Aviation Safety
                              -or-
                Why the cheapest seat on the plane 
                 is the one next to the cargo door. 
 

Copyright © 1996-1997 Tim A. Krell. All rights reserved.

Foreward

This mini-report was originally written many years back, while I was still in high school. I later recycled it for use in a composition class in college, but most of the information remains dated. The writing style is quite informal, as was customary in the classes I was taking, and so this report is by no means purports to be authoritative, complete, or even accurate. Bear in mind that this report was prepared in a composition, not an engineering class, where the primary emphasis was on form not content. My only reason for making this report available is that it does contain some interesting trivia and a few annecdotal case studies. So enjoy the paper for what it is worth, and if you don't like it, remember--you get what you pay for!

Tim A. Krell 
June, 1995

"PLANE CRASH HELD SURPRISE TO CREW" proclaimed the headlines of the New York Times. It was several days after the tragic accident of Eastern flight 401. On December 29, 1972, three able-bodied and experienced pilots flew a Lockheed L-1011 TriStar into the Florida Everglades after becoming distracted over a burned-out lightbulb. The lone survivor from the cockpit, would later tell investigators that, "There was never any alarm or concern in the cockpit . . . I don't think anybody knew the crash was coming, even the captain."(1)

As with most aviation accidents, there was not any one factor in the Eastern crash which could be pointed to as the cause of the accident. Rather, it was a combination of several unrelated factors, which, when combined led to the unthinkable. When the National Transportation Safety Board issued its final report on the accident, they said, "It is obvious that this accident . . . was not the final consequence of a single error, but was the cumulative result of several minor deviations from normal operating procedures which triggered a sequence of events with disastrous results."(2)

So what happened? How could a tragedy like this occur? Let's take a look back at that ill-fated flight. Shortly after nine p.m. on December 29, 1972, Eastern Airlines flight 401 left New York's Kennedy Airport headed for Miami. Sitting in the jump seat behind the captain sat Angelo Donadeo, a technical specialist. He was a "deadhead"--airline slang for an off-duty crew member who rides a flight free in order to return from another assignment. The flight was going very smoothly. As the crew turned onto their final approach to Miami International Airport, they began their pre-landing checklist. Everything checked out, except for one thing. The nose landing gear indicator had failed to illuminate. This meant one of three things had happened: (a) The nose landing gear had not locked into place, (b) There was some problem with the circuitry of the panel, or (c) The lightbulb on the panel had burnt out. Not being sure of which one of the three had happened, the crew radioed in and requested to circle the airport while they investigated this problem. The autopilot was engaged. This would hold the airplane straight and level at 2,000 feet while the crew tried to figure out what to do about their predicament. Four minutes later, the autopilot was somehow disengaged. However, the crew was so absorbed in trying to solve the landing gear problem they were oblivious to the fact that they had begun a 1,000 feet per minute decent.

The air traffic controller at Miami noticed that 401's altitude on his radar screen was at 900 feet--a far cry from their assigned altitude of 2,000 feet. "Eastern 401, how are things coming along out there?" inquired the controller. The controller would later testify that he thought there was something wrong with his radar scope, not the altitude of the airplane. The plane continued to descend. Meanwhile, the pilots were still fumbling with the instrument panel. Flight engineer Donald Repo and Technical Specialist Angelo Donadeo were in the "hell hole," a small compartment accessed by a trap-door in the floor of the cockpit. From inside this compartment, the crew could tell for sure whether or not the nose-gear was really down by looking through a peep-hole like apparatus. Back in the cockpit, the crew was beginning a gradual left turn. All of a sudden, First Officer Albert Stockstill realized something was wrong. "We did something to the altitude," he told Captain Robert Loft.

"What?" asked Loft

"We're still at two thousand, right?"

"Hey, what's happening here?"

At that moment, Donadeo would later tell reporters, "I put my eye to the hole--and the impact occurred."

