UPS cargo crash near Birmingham AL

[aterpster]

The only FAA "fix" I've seen so far because of this accident is that the procedures staff that covers the western U.S. has approved a change to the Dillingham RNAV 19 to change the holding pattern at ZEDAG to left hand turns.

[Desert185]

Did that 1900 have Capstone onboard?

[A Squared]

Originally Posted by Desert185

Did that 1900 have Capstone onboard?

The 1900's were not a part of Phase I of Capstone. However, many of the capabilities of the initial Capstone Equipment (ADS-B, Terrain mapping, real time weather) have become commonplace since then. I don't know what equipment they had installed.

[Desert185]

Big airplane or 185, I'm getting to the point that I don't want to go anywhere without my iPad and Foreflight.

[AirRabbit]

This listing of investigations includes those open investigations involving accidents or incidents which resulted in significant loss of life, physical damage, involve issues of importance to public safety, or which have generated particular public interest. This represents only a small portion of the investigations conducted by the NTSB, most of which occur at the regional level. See this listing of selected regional investigations for more information.

This accident has national safety implications for pilots everywhere in the U.S. What that quote pretty much proves is that the NTSB has their priorities messed up, to say the least.

I’m quite sure that some of my acquaintances (both the positive and the “not so positive”) at the NTSB would probably chuckle at the fact that I’m writing this, but …

I know of absolutely ZERO accident investigations – anywhere on the planet – that are not subject to at least some degree of influence – political, financial, personal, professional, and, likely, a whole litany of others. Additionally, the magnitude of each individual influence is directly influenced by the size of the public interest and the degree of the financial ramifications (i.e., penalties, law-suits, operating changes, replacements, etc., etc.) that are, or may become, involved. For whatever it may be worth, after having been involved in my fair share (perhaps more than my “fair” share) of airplane accident investigations – through one means or another – I remain substantially impressed with the work-product routinely generated by the US NTSB. From my personal observations, the NTSB-quote provided (above) is pretty much the plain and simple truth. In other words, with the numbers of accident investigations conducted by the NTSB (…and, by the way, those investigations involve all modes of transportation in the US – air, automotive/trucking, rail, maritime, and probably others that escape me at the moment) and the fact that ALL such investigations are all directly affected by the resources available to them – both personnel AND monetary – it is only logical that someone, someplace HAS to make decisions as to how much of those limited resources are to be allocated for any individual case. Don’t get me wrong – I have had my share of disagreements with this particular federal agency (some of you may recall my vociferous challenges – and I use “vociferous” as a diminutive term, to say the least – to the conclusions reached in the investigation of the B737 departure crash at Washington National Airport in January of 1982) but my respect for the mission of that agency and, particularly for the individuals working there, has not been clouded or reduced. While it may be an emotional response to “feel” that the NTSB priorities are “misplaced,” when all of the locations and methods that may be available to influence the actual priorities are considered – the bottom line simply has to be that despite whatever concerns or specific objections may occur, the end result is as good as it could possibly be … as long as humans are involved in the decision making. AND from that point forward, it’s up to all of us to take what information is provided and apply it to the way we and our respective organizations conduct our respective professions.

[Bergerie1]

AirRabbit


Well said, and I would say the same of the AAIB in the UK.

[aterpster]

Air Rabbit:

I’m quite sure that some of my acquaintances (both the positive and the “not so positive”) at the NTSB would probably chuckle at the fact that I’m writing this, but …

