Another Tragic But Ironic Aviation Accident

 

 

 

Earlier last week there was a fatal accident at Miami International Airport (KMIA).  An air cargo Boeing 767-300 overran Runway 30.  The jet, callsign Amazon Air Flight 7598, was owned by 21 Air, operating for Amazon.  It was completing a flight from San Juan, Puerta Rico to Miami.   There were thunderstorms in the area.  The aircraft touched down fast and much further down the runway than desired.  Failing to successfully stop or go around, the aircraft continued beyond the runway threshold with enough energy to cross the airport perimeter road where the aircraft collided with and crushed a 2012 white Ford Econoline van with seven occupants.  The aircraft then continued through the airport boundary fence and crossed NW 67^th Ave where it hit a Toyota Corolla before coming to rest short of a parking lot a quarter of a mile from the end of the runway.

 

If there is a haunting scenario for any pilot, it is a fatal accident where the crew survives. What could be worse.  Airplanes, as well as pavement, vehicles, and fences, are replaceable.  Human lives are not.  Death is the great equalizer. 

 

There is an old joke pilots tell after a few beers when their buddies will tolerate and laugh at their lame humor.  It goes like this…..

 

A guy is sitting at the bar having a drink after work when a fellow comes in and sits next to him.  In a very short time, the man can’t help but noticing a very strong and obnoxious odor.  Not wanting to be rude he tries to ignore the smell, but after a while it just became too much.  The guy starts to inquire more with the fellow next to him by making small talk.  After a short while he asks the fragrant fellow, “What do you do?”.  He replies, “I drive the truck that empties the airplane lavatories at the airport.”  The man says, “Wow, that’s probably a pretty stressful job with all the chaos and trying to get everything done on time.”. He said, “Yes, and what is worse is that sometimes the connection fails, and you get soaked with lavatory waste.”.  The man is understandably repulsed and says, “That’s awful, can’t you find a less disgusting occupation?”  He responds, “What, and get out of aviation?”

 

Notwithstanding the lavatory truck operator, the next worst job in aviation might be “Cabin Cleaner”.  Having to clean up after over privileged parents who let their feral children trash their first class seats as well as everywhere around them is demeaning and humiliating.  “Let someone else take care of it.”, is the flippant attitude often heard.  It wasn’t always that way.  In the “Golden Era” of airline travel, when passengers dressed up and manners were required, aircraft cleaning was a valued occupation.  They were employees of the airline with all the associated benefits.  When I was a young and junior airline pilot, cleaning crews were composed mostly of women 50+ who were housed under the concourse in a big room with shelves of supplies and banquet type tables.  In between flights they sat at these tables and worked, like Santa’s elves, on all sorts of crafts and other activities to pass the time.  Knitting, sewing, or reading and catching up on the latest airline gossip occupied the intermission between flights.  When the planes arrived, they brought out their shopping bags full of supplies and primped the airplane interior like a mother dressing her daughter for the prom.  Everything just perfect.  Safety cards, sickbags, magazines in just the right order.  Fluffing pillows, vacuuming up the peanut and pretzel dust, wiping down the seats with an efficiency that would make Lucy in the candy factory proud.  They were amazing.

 

After deregulation things changed.  Aircraft cleaning became a necessary evil.  Frank Lorenzo was not emotionally invested in aircraft cleaning. It became a cost to be minimized.  Vendors were contracted to provide the service at minimum cost.  Aircraft cleaning deteriorated to a sweat shop environment.  The job of aircraft cleaning became obligatory and unceremonious.  However, no one expected it would be fatal.

 

There is dignity in all work.  Showing up on time and performing the tasks assigned you is something to be proud of.  There are many mundane essential functions that need to be performed if an airline, or any business, is going to function successfully.  It ALL must work, or nothing works.  An airline operation can be compared to a complicated machine or dramatic performance.  Every participant, element and condition must come together at the correct moment or it completely unravels.  Timing and competence are mandatory.  An actor misses their cue. The lights don’t come up. The music is incorrect.  The performance fails.  The aviation industry is the same.  All elements must be present at the correct time.  Missing or late components don’t cut it.

 

Pilots, Flight Attendants, and the airplane are the stars of the performance.  They get all the attention.  They are what is seen.  What is unseen is the unbelievable numbers of people who “really” make it happen.  It is almost impossible to list all the people who are required for an airline, passenger or cargo, operate.  Fueling, maintenance, scheduling, catering, and baggage handling are the most obvious, but there are so many more tasks necessary.  Cabin cleaning is the nexus of most noticeable and least glamorous of airplane servicing occupations. Everyone wants the job done, but few really care about the people who do it.  I am ashamed to admit that I have been annoyed by the arrival of the cleaning crew when I am trying to get off the airplane after arrival. 

