It's Thursday, August 07, 2003.

Hello, I'm Eric Cooper with an IPNN Update.

{EMERY CRASH}

We reported yesterday on the NTSB's findings in the Feb. 2000 crash of an Emery

Airlines DC-8. The NTSB cited a disconnected right elevator control tab as the

likely cause of the crash outside of Sacramento Mather Airport. Former NTSB

Investigator Greg Feith was the lead investigator of that investigation before

he left the agency after 20 years in April 2000. Feith is now an International

Aviation Safety Consultant and recently attended the NTSB hearings on that crash

on behalf of the IPA. Feith says the investigation uncovered life saving

information that you can use in the cockpit. But first, he tells us how NTSB

investigators missed the boat, focusing only on maintenance and operations and

not other key issues that had developed such as a lack of FAA oversight.

{FEITH:}

The whole presentation focused on the maintenance aspect. There were a number of

areas--one key area was lack of FAA oversight of Emery as an operation. That was

never addressed or brought into the board's final determination of probable cause,

or even as a contributing factor. Which, when I was involved in the investigation,

I believed was a contributing factor in this accident, given the fact that the FAA

held the certificate for the carrier out of the San Jose, Flight Standards District

office, which was being managed by three inspectors who had very limited large air

carrier experience. Emery is located in Dayton, Ohio. There was no way for them

to perform adequate oversight. That, I believe, was a big contributing factor in

Emery's lack of oversight of a third party contract maintenance organization, which

was probable or likely the culprit in the improper maintenance.

{ERIC:}

So at this point, what can you do with this information? Do you just have to accept

the final ruling?

{FEITH:}

As a person on the outside, there is no formal recourse I have as an investigator,

former investigator, or aviation consultant. The only thing I can do is write

information based on the facts, conditions and circumstances (as I'm doing for the

IPA) and highlight those issue areas not addressed by the NTSB. The biggest concern

I have is that root cause investigation wasn't performed here. They stopped at

obvious cause. The real enhancement to aviation safety hasn't been discussed in a

proper forum, which in this case would have been the NTSB's report. The other forum

to enhance aviation safety is the safety board's recommendations to the appropriate

organizations (which in this case is the FAA) to take a look at other issues which

would have led or contributed to this particular accident; in this case, it's FAA

oversight. Emery no longer exists, but that shouldn't stop the investigative process

and the issues that have developed in the investigation from taking a global

perspective to benefit the industry as a whole, rather than looking to try to correct

a deficiency in a single organization.

{ERIC:}

Feith says the investigation also revealed that had the crew been trained to use the

elevator position indicator or EPI gauge, the crew may have noticed the problem during

their elevator position check.

{FEITH:}

This crew--not that they were faulted by the NTSB and not that I hold them accountable

either--they weren't trained to use this particular indicator in a manner that had they

really looked at the indicator during the course of checking their elevator position

check, they may have noticed that when they pushed forward on the control yoke that

they didn't get forward movement of the elevators. The key to this accident was that

the improper maintenance resulted in the control tab fitting becoming disconnected from

the pushrod. That tab ended up being jammed in a full trailing edge down deflection,

which aerodynamics--with the tab trailing edge down will force the elevator to a nose

up position. That's what led to an uncontrolled pitch up at rotation of the airplane

and a condition that the flight crew was unable to correct using conventional flight

control. So it's very key that when you do your flight control check that you pay

particular attention not only to the fact that it feels OK, because in a lot of cases,

you're only pushing and pulling against cable tension. So, you may not actually know

if the elevator or other flight controls are actually moving. All you're feeling is

the cable tension to the spring in the cable. Therefore it's crucial that you validate

it against any flight control indicator as well to see that movement is actually occurring.

(ERIC:}

Former lead NTSB Investigator Greg Feith is now an International Aviation Safety

Consultant, working with the IPA on these and other safety issues.