No form of transportation is accident-free. Planes crash, cars get wrecked, trains derail, boats sink, and kids fall off their skateboards. But of all the various forms of transportation, flying is among one of the safer ones. Consider this: in an average year, about 800 people die in plane crashes. Contrast that to the 60,000+ people who die every year on our highways. Loyd's of London, an authoritative insurance agency, has calculated that one is 20 times more likely to die in an automobile accident than on an airplane. But then again, how many of us commute to work daily in an airplane? Perhaps a better statistic would be that in 1988 there were .251 accidents per 100,000 aircraft hours flown. Out of those accidents, only .018 were fatal.(3)

When one starts to talk about safety in aviation, the subject of deregulation invariably comes up. Way back when, the government used to regulate the airlines with an iron fist. They would set fares, designate routes, and pretty much run the airlines. But all this changed in 1978 when Congress lifted these regulations. Can you guess what happened next? You guessed it--Price Wars!

     Good evening, I'd like to welcome you aboard the Mrs. Grace L.
     Ferguson Airline and Storm Door Company . . . Our airline was
     founded on the philosophy that what the American public was
     really looking for was low-cost overseas transportation.  We 
     have attempted to eliminate what we in the airline business call
     'frills' and 'extras' . . . like maintenance and radar and a whole
     bunch of technical instruments up in the cockpit . . . (4) 

Okay, but the airlines wouldn't cut back on maintenance, right? Well, you be the judge.

May 5, 1983. An Eastern Airlines L-1011 was en route from Miami to Nassau. The plane was at 23,000 feet and was starting its decent to Nassau. Suddenly an indicator light came on, announcing that the oil pressure in the Number 2 engine was dropping. The crew shut down the engine. Okay, no problem. The plane can still fly with only one engine out. However, in a few moments, the oil pressure started dropping on the Number 3 engine. The crew eased the power to the number 3 engine, but didn't shut it off completely. Okay. Still no problem. The plane can still run with an engine out, and one engine partially on. But then, the number 1 engine stopped rather abruptly. Okay, were still all right. In a few moments, the number 3 engine then quit. Okay, we still got the number 4 engine, right? Well, unfortunately, the L-1011 only has three engines. Now we do have a problem. The plane began to drop about 1,200 feet a minute, and needless to say, the people decided that this might perhaps be an opportune time to put on their life vests and read the safety information card. As the plane was about 3,900 feet above the Atlantic Ocean (they started at 23,000, remember) the Number 2 tail engine finally sputtered back to life and the plane was able to make a safe (and dry) emergency landing in Miami. Whew!

Why did the engines quit? It was due to an "oversight" by the maintenance men. Much to the chagrin of these conscientious, hard-working individuals, it was later discovered that they had forgotten to put oil seals on the oil plugs. Oops! I hate it when that happens! With the seal not in place, the oil can freely leak from the engine.

The mechanics said that they would have noticed the missing O-rings, as they are called, if they had been doing their work in the daytime. You see, they had to do their maintenance work late at night with flashlights and the lights of a pickup truck. Now do you think somebody's cutting costs where it comes to maintenance? No, of course not.

This was only the fourth incident of missing O-rings for Eastern. But in the finest tradition of "we never make the same mistake twice--er, I mean five times--in a row" Eastern finally got their act together. (But for how long?)

You'll also be happy to know that, according to a passenger on board the ill-fated flight, "The crew was not informed 100% of the procedure,"(5) The 32 year-old salesman from Longwood said he saw the flight attendants thumbing through a manual to find out how to open the emergency doors. The airline responded quite diplomatically, saying, " . . . it did seem that, in a pending emergency, if they [the flight attendants] have time to review their books to make sure they haven't left anything out, it is to everyone's benefit."

Well, perhaps. But I'm still not convinced. And although these last couple of examples happened several years ago (lest you think things have improved), there are still plenty of examples to pick from today. The failure to follow proper de-icing procedures apparently caused the crash of a USAir Fokker F-28 to crash a few months ago at LaGuardia Airport resulting in 27 fatalities. Don't the airlines ever learn? It's only been a few years since the tragic Air Florida crash in which a Boeing 737 plunged into the Potomac River in Washington D.C. shortly after takeoff. The reason for the crash: the crew did not follow proper de-icing procedures, amongst other things. As a result, the plane did not have enough power to take off. In fact they did not even have the on-board engine de-ice mechanism engaged. Investigators were shocked as they played back the cockpit recorder tape and heard the pilot clearly responding "off" when the co-pilot called out "engine de-ice" during the pre-flight checklist.

