby is trying to hire as many women and minorities as he can, he said he wanted 50 percent of the new hires to be minorities. They may meet the minimum requirements, but from what I saw, they have very little experience. United has a the training philosophy to train to proficiency with no threat of being fired for failing training. I don’t know how many times the gal I flew with went back for more training, but I was told she received a lot of extra training. That certainly wasn’t the way it was when I got hired, it was two extra sims and then you were out the door. I think you are spot on about that captain in the Toronto crash, there is no indication anyone reached up and pushed the power levers up to go around, after the aircraft said sink rate, and they were descending over 1000 fpm, no one did anything. Just unbelievable. Some people just don’t have it to be pilots now matter how much training they receive.
Tammy, Thank you for your comments. You’re right… some people don’t belong there. I think about the pilot not pushing up the power on that Toronto flight and I can only believe she was task saturated, not knowing what to do. I have the training manuals from Endeavor. It appears they teach how to fly in a steady state 15 knot crosswind. She was sitting helpless not knowing how to save the plane. I speculate she didn’t even hear the sink rate warning. Where was the captain’s head? There was a Delta A330 that the pilots forgot to engage approach (not on the MCP but in the box) that tells the plane they’re landing. So, on short final when they selected managed speed (correct to do) the power came up to give them 210 kts. Plane did not know it was in approach. Two go arounds! Same thing. Not until they the third…and the first officer refused the captain’s commands to go (I can only imagine how low on fuel they were)… he pressed on until 20 feet off the runway when the plane said, “retard” (more correct than not) That’s when he realized he could pull the power back. They always could have pulled the power back to control their speed. So, yes…thinking is essential, but when you’re not training and brain overload…it’s hard to think. When you employ someone based on anything but ability and experience, then you will get the deer in the headlights with the simplest tasks… like your first officer. We have a problem for sure. Thank you for the comment!!