I know of absolutely ZERO accident investigations – anywhere on the planet – that are not subject to at least some degree of influence – political, financial, personal, professional, and, likely, a whole litany of others. Additionally, the magnitude of each individual influence is directly influenced by the size of the public interest and the degree of the financial ramifications (i.e., penalties, law-suits, operating changes, replacements, etc., etc.) that are, or may become, involved. For whatever it may be worth, after having been involved in my fair share (perhaps more than my “fair” share) of airplane accident investigations – through one means or another – I remain substantially impressed with the work-product routinely generated by the US NTSB. From my personal observations, the NTSB-quote provided (above) is pretty much the plain and simple truth. In other words, with the numbers of accident investigations conducted by the NTSB (…and, by the way, those investigations involve all modes of transportation in the US – air, automotive/trucking, rail, maritime, and probably others that escape me at the moment) and the fact that ALL such investigations are all directly affected by the resources available to them – both personnel AND monetary – it is only logical that someone, someplace HAS to make decisions as to how much of those limited resources are to be allocated for any individual case. Don’t get me wrong – I have had my share of disagreements with this particular federal agency (some of you may recall my vociferous challenges – and I use “vociferous” as a diminutive term, to say the least – to the conclusions reached in the investigation of the B737 departure crash at Washington National Airport in January of 1982) but my respect for the mission of that agency and, particularly for the individuals working there, has not been clouded or reduced. While it may be an emotional response to “feel” that the NTSB priorities are “misplaced,” when all of the locations and methods that may be available to influence the actual priorities are considered – the bottom line simply has to be that despite whatever concerns or specific objections may occur, the end result is as good as it could possibly be … as long as humans are involved in the decision making. AND from that point forward, it’s up to all of us to take what information is provided and apply it to the way we and our respective organizations conduct our respective professions.

At the technical staff level I agree with you.

At the IIC level it is more spotty. Some are great, some are not, especially at the field office level.

At the management staff level it is more politics than science.

At the Board member level it is all over the map and has always been so.

I know for a fact that the BE1900 accident, although (unfortunately) a field office investigation, did have the technical assistance of a very sharp ATC expert at NTSB headquarters.

So, there is no doubt the Board has the necessary technical information and could have easily made a public technical statement long before now about the deadly aspects of ATC that day and the lack of altitude awareness on the part of the ill-fated crew. That type of safety alert could have been, should have been, issued and at very little incremental cost.

There is far more for pilots to learn from the BE1900 accident than from the UPS AB 300 accident.

[AirRabbit]

Say, what? All over what map?

Created as an independent federal agency in 1967, the National Transportation Safety Board (NTSB) has investigated more than 132,000 accidents and made more than 13,500 safety recommendations. The NTSB is recognized internationally as a preeminent accident investigation organization, employing 400-plus individuals and an annual budget of more than $100 million, and has 5 Board Members.

Deborah Hersman

NTSB Chairman Deborah Hersman is recognized as one of the nation's most visionary and passionate safety leaders who advocates for safety across all modes of transportation.. She emphasizes the NTSB's role as "the conscience and the compass of the transportation industry. Hersman has been the Board Member on-scene for more than 20 major transportation accidents, chaired scores of NTSB hearings, forums and events, and regularly testifies before Congress. Her leadership has created a more transparent and accountable organization by significantly increasing the quantity and quality of NTSB information available on the agency's website, holding more public meetings to highlight safety issues, and embracing social media to communicate with stakeholders and citizens. Ms. Hersman was first appointed as a Board Member by President Bush in 2004, reappointed to a second five-year term by President Obama, and appointed Chairman by President Obama in 2009, 2011 and 2013 with unanimous Senate confirmation votes. Previously, Ms. Hersman was a senior advisor to the U.S. Senate Committee on Commerce, Science and Transportation from 1999-2004 and served as Staff Director and Senior Legislative Aide to West Virginia Congressman Bob Wise from 1992-1999. Her efforts contributed to the passage of milestone bills such as the Motor Carrier Safety Improvement Act of 1999, Pipeline Safety Improvement Act of 2002, Transportation Equity Act of the 21st Century, and Amtrak Reform and Accountability Act. She received B.A. degrees in Political Science and International Studies from Virginia Tech, and an M.S. in Conflict Analysis and Resolution from George Mason University. She holds a commercial driver's license (with passenger, school bus, and air brake endorsements) as well as a motorcycle endorsement.

