AIR SAFETY WEEK

July 1, 2002

Conditions were ripe for catastrophe unless dramatic improvements were made, warned a pilots' union safety newsletter prepared shortly before the fatal crash of an Emery Worldwide Airlines (EWA) DC-8 freighter.

"The crash happened right when it came out," recalled Capt. Tom Rachford, a member of the Air Line Pilots Association (ALPA) safety committee at Emery.

The newsletter, called the Crews-Aider, was prepared prior to the Feb. 16, 2000,crash of an Emery DC-8 freighter and was published with chilling coincidence right at the time of the crash.

The newsletter was written by Kevin Murray, a DC-8 flight engineer, who at the time was the ALPA central air safety chairman and accident investigator. In a telephone interview, Murray, who is no longer with Emery, said he was so concerned about unsafe conditions that "I went out of my way to slip it under the door of every corporate office."

Murray lived 30 miles away from the crash site and was there within an hour of Flight 17's fiery impact. He recalled being staggered by the amount of damage caused by 80,000 pounds of burning jet fuel. "I was horrified to think what would have happened if the aircraft crashed a few miles north into a crowded Sacramento neighborhood," he recalled.

Many of the concerns expressed in the document were revealed more fully in the National Transportation Safety Board's (NTSB) recent hearings into the circumstances of the crash and the maintenance practices that contributed to it (see ASW, May 27).

The pilots were not alone in their concern about the safety situation at the carrier. A few weeks after the crash, NTSB investigators interview Mark McConaughy, assistant principal operations inspector at the carrier for the Federal Aviation Administration (FAA). McConaughy's concerns reflected many of those expressed in the pilots' newsletter. A DC-8 rated pilot with 22 years in law enforcement. McConaughy brought a unique perspective to the compliance issue at Emery.

More than a year after the crash, Emery agreed to cease operations after Federal Aviation Administration (FAA) inspectors found more than 100 unresolved safety issues ranging from "mechanical irregularities" to operating unairworthy aircraft" (see ASW, May 20).

In the meantime, the investigation into the Flight 17 crash continues.

The NTSB may hold additional public hearings. At the very least, Emery officials will be deposed for further testimony as to conditions and practices at the time of the crash. The NTSB is probing deeply and relentlessly. The worst findings may yet to come.

Extracts of the newsletter below provide grim insights into what was

known, when it was known, and who knew it. The document shows how repeated warnings were ignored and a foreseeable and preventable fatal crash occurred. The carrier's "voluntary" shutdown amply validates the warnings beforehand.

One thought occurs: employee publications such as this may be useful reading for management. If the official system reports "all is well," yet remarks of the type expressed below are being made, that dichotomy should serve as stimulus for further inquiry. As the saying goes, precision comes from variety. From multiple inputs one can glean a more precise view of the true situation.

One other object lesson emerges, in the form of the adage, "If you think safety is expensive, try an accident."

Readers are invited to pay special attention to the sections on Flight Control Problems and ALPA Goals:

Unfortunately, due to the current safety culture at EWA, priorities dictate that this Safety Newsletter be more of an "EWA Crewmembers' Survivors Guide" than a document intended to provide each of you with pro-active flight safety material.

Management Meetings

Senior management individuals from Emery Worldwide held meetings with crewmembers last summer ... management explained how EWW's [Emery Worldwide] customer base is being shifted to a clientele who demands faster and more reliable on-time delivery of critical goods, for which they pay a premium price (Gold Priority Freight). This makes excellent business sense and we should laud the shift from "practicing delivery of cheap freight for little or no profit."

Considerable emphasis was placed on the important role crewmembers play as an integral link in the shipping chain. However, as the speeches progressed, it became clear that management's concept of how to best achieve reliability and success differs somewhat from ours. It seems management believes crewmember cooperation and dedication can replace adequate aircraft maintenance, fleet modernization and sound management ... We will not be duped, coerced, or intimidated into pushing either our aircraft or our physiological limits any further. Management has dealt us a losing hand and we are the ones who have everything to lose, not them!

Meanwhile, [parent company] CNF management makes minimal investment in EWA aircraft and our safety, as our aging DC-8 fleet shrinks, further deteriorates and becomes increasingly unreliable and more expensive to operate.

