'Time to Stop the Killings' in Air Cargo Industry, Father of Dead Emery Pilot Vows

"They were dead the moment they started the engines," concluded Donald Land, father of George Land, who was the first officer on Emery Worldwide Airlines (EWA) Flight 17.

The DC-8 freighter crashed into an automobile auction lot during a desperate Feb. 16, 2000, attempt to return to Mather Field in Rancho Cordova, Calif., from which the plane had taken off just two minutes before (see photo).

Unable to lower the nose, the crew thought they had a center-of-gravity (CG) problem with the airplane's 65,000-lb. cargo load. The cockpit voice recorder (CVR) has First Officer Land telling Capt. Kevin Stables and Flight Engineer Richard Hicks, "We're gonna have to land fast." The crew's last transmission to air traffic control was "Emery 17, extreme CG problem." The pilots had no way of knowing they were dealing in reality with a flight control problem that felt like a CG problem. The airplane, as it turned out, was missing the bolt connecting the right elevator pushrod to the elevator tab control arm (see illustration). When the elevator tab is moved up or down, the aerodynamic force moves the entire elevator. Since the elevators are aerodynamically balanced to move to the nose-up position, there is insufficient nose-down force from a correctly connected elevator tab on the opposite side to overcome a disconnected right tab.

The connecting bolt is a life-or-death part. During two days of recent fact-finding hearings by the National Transportation Safety Board (NTSB), its first public deliberations into a cargo jet crash, it was revealed that the bolt was never found at the accident site (see ASW, May 20, p. 8). It was apparent that the bolt most likely had been installed backward. Absent a restraining cotter pin, the bolt could slip out. It was a maintenance error that killed. A ratcheting sound was picked up on the CVR, possibly indicating that elevator movement was restricted. According to Frank Hildrup, NTSB investigator-in-charge, "The elevators never traveled below neutral."

The flightcrew did not know. As a result of a history of jammed elevators (including a 1972 case involving an axe handle wedged in the elevator hinge line), DC-8 crews were required to conduct a preflight check of elevator movement, and another check while passing through 80 knots on takeoff (for a telltale "dip" in nose movement indicating proper elevator function).

These checks were to assure that the elevator wasn't jammed. A missing bolt, thereby allowing maximum free play, could go undetected during the preflight walkaround. A few days before the crash, the left and right elevator dampers were found swapped; disassembly and repair of this maintenance error involved removal of the elevators, tabs and connecting assemblies. It is during this process that Emery technicians most likely incorrectly replaced the connecting bolt. When inserted correctly, the bolt cannot slip out. Indeed, it will be kept in place by an aerodynamic fairing. However, a reversed bolt can slip out of position, as the fairing is not close enough to hold it in place.

After two days of hearings, big and sobering issues emerged. They include matters of maintenance compliance, Federal Aviation Administration (FAA) oversight of Emery's operation, the qualifications of Emery personnel in key positions involving reliability, quality control and quality assurance (in Emery's case, these three critical positions were all held by the same person, another issue of concern). Last, but not least important, the inadequacy of instructions to perform maintenance on a key component like the horizontal stabilizer and elevators.

According to NTSB Member John Goglia, who chaired the public hearings, "The job card had no explanation" for work on the elevators. "We heard repeatedly it's all OJT, on-the-job training," Goglia said. Emery's work cards, bereft of detailed instructions on how to install the bolt to the connecting rod assembly, also lacked specific post-work inspection requirements. At NTSB urging, 29 other airplanes were examined, with horrifying results. Bolts were found installed backwards on 11 planes, in five of which both the left and right-side bolts were reversed, and on one plane the pushrod itself was installed backward. An FAA inspection of Emery a month before the crash provided chilling warning signs that the carrier's maintenance program was out of control (see box RASIP).

Goglia has vowed to "pursue every lead toward an ultimate solution." Emery's checkered maintenance history is under scrutiny (see box X).

The carrier agreed under FAA pressure to suspend operations (see ASW, Aug. 20, 2001, p. 8). While not flying, the carrier still holds an operating certificate. The FAA recently extended the certificate, originally slated to expire May 15, 2002, to Dec. 4, 2002. The company currently is negotiating to terminate essentially all of its aircraft leases, and an FAA official explained that the extension was allowed to facilitate this process. "We do not anticipate any more extensions," he said.

While the case at hand involves a troubled cargo carrier, it has implications for all cargo carriers, and for passenger carrying airlines as well. Families of the dead flight crew are seeking congressional hearings. They want standards tightened for the air cargo industry. To this end, Donald Land, a professional engineer who followed closely the two days of NTSB technical hearings, hand delivered to every chairman and ranking member of the aviation committees and subcommittees in the both houses of the U.S. Congress a package laying out the key issues as he sees them (see box LAND).

Appalled at the sloppy practices and lax oversight revealed by the witnesses, Land wrote, "Had my wife Marion and I known prior to the crash and death of our son what we now know, we would have asked George to leave Emery. Not having this opportunity, we urgently request your efforts towards establishing public congressional hearings into the regulation, function and moral responsibilities inherent in successful participants in the air cargo industry." "The FAA is awarding airworthiness certificates to unqualified people [and] companies. It is time to stop the killings," Land declared.