Robert L. Sumwalt

Robert Sumwalt was sworn in as the 37th Member of the National Transportation Safety Board in August 2006, whereupon President George W. Bush designated him as Vice Chairman of the Board for a two-year term. In November 2011, President Barack Obama reappointed Member Sumwalt to an additional five year term. His term of office as a Board Member will run until December 31, 2016. Prior to coming to the Board, Mr. Sumwalt was Manager of Aviation for SCANA, a Fortune 500 energy-based company. Mr. Sumwalt was an active pilot for 32 years, including 24 years as an airline pilot with Piedmont Airlines and then US Airways. He logged over 14,000 flight hours and earned type ratings in five aircraft. Mr. Sumwalt worked on special assignment to the US Airways Flight Safety Department from 1997 to 2004, where he was involved in the development of numerous airline safety programs, and he served on the US Airways Flight Operational Quality Assurance (FOQA) Monitoring Team. Mr. Sumwalt served as an air safety representative for Air Line Pilots Association (ALPA) for 17 years and he chaired ALPA's Human Factors and Training Group. He was a co-founder of that organization's Critical Incident Response Program, which provides guidance to airline personnel involved in traumatic events such as accidents. From 1991 to 1999, Mr. Sumwalt conducted aviation safety research as a consultant to NASA's Aviation Safety Reporting System, studying various issues including flight crew performance. Mr. Sumwalt co-authored a book on aircraft accidents and he wrote chapters pertaining to aircraft accident investigation in two books. He has written extensively on aviation safety matters, having published over 90 articles and papers in aviation trade publications. In 2003, Mr. Sumwalt joined the faculty of the University of Southern California's Aviation Safety and Security Program, where he was the primary human factors instructor.
 

Mark R. Rosekind

On June 30, 2010, Mark R. Rosekind, Ph.D., took the oath of office as the 40th Member of the National Transportation Safety Board (NTSB). He was nominated by President Obama and confirmed by the United States Senate for a term that expires December 31, 2014. Dr. Rosekind has served as the Board Member on-scene for five major transportation accidents, including the 2011 Reno National Championship Air Races crash. He has also participated in NTSB public hearings and forums on issues such as substance-impaired driving, general aviation safety, distracted driving, and international safety investigations. He advances the agency's advocacy goals on substance-impaired driving and fire safety. As one of the world's foremost human fatigue experts, Dr. Rosekind has led the field with innovative research and the implementation of programs in diverse settings, including all modes of transportation. He has published more than150 scientific, technical, and industry papers and has given hundreds of presentations to operational, general, and scientific audiences. His achievements have been acknowledged through numerous honors and awards, including NASA's Exceptional Service Medal; the Mark O. Hatfield Award for Public Policy from the American Academy of Sleep Medicine; six other NASA Group/Team Awards; two Flight Safety Foundation honors, the Presidential Citation for Outstanding Safety Leadership and the Business Aviation Meritorious Award; and Fellow of the World Economic Forum in Davos, Switzerland. Before his appointment to the Board, Dr. Rosekind founded Alertness Solutions (AS), a pioneering scientific consulting firm that specializes in fatigue management and served the company as its first President and Chief Scientist. Prior to AS, he directed the Fatigue Countermeasures Program at the NASA Ames Research Center and was Chief of the Aviation Operations Branch in the Flight Management and Human Factors Division. He launched his professional career as the Director of the Center for Human Sleep Research at Stanford University's Sleep Disorders and Research Center. Dr. Rosekind earned his A. B. with Honors at Stanford University, his M.S., M.Phil., and Ph.D. at Yale University, and completed a postdoctoral fellowship at the Brown University Medical School.

Christopher A. Hart

Christopher Hart was sworn in as a Member of the National Transportation Safety Board on August 12, 2009, and designated by the President for a 2-year term as Vice Chairman of the Board on August 18, 2009. In August 2013, President Obama nominated him for a second term as Board Member, and he continues to serve as Vice Chairman. Mr. Hart joined the Board after a long career in transportation safety, including a previous term as a Member of the NTSB. Immediately before returning to the Board, Member Hart was Deputy Director for Air Traffic Safety Oversight at the Federal Aviation Administration (FAA). He was previously the FAA Assistant Administrator for the Office of System Safety. He served as a Member of the NTSB from 1990 to 1993. After leaving the Board, he served as Deputy Administrator of the National Highway Traffic Safety Administration, before moving to the FAA in 1995. From 1973 until joining the Board in 1990, Mr. Hart held a series of legal positions, mostly in the private sector. He holds a law degree from Harvard University and Master's and Bachelor's degrees in Aerospace Engineering from Princeton University. He is a member of the District of Columbia Bar and the Lawyer-Pilots Bar Association. Mr. Hart is a licensed pilot with commercial, multi-engine, and instrument ratings.