 

Rolando Aleman Leon, 55; Yoel Rodriguez Narajo, 53; Julio C. Pineda, 75; Carlos Acosta Fajardo, 53; and Javierk Reyes Quevedo, 47 were all occupants of the Ford Econoline van who died when it was crushed by the Boeing 767 in this tragic accident.  They were members of a cleaning crew that had just finished doing their job.  They were essential participants in that meticulously choreographed performance that is called air transportation.  I don’t know the backgrounds of the people, but they were working to provide for themselves and their families.  Doing work that no one gets applauded for but gets called out when it’s not correct. They had dignity.  After the wreckage is removed and the investigation is complete, this cleaning crew will be remembered only by their friends and families.  Their names will be annotated somewhere in the NTSB report.

 

I will absolutely stipulate that this crew did not depart San Juan with the intent of destroying their aircraft as well as killing and injuring many people.  Pilots are given a tremendous amount of respect for what is required to achieve their skills and position.  It is well deserved in most all cases.  However, with that respect and position comes the commensurate responsibility to perform.  I will paraphrase a thought that has been attributed to many people from Mahatma Ghandi to Will Rogers, “A society or group is judged on how it treats the least of it’s members.”  The aviation industry would do well to reflect on this.  Who gets the least recognition in aviation? This tragic accident is a gut-wrenching example.  Who would ever think a cleaning crew would lose their lives in an airplane accident.  The irony is excruciating

 

The NTSB will do a thorough and effective review of the accident.  The resulting report will let everyone know how this unbelievably sad and tragic accident happened.  The “why” is much more elusive.  It does not appear in the early stages of the investigation that there were any mechanical failures with the aircraft.  Fortunately, with the help of a flight data recorder, a cockpit voice recorder, and the crew’s recollection, we will learn the human factors components and quality of decision making that led to this accident.  From that information it is essential we learn how to reduce the potential for this scenario in the future.  Tragically, we will never learn how this crew of aircraft cleaners could have avoided their fate. 

 

 

I’m Back…..I Don’t Think Anyone Noticed I was Gone

 

 

 

 

It’s been over eleven years since I retired.  I have not been behind the controls of any aircraft since.  I have however, with my wife, driven our 1931 Model A Ford pickup tens of thousands of miles across our beautiful country.  From the Grand Canyon to Kitty Hawk and most places in between.  I thought when retired, I would not be able to relate to the aviation community the same as when I was part of it.  To my surprise and regret, current events indicate I still can.  Aviation has not changed.

 

I assumed that with a new generation of pilots and aircraft I would not be able to share the same connection I once had with today’s aviation community.  I did not anticipate that although the pilots younger and the airplanes newer and more sophisticated, the “human-machine” interface would be the same. I don’t know if I was optimistic or just naïve.  When robots and AI take over, then it might be different. Today’s highly complex flight management systems still do not possess critical thinking or decision-making skills.  These modern aircraft are still dependent on a human, either physically or remotely connected, to effectively manage and safely execute their assigned mission.  Student pilots in primary training and a veteran A380 Captain continue to share the same profound role.  That is the responsibility for and authority over the machine they are operating.  

 

So, to use a popular phrase from the current lexicon; “Let’s have a conversation.”.  I will let you know what I think, but more importantly, invite you to explore with me what WE can think about.  I want to see the new generation of pilots look differently at how they can interface with their machines more effectively.  Recent events indicate looking at this challenge in the same traditional way is not working.  I don’t believe that abdicating more and more responsibility to process, procedure, and technology is the answer.  Let’s talk about it.

Aged To Perfection

Today is a pretty special day. Exactly 61 years ago, in Seattle, was the first flight of Dash-80, the prototype of the Boeing 707.   The 707 is one of the most important and iconic airplanes ever built. She had a great career, but things change and she became out dated and no longer relevant.

I retired from the flight deck the first of the month and since I am no longer flying, I have decided to retire the blog as well. This will be my last post on Flying The Backside.   It’s time for someone else, someone younger, more relevant to write about human factors in aviation. These topics are the same as 40 years ago when I started, but yet they seem different.  I can’t really relate to them now.  Flying is so much more complicated than it used to be.  I would find it very challenging to be a young pilot today trying to figure out what I should know and what’s really important.  Stick and rudder skills have been replaced with alpha-numeric key strokes.  Decision-making has been eliminated and replaced with rote compliance.  It is no longer necessary to know why we, as pilots, do what we do.  Just follow the recipe.

It wasn’t always this way.  The transition from props to jets was hard, but nothing like this.  It was airplanes to airplanes, not airplanes to the App Store.

Today is also my wife’s birthday.  She too was born in Seattle, Washington on July 15^th, 1954.  Dash-80 has not flown in many years.  My wife, however, has never been more attractive or vibrant.  She supported me and sustained me throughout my career and is now ready to embark with me on a new adventure, traveling in our RV.  We look forward to rediscovering America and each other.

Thanks to everyone who read, subscribed or commented and I look forward to sharing my experiences from the road.  Until then, fly safe and watch out for each other.

