decision-making

The FAA Charter

The hard question

The Kapton History

1. Introducing more exhaustive inspections of 20 year old aircraft and
2. Advocating replacement of the metallized mylar insulation blankets at the next heavy maintenance. However I believe this was already a Boeing recommendation in late 97.

Many wiring experts are not convinced that it is possible to effectively inspect or test the hundreds of kilometres of wiring in modern aircraft. The aromatic polyimide insulation of Kapton wiring inevitably becomes brittle with age and develops invisible hairline cracks that make it prone to arcing or flash-over. These events can generate local temperatures of over 5000 deg K . [incorporate shot of flash-over arcing]. Because of this deterioration the wiring experts say that the ageing wiring problem can only be rectified by replacing it. Bearing in mind that the Swissair accident MD11 was less than half the age that the FAA is advocating inspections for, any outcome that implicates wiring will cause much passenger concern about more than just MD11 aircraft.

Quest: Many critics of the FAA say that only more crashes and passenger deaths will bring about affirmative air safety action by the FAA. Does the FAA have the courage and political support to be able to make any hard decisions that may be required?

Quest: Does the FAA have the option of rejecting any findings, or just not implementing any recommendations that might come out of the Canadian Investigator’s report?

Quest: If the Canadian TSB turns up evidence linking the SR 111 fire with Kapton wiring and the insulation blankets will the FAA be mandating further action, perhaps replacement of Kapton-type wiring with the safe Teflon-coated variant that is being used now in new-build aircraft?

Economics or Safety?

Third Man Duties

It would appear that, in light of the electrical causes of the Swissair accident, reliance upon an electronic Flight Engineer is much like putting your faith in a fire-engine that is itself on fire. It’s been further suggested that a third crew member may have made a big difference in the Swissair accident by being able to fight the fire and backup the pilots. Generally speaking incapacitation of any one pilot in a two-man crew leaves the lives of hundreds of passengers hanging by a single thread. Many Airline pilots feel that although a third man may not be required under normal operations, he becomes an essential key to success and survival when things start going wrong. Airlines and manufacturers seem to be economically committed to the two-man concept.

Quest: Does the FAA see this as an issue or is it just up to the designers and likely to stay the same because of the better economics of the two-man operation in a deregulated system?

Background: Getting away from the MD11 and speaking more generally about the two-man crew concept; many airline pilots have expressed a view on their Internet forums that a third man is essential simply because it may well be necessary for the captain, in an emergency, to send a technical flight-crew member down the back, whether it’s to investigate a cabin crew report or to subdue an unruly passenger. The concern is that sending the first officer [or the Captain going himself] is extremely undesirable because it detracts from the cockpit cross-checking that the whole concept of crew resource management is built upon. In addition the third man "systems supervisor" crew position is seen as a very valid training ground through which a third pilot can pursue an orderly progression to command. This system is already used by a number of very reputable long-haul airlines such as QANTAS and Cathay.

Simulator Training and

Emergency Drills

Smoke checklists

Quest: Is the FAA aware of this and what regulatory control does it have to rectify this situation?

Background: Airline checklists for smoke-in-the-cockpit are traditionally designed to step-by-step track down and then eliminate the cause by turning off the power to the failed system or avionics box. It’s been said that in the context of Kapton wiring setting fire to mylar insulation blankets and the fire being propagated between the metal skin and the cabin or cockpit lining, this might prove to be a fatal delay. Instead it has been proposed that crews should have an immediately selectable electrical configuration that will give them a very basic "get you home" ability. In this way, by responding immediately, they can avoid the hazards of an electrical fire and toxic smoke developing out of control because the power is not being cut.

Increased reliance upon electronics

Redundancy flaws

Electric Fundamentals

Computerisation

Pilot disempowerment

The unthinkable

The silly bootstrap

No boost-out =die

Everybody dies

Quest: Supposedly triple redundancy makes aircraft computer systems perhaps not fault-free but essentially flawless and the sort of computer defects that we’re all familiar with just cannot happen in the modern airliner’s hardware or software? Would that be the official view of the FAA?

Background: We have it on good authority from an MD11 pilot that their Company policy is against pulling circuit-breakers, that they have no ready inflight access to circuit-breaker panels, they anyways have no technical knowledge of [or reference manual about] individual circuit-breaker functions and that circuit-breakers may well therefore not even exist – as far as MD11 pilots are concerned. Many pilots find that this is quite disturbing because in any electrical system the CB is the protective device. You have to know whether it’s in or out and whether or not it might have failed to function and protect its circuit or equipment. Failure of a circuit-breaker to pop can cause a fire.