Earl F. Weener

Earl F. Weener, Ph.D. took the oath of office as the 41st Member of the National Transportation Safety Board on June 30th, 2010. He was nominated by President Obama and confirmed by the Senate for a term that expires December 31, 2015. Dr. Weener has an accomplished career in aviation as an engineering executive, safety advocate, industry safety spokesperson, engineer and pilot. He has given numerous presentations on aviation safety in airline operations, as well as corporate, business and general aviation safety. Most recently, he was a Foundation Fellow for the Flight Safety Foundation, where he led international industry teams to develop means to reduce accidents through coordinated industry programs in areas such as ground operations and runway excursions. Prior to his appointment to the Board, Dr. Weener enjoyed a twenty four year career with the Boeing Company. During his time with Boeing he held a series of Chief Engineer positions, including the Airworthiness, Reliability and Maintainability, and Safety organization, the System Engineering organization, and Safety Technology Development. He also served four years in Washington, D.C., as Boeing's Manager of Engineering and Technical Government Affairs. As well, Dr. Weener was integrally involved in the initial development of the Boeing two-crew 747 flight deck concept and the development of the 757/767 flight decks, the initial advanced technology commercial transport glass cockpit. Aside from his professional career in aviation, Dr. Weener is an experienced commercial licensed general aviation flight instructor and charter pilot, in addition to owning a Beechcraft Bonanza and remaining an active general aviation pilot. Dr. Weener also has extensive marine experience. He obtained his U.S. Coast Guard Master's License in 2000. In addition to navigating the waterways of the Pacific Northwest, he spent four years cruising both the inland waterways and coastline of the U.S., living aboard a specially built steel hull trawler. His travels included the East Coast Intracoastal Waterway, the Great Lakes, the waterways from Chicago to Mobile, Alabama, the West Coast, as well as the inside passage to Alaska. Dr. Weener earned all three of his academic degrees in Aerospace Engineering from the University of Michigan - his bachelor's degree summa cum laude, master's degree and doctorate. Among his awards is a 1994 Laurels Award from Aviation Week and Space Technology, and in 2005 he was awarded the Honeywell Bendix Trophy for Aviation Safety. He has served on the Flight Safety Foundation Board of Governors and on the Foundation's Icarus Committee, and International Advisory Committee. He was also a director of the Northwest Bonanza Society.

[aterpster]

AirRabbitt:

Say, what? All over what map?

I was speaking of the long-term. There have been some real odd ducks over the years I have been involved.

Their resumes always look good, of course. The only one on the present board I know to really be qualified, at least for aviation, is Sumwalt.

[AirRabbit]

I was speaking of the long-term. There have been some real odd ducks over the years I have been involved.
Their resumes always look good, of course. The only one on the present board I know to really be qualified, at least for aviation, is Sumwalt.