Well enough of that, let's take a quick time-out for a pop-quiz. What's the number one cause of airplane crashes? Maintenance? Wrong. Air Traffic Controller screw-ups? Nope. Large, ugly seagulls stalling the engines after they're sucked in and turned into Shredded Tweet? No, no, no. Pilot Error! Nobody wants to believe that pilots make mistakes, but unfortunately, they do, as we saw so vividly in the case of Eastern flight 401. Between 1983 and 1987, pilot error was identified as the broad cause/factor in 68.4 percent of fatal accidents. Ouch! It's the thought of pilot error that makes the issue of aviation safety such a sensitive one, and has many afraid to fly. Perhaps you aren't paranoid about flying, though. Well, keep reading.

Once upon a time there was this Republic Airlines DC-9. It was flying over Utah at about 33,000 feet when suddenly, much to the dismay of the passengers and crews, the engines abruptly stopped. The plane plunged about 20,000 feet while the crew tried to figure out what in the sam hill was causing all of this. Well, (you're going to love this one) the pilots soon discovered that they had forgotten to switch on the fuel pumps for the center fuel tanks as required by the checklist. Kind of like putting gas in the lawn mower, but forgetting to pull the starter rope. Oh well, it's those minor, insignificant details that get you, right? Alas, they finally got the fuel pumps pumping, and, thus, the engines going again. A close call, needless to say.

Remember the National Airlines 727 that went surfing in Escambia Bay? Well there's a story behind that one too! The pilot wasn't really paying attention to the altimeter (the gauge that tells how high you are), as he was approaching Pensacola. A device in the cockpit known as the Ground Proximity Warning System sounded its alarm. This alarm tells the captain that he is either (a) about to plow into the ground (or sea, as it may apply) or, (b) he is descending too fast. Well good 'ol Captain Kunz (that really is his name) opted for the latter one, deciding that the alarm must be going off because he was descending too fast (duhhh . . . .) So he disengaged the alarm and, without so much as glancing at the altimeter, continued on his decent of 1,600 feet per minute. Well, as you know, the plane bit the dust (or seaweed in this case). The National Transportation Safety Board report said that the probable cause of the crash was "the flight crew's unprofessionally conducted, non-precision instrument approach."(6) Non-precision?!? I'd say! They were off by about 3 miles!

The flight crew told investigators that they had become distracted after they fell behind on their checklist. Sound familiar? Crew preoccupation with minor problems is a common cause of aircraft accidents.

Okay. Now that I've totally destroyed any thoughts you might have had about flying, let me jump to the flip side and tell you about what's being done to keep aviation one of the safer forms of transportation.

Whenever an aviation accident occurs, the National Transportation Safety Board is there to investigate. Created in 1974 by the Independent Safety Board Act, the NTSB's mission is "to determine the 'probable cause' of transportation accidents and to formulate safety recommendations to improve transportation safety."(7) The NTSB performs this job very well. The only problem is that the airline industry and the Federal Aviation Administration is often reluctant to respond to the safety recommendations of the NTSB. In itself, the NTSB is powerless. It can only make recommendations. It is then up to the FAA to implement these recommendations.

The FAA has a tremendous amount of power over the airline industry. In short, the FAA controls the industry. Amongst other things, the FAA can issue what is known as an Airworthiness Directive. This directive will require the airlines and/or manufacturers to perform certain tasks with regards to the airplane. If the directive is not complied with, it becomes illegal for anyone to fly the plane.

Airline manufacturers are also working to bring improved safety through improved design. The Boeing 757/767 series of aircraft are equipped with a new computer system known as EICAS, which makes the monitoring part of the crew's job much easier. Instead of constantly scanning a myriad of gauges and panels, the crew can simply look on two computer screens which consolidate the wealth of information into an easy-to-read format. For the first time, pilots can now call up what they want to see and when they want to see it. Also, the 757/767 is much more automated. These planes can perform a completely automated take-off, flight, approach, and landing. The infamous "non-precision" approach is a thing of the past when the autopilot is in control. It performs with amazing accuracy.