Stoplights

Ok, so I am in the last month of my career.  I have been asked what are the best and worst parts.  The best are the memories of incredible people and places.  The worst are the missed opportunities.  Providence gives us opportunities and it’s a sin to waste them. As the heir of the greatest generation my contemporaries and I were bequeathed almost unlimited opportunity in aviation.  We did a lot of good things, but we could have done better.  We could have more effectively established the partnership between threat identification and mitigation and standardized operating policy.   I regret the part I played in that.  Did we leave the industry with the more opportunities or are they just bigger challenges.  I am not sure there is a difference, but I am sure that we have not adequately prepared the next generation to understand and meet them.  We have taught them to obey rather than think.

Personally, as I reflect on my career, I have been trying to access what I have learned from four decades of flying airplanes for a living.   It all comes down to this.  We have only been marginally successful at exploiting technology in modern aviation. We have been mostly ineffective in this area because we now value data (information) over decisions.  Since technology is vastly better at information acquisition and management than humans, we are now working for the machines.  We are now the robots.  We don’t use technology to decide what to do, we do what the machines tell us to do.

This all became clear the other day when our family was in the car at an intersection when the car in from of us made a left turn with a red arrow displayed on the traffic light.  The turn was made after the oncoming traffic had cleared and was safe in every way except that there was a red light (arrow).  My family all thought the maneuver was very dangerous.  I asked them why and our discussion was very revealing. 

Just because the light is green is it safe?  Is it always unsafe when the light is red?  Can we trust that the light will always achieve the desired outcome?   Does the stoplight replace decision or just display information?  Can a display of information replace human analysis of the situation?  I believe we would all say no, however what do we practice?  Will the auto pilot always level the airplane at the right altitude?  How do we know it's the right altitude?  Technology can supply information, and lots of it, but only humans can provide the context.  Automation can perform complicated tasks accurately and efficiently, but in what combination.  Just yesterday local teenager was killed when his car rear-ended a semi truck while he was texting.  Is the answer to texting in the car collision avoidance technology?  Really?

Moreover, aren’t policy and procedure just the written version of stoplights.  Volumes are written that say do this don’t do that.  Go this way, don’t go that way.  Like the stoplight there is only binary instruction.  Red STOP and green GO is all we get and we must intuit the context.  Unfortunately, the “why” behind policy is usually much more difficult to derive than that of the traffic signal.  Often the “why” is simply unknown to the user.  Standardized verbiage at specific altitudes are a great example of this.  Compliance trumps understanding.

Machines and their instruction manuals are simply tools.  Tools are what have allowed man to achieve dominion over all other creatures on the planet.  Since the dawn of humankind, man has been using tools to improve their lives, albeit, not without significant collateral damage.  The proliferation of highly sophisticated tools, i.e. technology, is the greatest threat future generations of aviators will face.  This threat exists because of the fundamental flaw of machines, binary decision making.  It is all “1’s and 0’s”, a vast array of little digital stoplights.  Until we move from digital to the next higher level of technology these tools will all lack the uniquely human concept of “maybe”.  Judgment, or the resolution of “maybe” is where humans out perform machines.  A human, unless he cheats, cannot beat the computer at chess because it is computation.  There are a finite number of moves.  Knowing how to write the algorithm for the computer does not make the programmer a chess player either.  It just means he is good at writing code.  The computer is making the “decisions”.  However, when randomness in introduced into a game such as dice with backgammon or cards with poker the computer doesn’t do as well.  The computer doesn’t know what will happen, only what might happen.  The infinite number of “maybes” in the real world makes the roll of a dice seem almost boring. 

The concept of maybe is the inscrutable link between the one and the zero.   It is the fork in the road.  The choices we make are important and the factors in the real world are often unpredictable and random.  This is the difference between risk assessment and threat management.  Risk assessment is the statistical product of probability and severity.  Risk can tell you what the probability of an event is and how bad it can be.  Pretty cut and dried.  Threat management, however, is the process we use to hopefully adjust (lower) those factors (probability and severity).  The environment that is aviation is not predictable, therefore, we cannot totally abdicate the decision making process to technology.   We must use machines and their instruction manuals for what they are, tools. They are not and should not be used as a substitute for decision making.

The 787 Dreamliner that I am about to leave behind is the most sophisticated airliner ever built, but it is still just an obedient, but fallible machine that will only do what it has or has not been programmed to do.  Flying the 787 or any other modern airliner is not playing chess with a fixed number of choices.   We are operating in real time in a capricious and unforgivable environment that can only be tamed by the magnificence of the human brain.  We have turned the corner.  There are no human pilots that can fly the modern airplane as accurately and efficiently as it can fly itself.   How will we teach tomorrows aviators to effectively use these incredible machines?   Is the future of aviation really just the deployment of more and better stoplights?  I believe we could have done better.