I certainly don't mean to argue, but it seems that while Robert Sumwalt has the kind of background that pilots would like to see … it is just as true, like almost anything else, when looking for a person to fit a particular role, there will always be some with the very specific qualifications you are seeking and others who have qualifications that may be different but just as good – and I’d easily put Dr. Weener in that category with his back ground at Boeing, specifically his developmental work on the two-crew 747 flight deck concept and the development of the 757/767 flight decks, as well as the initial advanced technology commercial transport glass cockpit development. When we consider the kinds of issues that will be, or have become, prevalent, it seems that one of the bigger issues are those of “rest, sleep, and/or fatigue” issues and certainly Dr. Rosekind’s background and expertise in these areas cannot be dismissed. Additionally, it’s pretty clear that Mr. Hart’s background in governmental affairs and his familiarity with the FAA’s Air Traffic Safety Oversight office and his history with the FAA as the Assistant Administrator for the Office of System Safety earns him considerable respect. That leaves only the current Board Chairman, Deborah Hersman … and she’s been a board member the longest of all of the Board Members, and before joining the Board was a senior advisor to the US Senate Committee dealing with Commerce, Science, and Transportation issues. If my memory serves, she has held more “open” meetings and hearings and has put more information on the NTSB website than any of her predecessors and has a pretty good reputation with both “Capitol Hill” and the press – not an easy feat in and of itself.

Does this get us to the point of it being a “perfect” NTSB for airline and piloting issues? Probably not. And, I’d bet that any of those 5 members would agree – but, and again, airlines and pilots are not the only areas of concern for the NTSB. Sure, there are, and always will be, excellent and not-so-excellent participants on any given transportation accident or incident … but where is there anything different? So … perfect? … nope! … but … good? Yeah, I think they’re pretty darn good. And, yeah, I’ll continue to criticize and critique and offer my comments (pro and con) when and where necessary … but I’m not at all ready to throw the NTSB under the proverbial “bus.”

[aterpster]

AirRabbitt:

… but I’m not at all ready to throw the NTSB under the proverbial “bus.”

Nor am I.

[pattern_is_full]

@ aterpster - first understand that I generally always appreciate your comments and experience.

However, in this case, I really have to question why you say:

The BE1900 crash at Dillingham..... was a gross, fundamental screw up by a government employee; the controller.

Here are stated FAA policies, from both before the Dillingham accident, and after, regarding ATC responsibility for terrain avoidance.

FAA emphasis - ALL CAPS
My emphasis - underlined and or bold

From Air Traffic Bulletin - April 2004: U

Minimum Altitude Emergencies
/*TER/ Controlled flight into terrain (CFIT) accidents, departure accidents, and approach accidents sometimes occur even though the crew was always in complete control of the aircraft. These accidents and minimum altitude emergencies often stimulate heated discussions of who really was responsible for terrain and obstruction separation when the accident occurred.

Pilots always share responsibility for terrain and obstacle avoidance. A flightcrew should be generally aware of terrain and obstruction elevations and should never accept instructions that do not ensure adequate terrain clearance. A controller is required to issue a safety alert to an aircraft if the controller is aware the aircraft is in a position/attitude that, in his/her judgment, places the aircraft in unsafe proximity to terrain or obstructions. Air traffic controllers issuing specific** altitude instructions and clearances accept responsibility for terrain avoidance.

Pilot charts depict minimum en route altitudes, minimum obstruction clearance altitudes, off route obstruction clearance altitudes, and other altitudes. Minimum vectoring altitudes, available only to ATC, can sometimes be the best and lowest altitudes available for instrument flight. Pilots receiving altitude assignments below charted altitudes typically assume they are being assigned the minimum vectoring altitude.

There should be no confusion as to whether ATC is assuming responsibility for terrain clearance.

From FAA AIM revison dated 8/22/2013 - Section 4. ATC Clearances and Aircraft Separation: http://www.faa.gov/air_traffic/publi...m/aim0404.html

4-4-1. Clearance

a. A clearance issued by ATC is predicated on known traffic and known physical airport conditions. An ATC clearance means an authorization by ATC, for the purpose of preventing collision between known aircraft, for an aircraft to proceed under specified conditions within controlled airspace. IT IS NOT AUTHORIZATION FOR A PILOT TO DEVIATE FROM ANY RULE, REGULATION, OR MINIMUM ALTITUDE NOR TO CONDUCT UNSAFE OPERATION OF THE AIRCRAFT.

b. 14 CFR Section 91.3(a) states: “The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.” If ATC issues a clearance that would cause a pilot to deviate from a rule or regulation, or in the pilot's opinion, would place the aircraft in jeopardy, IT IS THE PILOT'S RESPONSIBILITY TO REQUEST AN AMENDED CLEARANCE.