Crew Fatigue at EWA

"The often chaotic and disruptive EWA ... methods of crew and flight scheduling resulted in abnormally high and dangerous levels of fatigue ...

Therefore, for your future use, when being "flipped" in and out of night and day flying, the following statement, since it [is] essentially EWA management's own words, would be appropriate to refuse a flight:

"As per information submitted to the FAA by EWA management in EWA's 'Flight and Duty Time Petition for Exemption' dated 19 April 1999, this flight creates a situation that forces me to continuously adjust my sleep patterns in opposing circadian cycles. According to EWA management's own assertions made to the FAA, this situation does not enhance flight safety and is contrary to the intent of the FARs."

Cut out and carry it in your flight bag.

Aircraft Maintenance

Analysis indicates that when maintenance discrepancies are initially written up, they often are not investigated or repaired properly and repeat, over and over again. A review of EWA log books will reveal many malfunctions are frequently being signed off by one of the common EWA "no fix" methods, such as "could not duplicate," "cleaned cannon plug," "within limits," etc.

Unfortunately, just when our aging DC-8s need the most attention of their long and insufferable lives, EWA, due to cost saving measures instituted by CNF, has been forced to replace many highly experienced full time EWA aircraft mechanics with less experienced and poorly trained part time contract mechanics. The contract mechanics are often directed on how to troubleshoot and repair aircraft over the phone by EWA Maintenance Control. This often occurs without proper training, experience, knowledge, spare parts or proper equipment available.

The following is an example of an incident involving a "no fix" maintenance sign off. During landing, a crew had to make a frantic search for the always-elusive anti-skid switch (aircraft differences) when they discovered they had NO BRAKES on roll out. After the anti-skid was turned off, the crew was able to stop the aircraft using manual brakes.

The brakes had recently been written up several times for loss of braking. After landing, the captain informed Maintenance Control that he would not fly the aircraft out that night unless something was actually "fixed" as opposed to signed off as "could not duplicate, within limits, cleaned cannon plug, deferred coffee pot, performed human sacrifice, etc."

That night, the brakes were signed off with something to the effect, "Brakes passed brake decay check OK, no defects noted." The captain then informed Maintenance Control that, as promised, they would not fly the aircraft until "something was actually fixed." Maintenance Control then told the captain he was refusing a "green" aircraft because "the sign off was legal." The crew stood their ground and refused to fly. Unfortunately, the aircraft (and the horses on board) missed the sort. According to the EWA Fleet Reliability report, the brake control valves were then replaced.

Flight Control Problems

In another incident, a reported aileron trim problem was signed off as a "fuel imbalance" problem. The following flight experienced aileron control problems and made an emergency return. Inspection revealed the aileron bus cable was broken and cables were dangling from the right aileron. Repairs were made, only to have the next crew break the same cable on the flight control check.

It was later determined that the control cable to the right aileron power pack was broken, causing unsynchronized aileron movement and repeatedly breaking bus cables. Since all flight control repairs require flight control checks and an authorized inspector acceptance and sign off, it is hard to believe that adequate inspection or troubleshooting was accomplished between the three bus cable failures, the subsequent inspection acceptance sign offs, and the crew's attempts at flying the aircraft.

These types of incidents are occurring frequently at EWA and with an increasing potential for disaster.

EWA Aircraft Loading Incidents

EWA experienced two serious aircraft loading incidents ... On a flight from an outstation, the weight of special metal racks used for loading auto parts (14,000 lbs.!) was excluded from the cargo weight.

In another incident,after a captain noticed reduced aircraft performance, he requested that freight be re-weighed after landing for weight verification. Out of the three ULDs [universal loading devices] weighed ... one was at least 2,000 pounds heavier than reported and the other two were more than 2,000 pounds heavier between them. This resulted in maximum floor loading structural limits being exceeded. If averaged over 18 [cargo] positions, this could have equaled 24,000 pounds!

An investigation by EWA revealed a scale at the hub had been hit by a forklift and damaged but not reported. It is not known how long the scale had been damaged or how many other EWA and contract aircraft had floor-loading limits exceeded.

The key to preventing loading, C.G., and performance problems is to catch them while you can still safely do something about it! Chances are, if you suspect something is wrong or if it "just doesn't feel right," then something probably is wrong and you need to do something about it, before takeoff.