The mechanics of the airplane have been greatly improved. If the planes are properly maintained they can "last forever" according to the manufacturers.(8) All of the "bugs" so to speak have been worked out, and now, the chances of the mechanics failing are very rare. Thirty years ago, the likelihood the equipment would fail was 10 times higher than it is now.(9)

What about the human factor of the airline accidents? That problem is being attacked as well. Cockpit Resource Management, or CRM, has been adopted by a growing number of airlines. One of the elements of CRM training include communication training. Using techniques borrowed directly from business management, crews are taught to recognize how their individual styles can create the communication blocks which cause accidents.(10)

Over the last couple of years, the subject has been aging aircraft. After the Aloha Airlines incident in 1988 which turned a Boeing 737 into a convertible, the focus of the aviation industry suddenly switched to the issue of aging aircraft. In a massive industry effort involving government agencies, manufacturers, airlines, and various other organizations, the aviation community attacked the problem head-on.

     We've taken this issue and have been pushing on it and we are
     beginning to see airplanes inspected and maintained better than
     they've ever been in their lifetimes.(11) 

The FAA has imposed many new regulations with regards to aging aircraft. New, tougher maintenance standards have been imposed. Maintenance inspectors whose job was once confined to paper work are now going out on the field. Instead of taking the airline's "word" on whether or not maintenance work is being done, these inspectors are now going out to see the planes for themselves.

Although aging aircraft is admittedly a serious problem, this doesn't necessarily mean that the next time you flush the toilet wrong an engine will fall off. But alas, engines do fall off due to problems in the lavatory. This was clearly demonstrated a couple of years ago, when a leaky toilet caused the engine of a Northwest Airlines 727 to fall off. Reports later showed that ice from the leaking lavatory apparently broke away and struck the engine, causing it to tear off.(12) You see, the 727 engines are designed to "break away" under intense stress so the vibration will not cause damage to the airplane. This same sort of situation put the airlines in deep doo-doo (excuse the pun) twice before--in 1974 and 1985. In both instances, the cause of the engine falling off was attributed to a buildup of ice from the plane's lavatory dislodging and striking the engine. Kind of makes you think twice about wanting to use the bathroom en-route. Anyway, I was talking about maintenance, wasn't I? Okay, back to maintenance . . .

Indeed, planes are finally being inspected like they should be. This is no doubt due to the fact that now it is economically sensible to do so. The cost of replacing aging aircraft is enormous, but aside from that, the aircraft industry simply cannot keep up with the growing demand for new aircraft. Therefore, maintenance now "makes sense"; the promise that planes will last forever is just what the airlines were hoping to hear. It's rather upsetting to observe that the airline industry tends to make its decisions based on economy rather than safety-- finances rather than what's best for the people who have to fly on those planes.

Although the number one cause of airline accidents is "Pilot Error," this is only part of the picture. The flip side of Pilot Error is the airlines alarming indifference towards safety. In his book, Safety Last: The Dangers of Commercial Aviation, Captain Brian Power-Waters makes a very alarming indictment of the airline industry. Captain Power-Waters describes the immense pressure that airlines place on their pilots to make schedule, fly with lesser and lesser amounts of fuel, and to do other unsafe things in the name of economics. Other pilots are beginning to say the same thing.

     Oh, there are very strong pressures about keeping integrity with
     the schedule and accepting airplanes that have mechanical
     deficiencies and flying in weather that you certainly don't want
     to fly in, but it's not illegal for you to fly in.(13) 

So where does that leave us? Hmmm . . . Perhaps a better question is what should one do when getting ready to fly? First of all, don't fly the Mrs. Grace L. Ferguson Airlines of today. Pick an airline that is making good profits because they are the least likely ones to be cutting corners when it comes to safety. Second, pay attention to the flight attendants before the flight when they explain about emergency procedures. Third, don't become irregular when the pilot announces that they are encountering a little turbulence or some minor difficulty. Otherwise, you'll end up having to go to the lavatory several times--which as we discovered could, in itself, create a whole host of other problems. And finally, if anything should happen, stay calm. Panic can kill in an emergency.