It seems to me the FAA is clearly telling their own staff - and pilots - that ATC responsibility for terrain avoidance is, at most, "advisory." While one can certainly question the FAA policy, I don't see where a controller who follows that policy can be said to have "screwed up."

It wouldn't surprise me if the delay in issuing a report on Dillingham is more due to an interagency wrangle than a top-down politics issue. The NTSB is arguing (as you have) that the controller flew the plane into the hill, while the FAA is maintaining (strongly - as emphasized in the August document) - "That ain't our job!"

**editorial question: is "maintain at or above" a specific altitude instruction?

[Bergerie1]

Which is why I agree so strongly with A Squared's post 976 in my post 977. Regardless of whether one is flying in radar or non-radar airspace the pilot MUST always be aware of the MSAs and the location of the terrain.

[Capn Bloggs]

Wow. As someone who has never operated in the US environment (nor red the report, only read Aterpster's comments) I reckon that FAA attitude to terrain avoidance responsibility is pretty poor. Why are they called "controllers" if they carry only 50% of the can if they splat you against a hill on a vector below the MSA?

If a private company had that policy/did that, they'd have their backsides sued-off in a flash.

Cop-out 101, methinks.

[Kangaroo Court]

Blogs and all,

Have been flying in the US for 23 years and it's getting much worse with every day. I've flown in third world countries that have had controllers taking more individual responsibility and accountability.

[aterpster]

pattern is full:

It seems to me the FAA is clearly telling their own staff - and pilots - that ATC responsibility for terrain avoidance is, at most, "advisory." While one can certainly question the FAA policy, I don't see where a controller who follows that policy can be said to have "screwed up."

There is no doubt that the FAA has recently tried to waltz away from policy stated strongly after the 1974 TWA 514 accident. Some in the industry feel that it the FAA continues down this absurd path pilots should refuse radar vectors (approach control) or MIA assignments (centers). That would be a war.

It wouldn't surprise me if the delay in issuing a report on Dillingham is more due to an interagency wrangle than a top-down politics issue. The NTSB is arguing (as you have) that the controller flew the plane into the hill, while the FAA is maintaining (strongly - as emphasized in the August document) - "That ain't our job!"

Good point.

**editorial question: is "maintain at or above" a specific altitude instruction?

That is probably one of the core arguments going on internally. I have never received such an off-route clearance. To be a bit absurd I suppose the BE1900 was legal to climb to 10,000 or FL 200 if he saw fit.

[aterpster]

Begerie1:

Which is why I agree so strongly with A Squared's post 976 in my post 977. Regardless of whether one is flying in radar or non-radar airspace the pilot MUST always be aware of the MSAs and the location of the terrain.

When I have time later in the week I'll post one of FAA's convoluted MVA charts for a mountain area airport. It is not possible for a pilot to double check ATC altitude assignments in such cases. The big boys have TAWS, which is probably making saves we never hear about.

It would, however, been easy enough for the BE1900 crew to catch what I will continue to call ATC's huge screw up. Sadly, they didn't use the tools they had, particularly the minimum altitude for the holding pattern.

[aterpster]

K.C.

Blogs and all,

Have been flying in the US for 23 years and it's getting much worse with every day. I've flown in third world countries that have had controllers taking more individual responsibility and accountability.

That is a reflection of the current management of the FAA's Air Traffic Organization. It is pathetic.

Had the Dillingham crash been a Part 135 flight with 20 paying customers, this would have already been in the informed-public debate.

[A Squared]

Originally Posted by aterpster

Had the Dillingham crash been a Part 135 flight with 20 paying customers, this would have already been in the informed-public debate.

If it had 20 paying customers, it wouldn't have been a 135 flight.

(I'm just yanking your chain a little, I know what you mean)

[aterpster]

A Squared:

If it had 20 paying customers, it wouldn't have been a 135 flight

What's the limit? I don't have a clue. I thought Part 135 is common in Alaska for on-demand transport of people.