Unfortunately, loading problems usually only manifest themselves after it is too late. Being 9,000 feet down a 10,000-foot runway at max weight and full of jet juice is no time to be troubleshooting your loading, C.G., or airspeeds. The NTSB accident lab has dozens of banged up cockpit voice recorders which prove this.

Loading problems culminated when [an] FAA inspection team descended on Dayton last summer. The inspection uncovered serious safety problems with aircraft cargo doors and aircraft loading. It is clear the FAA means business and ... [an] FAA inspector participating in the inspection remarked, "EWA came very close to being shut down during this inspection." These remarks came close on the heels of the FAA's Jan. 18-28, 2000, Regional Aviation Safety Program (RASIP) inspection of the carrier. (See ASW, May 27)

ALPA Goals

Without adequate safety, there can be no Emery Worldwide Airlines.

ALPA is concerned that if EWA experiences a catastrophic accident (regardless of cause or fault), the resulting thorough and far-reaching NTSB, DOT and FAA accident investigation may uncover enough damaging evidence about EWA operations that EWA could possibly be "shut down." Historically, EWA ... has not received in-depth scrutiny and oversight from the FAA, such as which a passenger airline would receive.

- end of newsletter -

Transcript of NTSB interview with Mark McConaughy, FAA assistant principal operations inspector for EWA (extracts):

* On the overall situation

"As the assistant DO (director of operations) here has quipped on occasion, this was the largest inexpensive airline in the world."

"The maintenance side of the house tends to run the whole show and they don't tend to listen to the Ops [operations] side a whole lot."

"I'd say the company generally has a compliant attitude ... as I heard someone quip once, this isn't an evil empire but there might be a few evil people in the empire."

"When you find areas where things won't go away, you need to look at who's responsible for that area and what they are doing to correct it. And if they're not doing anything to correct it, are they condoning it? And if they are condoning it, well, then you've got a whole other kettle of fish."

* On the state of the manuals

"Sometimes they'll say things like, 'typically' or 'when able' or 'as required' and just vague statements. Required by who? By what?"

* On the minimum equipment list (MEL)

"It's going to get a lot tighter than it was ... [there's] a whole lot of room for, well, like my wife lovingly puts it, wiggle room."

* On maintenance and compliance

"The other day they had a DC-8 come in here from a heavy maintenance check, and they were going to do the anti-skid test on the landing gear and they did and they promptly blew all eight tires. And maintenance control told them to taxi it to the gate."

"Another thing that's a problem is ... with these repeat write ups in the maintenance [documents]. This is something I've gotten complaint after complaint on. I have suggested to my superiors the possibility that a criminal investigation needs to be opened into some of this ... as for as these sign offs. I mean, you need to write 'Once Upon a Time' across the page because it's a fairy tale."

"[Some] say we can't start a criminal investigation unless we have the actual paper. Well, as I told you, I was a police officer for 22 years. Maybe I'm coming at this from a little different angle ... I mean, this kind of stuff just jumps out at me ... it doesn't take a rocket scientist to figure out what's going on here. And what I'm saying is the paperwork. If you're not right there when the incident occurred to see what was really going on, when the paperwork was done, we don't have the ... tools ... to be able to pull somebody in the room, hey, Todd, you put this down here on the paper, now what's the deal?"

"And if ... you can prove someone made a false statement intentionally just for the purpose of moving an airplane ... to me that's criminal ... like on these load planning sheets, they get signed before ... the last pallet goes on the airplane. What it says, in that statement is, I certify that all the containers are properly loaded, blah, blah. But it goes on and says, I certify that all this has been done. Well, it's not done when he signs it. That's a false statement. You know, those kinds of things need to go away."

* On check rides

"Especially the new hire training, if someone's not ready to take a check ride, they don't even put them up for it ... And it's kind of bad from our [FAA] standpoint, because it skews the results so it looks like we don't have any failures or very few failures ... which kind of, you know, okay, are you Santa Claus?"

Source: NTSB, Docket No. SA-521, Exhibit No. 2-C

>> The unabridged version of this article may be viewed at http://www.aviationtoday.com/reports/foretold.htm <<