>> Land, e-mail donwland@aol.com; Goglia, e-mail gogliaj@ntsb.gov <<

LAND 'The FAA Certification Process Must be Restructured' Donald Land letter to the U.S. Congress (extracts)

Issue: We write with concern to the danger of us all from the air cargo flights now operating. Emery Flight 17 was operating out of Rancho Cordova, Calif., airport, which at that time had no operating control tower, no airport traffic area, no terminal control area, and most importantly, no active, qualified aircraft fire fighting equipment or personnel. The local fire department arrived 20+ minutes after the crash, which by then was fully developed. Their decision was to let it burn itself out (this decision may have later hindered the crash investigation. Point of concern: On-site fire fighting equipment manned 24/7 [24 hrs./day, 7 days a week] needs to be required for the air cargo industry.

Issue: This kind of operation may be typical of smaller, less financially qualified air cargo carriers. The base for Emery prior to moving to Rancho Cordova was nearby Sacramento, Calif., International Airport, where rescue, fire fighting and emergency equipment with trained personnel are available [24/7]. The safety of crew members and that of the public would be enhanced if large-fleet cargo carriers such as EWA (parent company CNF, a $5.2 billion a year company) were required to operate at competently-equipped airports. Point of concern: Huge cargo planes need to be required to operate from fully equipped airports.

Issue: The NTSB investigators and the hearing chairman are to be commended for their expertise and [their] determination to discover the probable cause of my son's death . The hearing was recessed at the end of two days by the investigator Chairman John Goglia due to the witnesses' inability to provide sufficiently qualified and competent information. It became apparent during questioning of Emery's two witnesses . that persons who were not qualified had been placed in extremely responsible positions. Their obvious lack of knowledge, technical and management skills should automatically have disqualified them from being considered for the position, much less occupying [them] for years. Point of concern: higher qualifications must be set for those in life-safety positions.

Issue: Even as a practicing professional mechanical design consultant with a masters degree in Mechanical engineering in the building services area for major corporations, I found the technical data presentations and question sessions tedious . and in many cases requiring expert, unbiased clarification.

Point of concern: A congressional hearing for improving the life safety standards for our out of control, barely regulable [sic] U.S. air cargo industry is called for to protect the general population . The FAA certification process must be restructured to allow for the elimination of candidate corporations, partnerships, or individual businesses whose previous work history contains attempts to subvert existing standards, and whose moral responsibilities to the industry, employees and [the] general public is visibly lacking! Source: Donald Land, PE, May 14, 2002

Illustration Pushrod, connecting bolt and crank assembly that translates pilot control column inputs into elevator tab movement, which in turn causes the elevator to move in the desired direction. A "control anomaly" was noticed about eight minutes before landing during the flight immediately preceding the accident flight. The elevator moved trailing edge up (airplane nose up) when the pilot pushed the airplane over to resume the descent after a brief pause. Source: NTSB, Emery 17 Airplane Performance Study, Docket No. SA-521, Exhibit No.13A Photo of crash site Emery Flight 17 crash site.

Capt. Tom Rachford, member of the Emery pilots group, observed, "Had Emery Flight 17 departed on time, there reportedly were 250-300 people in the auto auction yard where the aircraft disintegrated in a fiery ball, fueled by over 70,000 lbs. of fuel." The NTSB hearing, he added, went a long way to substantiate "why studies have shown the fatal or hull loss accident rate for cargo aircraft to be four to five times that of the passenger industry."

Another Incident of Note April 26, 2001, Nashville, Tenn. DC-8-71F, Emery Worldwide Airlines, Inc. "According to the pilot, the freighter flight was normal in all aspects until the landing gear [was] extended for landing. The left main landing gear (LMLG) indicated 'unsafe,' and all attempts . failed to extend it. An emergency LMLG retracted landing was performed with minimal damage . Postcrash investigation revealed that company maintenance installed a one-way check valve in the LMLG extend hydraulic lines instead of a restricted flow valve. The wrongly installed valve had no factory specification part number attached, and the tag reportedly removed from it at installation possessed the wrong factory specification number . The valve installation mechanic and the company inspector both stated that the finished job was leak and 'ops' tested.

"The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows: "The failure of company maintenance personnel to install the correct hydraulic landing gear extension component, and the failure of company maintenance inspection personnel to comply with proper post maintenance test procedures, resulting in . the subsequent LMLG up landing. A factor in the accident was the improper identification tag marking on the replacement component, and no marking on the component itself."

Source: NTSB Case No. MIA01IA129

RASIP 'Limited and Sparse' Maintenance Training Report of Regional Aviation Safety Inspection Program (RASIP) of Emery Worldwide Airlines, inspected Jan. 18-28, 2000 (extracts)

Findings

Unable to locate procedures n the Maintenance Policy and Procedures Manual for scheduling maintenance between heavy checks.

The Inspection Procedures Manual . wording . appears to allow maintenance personnel . to "N/A" inspection items with no prior approval or authorization from Quality Control.

The 121 Conformity Checklist used by Emery has no provisions for sign-offs other than the one at the end of the checklist. This does not allow accountability for any of the personnel accomplishing the various tasks contained on the list.

The Maintenance Policy and Procedures Manual appears to be mostly policy, very little procedure.

Comments The basic overview . by the inspection team is that training at Emery appears to be very limited and sparse . there does not appear to be any formal classroom type training except for Basic indoc [indoctrination] and approximately five other systems courses. The bulk of the training appears to center around previous employer training, the maintenance letter distribution program and any on the job type training that is documented. This lack of structured training became evident when the log write-ups and log pages were reviewed. There are numerous repeat write-ups which seem to reoccur after they have been signed off as corrected. The ability to troubleshoot the write-ups and come up with a successful fix on the first occurrence of a problem is rare. Source: FAA, Flight Standards Div., Great Lakes Region, RASIP report of Feb. 1, 2000