Quest: Against that background would it be correct to say that, because the designers have decreed that an electrical failure would always be out of the question, pilots have been intentionally designed out of the control loop? Do you see that as a desirable by-product of computerisation of cockpits?

The Bluecoat Project http://bluecoat.eurocontrol.fr/

The Bluecoat Project was initiated by Bill Bulfer an airline pilot who has written user guides for the flight management systems on board certain Boeing aircraft. The purpose of the project is to generate and maintain ongoing discussion between the designers of these computer systems and the pilots who use them, and has expanded to include regulatory authorities and noted researchers. The project maintains public information and reports on its WWW site, as well as private information for members. The public reports are a fine resource for those interested in current computer-related issues in aviation safety.

Background: Leading on from my last question. Ever since the Airbus crashed in the trees on that airshow low flyby, pilots have had doubts about their diminishing inputs into the controllability equations [show clip of A320 crash]. Each new generation of aircraft seems to seat the pilot further towards the back of the bus, even though there is now a large data-base of incidents where each pilot thought the other was flying and it was actually the autopilot computer demonstrating that it had a mind of its own.

Quest: Aircraft designers seem to be intentionally excluding pilots from active participation to the point that pilots either feel guilt, reluctance or uncertainty about intervening and imposing manual control. In some cases this has led to confusion about which pilot was flying. In other cases instinctive pilot input was fought by the autopilot which had an agenda of its own. What do the designers have in store for us next? Will the pilot ever be out of the loop entirely?

http://www.rvs.uni-bielefeld.de/~ladkin/Incidents/ = computerised flight incidents

Background: We know from the CVR that the Swissair copilot lost his entire flight instrument display just 30 seconds before the aircraft experienced what was probably a total electrical failure [show cockpit schematic and or photo]. It’s therefore probable that the Captain’s CRT display was also lost. The Swissair Chief Pilot Hildebrand said that a total electrical failure was just unthinkable.

Quest: Disregarding the further complications of a fire and toxic smoke, in the simpler case of a total electrical failure would the pilots in an MD11 have any fall-back conventional flight instruments? Would they be able to maintain control in instrument conditions?

Quest: Would it be correct to say that even if they had been able to maintain visual flight conditions the aircraft was not flyable anyway due to the hydraulic pumps being electrically controlled and there being no manual boost-out flight control system?

FAA Inertia or

Conflictions of Interest?

Indeterminable

Collusion as a form of Integrity

20^th birthday for Dereg

The Fire Engine’s on Fire

Prompt Action

Interim finger-crossing

Quest: Is the FAA’s reticence to act brought about by Government pressure or pressure from the airlines or is there a genuine belief that there is no problem?

Quest: What will it take in your view before the FAA will be convinced of the need for affirmative action?

Background: The nature of these airborne fuselage fire accidents is typically loss of electrics to Flight Data Recorders and ATC transponders, loss of comms and wreckage that discloses very little – because of the high-speed impact. TWA 800 was a little different because the wiring fault caused an inflight fuel explosion. The Silkair accident was similar in many respects to SR 111. Many experts are dismissing the oxygen cannister theory with respect to the Valujet 592 crash because that 25 y.o. DC9 had a recent history of electrical problems.

Quest: If the Canadian investigators cannot come to any firm conclusions about the Swissair accident be because of the fragmentation of the wreckage and recovery difficulties, would you still think that FAA action is warranted – or will the travelling public, or your Office, be content with another "undetermined" finding?

Quest: In your opinion are the Flight Safety organizations [such as the prestigious Flight Safety Foundation, IFALPA or the ATA] paying sufficient attention to the debate about faulty aircraft wiring and insulation? Before you answer that let me say that it’s been suggested to me that many of these organizations have a membership that is classically described as "constituent vested interests", that because of the damage that might be done to the airline industry and manufacturers, every effort is being made to sweep the whole problem under the rug. Their very pragmatic defense is that the incidence of accidents doesn’t warrant intervention [i.e. if it isn’t sufficiently bust don’t fix it].

Quest: Much of the criticism about the FAA’s watch-dog role has to do with the fact that it’s spread very thinly and that this has been brought about by US deregulation, competitive pressures and the aging of the US Fleet. It’s now the 20^th birthday for deregulation. Has it come of age or should the industry be de-deregulated?