My doctor once told me, "If you knew all the possible side effects of Penicillin, you'd probably never take it for the rest of your life."(14) And while I am stretching it a bit, that's pretty much the same thing with aviation. Admittedly, the aviation industry does have its problems, as does any form of transportation. And I'm sure if we knew all of the things that went on with the airlines, we'd probably never fly again. But even with all of its problems, the airlines are getting safer, and still remain one of the safest forms of transportation next to the shoe leather express.

The airline industry still has a long ways to go, and it won't get any easier for them. Rising costs of fuel, an uncertain economy, and recent price wars have created a terrible temptation for the airlines to cut corners. While deregulation did make for a more competitive marketplace, it is disturbing to think that it may have been at the expense of safety. The burden for aviation safety, however, ultimately falls on our shoulders. In a free marketplace, we the consumers are the final arbiters. A free market guarantees us a wealth of choices for air travel, but in the end we as consumers decide which airlines stay and which airlines go.

Let's hope we make the right choices.

Endnotes

1. "Plane Crash Held Surprise to Crew," New York Times, 12 January 1973, p. 65, col. 1.

2. Rob and Sarah Elder, Crash (New York: Atheneum, 1977), 202

3. National Transportation Safety Board, Annual Review of Aircraft Accident Data (Washington, D.C.:GPO, 1991), 11.

4. Bob Newhart, "Mrs. Grace L. Ferguson Airline & Storm Door Company", The Best of the Button-Down Mind, copyright unknown.

5. "Passenger on Eastern Jet Tells of Near Disaster", New York Times, 18 May, 1983, p. 14, col. 5.

6. "Fatal Jetliner Crash in Florida Is Attributed to Errors by Flight Crew", New York Times, 11 November 1978, p. 66, col. 3.

7. National Transportation Safety Board, National Transportation Safety Board, (Washington, D.C.:GPO, 1991), 1.

8. "Aging Aircraft", King 5 News Extra, writ. by Glenn Farley, (Seattle: King Broadcasting Company, 1989).

9. "Why Planes Crash"; written, directed, and produced by Veronica L. Young, Nova, (Boston: WGBH Educational Foundation, 1987).

10. "Why Planes Crash"; written, directed, and produced by Veronica L. Young, Nova, (Boston: WGBH Educational Foundation, 1987).

11. "Aging Aircraft", King 5 News Extra, writ. by Glenn Farley, (Seattle: King Broadcasting Company, 1989).

12. "Leaking Toilet May Have Disabled Jetliner", Bremerton Sun, 5 January 1990, pg. A5, col. 3.

13. "Why Planes Crash", 1987

14. My Doctor.

Bibliography

Bailey, Francis Lee. Cleared For the Approach: In Defense of Flying, New Jersey: Prentice-Hall, 1977

Beaty, David. Strange Encounters: Mysteries of the Air, New York: Antheum, 1984.

Elder, Rob & Sarah. Crash, New York: Antheum, 1977.

National Transportation Safety Board. 1988 Annual Report to Congress, Washington, D.C., U.S. Government Printing Office, 1991.

National Transportation Safety Board. Annual Review of Aircraft Data: U.S. Air Carrier Operations Calendar Year 1988, Washington, D.C., U.S. Government Printing Office, 1991.

National Transportation Safety Board. Annual Review of Aircraft Data: U.S. General Aviation Calendar Year 1988, Washington, D.C., U.S. Government Printing Office, 1991.

National Transportation Safety Board. National Transportation Safety Board, Washington, D.C., U.S. Government Printing Office, 1989.

Page, Eddy Potter. Destination Disaster, New York: Quadrangle / The New York Times Book Co., 1976.

Power-Waters, Brian. Safety Last, The Dangers of Commercial Aviation: An Indictment By An Airline Pilot, New York: Dial Press, 1972.

Thurston, David B. Design for Safety, New York: McGraw-Hill Book Co.,1980.

United States Department of Commerce, Bureau of the Census. Statistical Abstract of the Untied States, Washington, D.C., U.S. Government Printing Office, 1989.

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