Background: The MD11 was the first aircraft to dispense with the Flight Engineer because of the electronic monitoring and fault-handling response system that was designed to reduce the workload for the two pilots.

Quest: It would appear that, in light of the Swissair accident, reliance upon an electronic Flight Engineer is akin to putting your faith in a fire-engine that is itself on fire. It has been suggested that a third crew member may have made a big difference in the Swissair accident. Generally speaking incapacitation of either pilot in a two-man crew leaves the lives of hundreds of passengers hanging by a single thread. Airlines and manufacturers seem to be committed to the two-man concept. Do you see it as an issue that your office would take up?

Background build-up: Air crash investigations are very complex and may take a long time to come up with findings. TWA 800 is a typical case in point. Everyone in the industry regards any interim fixes based on early indications, hunches or reasonable presumptions to be premature. In fact there is a very dismissive stance that essentially says: "You must wait for the investigator’s report". It is understandable that investigators want to base their findings on facts and realize full well that their conclusions will have a very big impact upon litigation, culpability findings and settlement amounts. However taking the Swissair accident as an example there has already been much criticism about the following aspects: [scroll down screen listing]

Reliable Power sources for the cockpit voice recorder, comms and ATC transponder [in the event of electrical failure]

Inadequacy of the two-piece smoke-masks and goggle-set

Inadequate cockpit lighting

Non-utilization of the EVAS plastic bag system for being able to view flight instruments in a smoke-filled cockpit.

Hand-held cockpit fire extinguishers

Inappropriateness of smoke checklists [both in the MD11 and most other airliners]

The critical time factor in airborne fire situations [versus immediate landing with no fuel-dumping]

The function of the MD11’s Smoke/Elec switch in a Kapton fire scenario

Most importantly, the total vulnerability of all-electric airliners to total electric failures.

Quest: In your opinion, does a tardy finding have an undesirable effect upon flight safety in the interim?

Quest: It’s been claimed that the checklist procedure that’s been traditionally used for smoke-in-the-cockpit is very inappropriate in a Kapton wired aircraft. Why is this and what procedure would be better?

Wiring Expert or

Nature of Kapton

Quest: What is the scenario for concern here?

Answer: There’s about 260 to 300 kms of this wiring in a modern airliner, most of it energy carrying. The amount of wire that goes into an airliner has increased exponentially with the seat-back entertainment units, floor lighting and computerized flight decks. It would simply be cheaper to trash the aircraft and buy a new one. You cannot effectively inspect it because the cracks in the insulation are so fine – and you can’t access a large percentage of it because it runs through conduits or bulkheads or inaccessible areas. Even borescoping won’t work. Moving it can cause the very damage that you’re trying to detect. It’s unfortunately part of the structure and cannot be removed like an avionics box for bench-testing.

Quest: Both Boeing and the FAA have strongly suggested that airline operators remove the mylar insulation blankets and replace them with a safe non-flammable alternative. Won’t that break the chain of events that might lead to a cabin or flight-deck fire and toxic smoke?

Likely SR 111 Cause

Checklist failings

Solutions

Modification

Answer: Yes, there’s the rub. It’s a design consideration that just wasn’t allowed for.

Quest: Is there another solution?

Answer: If you must kill the electrical system in order to contain and perhaps extinguish the fire you must have another system with which to replace it. I call it the Flight Essential bus. It’s a "get you home" minimally basic AC & DC bus that is immediately selectable when a smoke-in-the-cockpit situation arises. The act of turning it on secures the other normal Kapton-wired busses. Its main characteristic is that it is a virgin bus – it’s normally unpowered. It can be run from any generator, its wiring is a stand-alone TKT loom that runs clear of any Kapton harnesses and avoids any commonality. It can power only the basic standby flight instruments and engine instrumentation, fuel and hyd pumps, lights, comms and avionics that are required for a survival diversion. It’s a "get you home" configuration that eliminates the sort of inflammatory, crazily optimistic trouble-shooting checklist that didn’t work for SR 111. The passengers won’t get any hot food or entertainment but they’ll get a voucher at their destination. I emphasize that once you take the power off the faulty Kapton looms the fires are not self-sustaining and will probably fizzle out or be easily extinguished. Leave the power on and they’ll spread, generate toxic smoke and damage other systems.

Quest: So you’re saying that aircraft with Kapton wiring must either be trashed or wired for this safety bus that you call a Flight Essential bus? Is this a big modification? Will the airlines wear it?

Answer: It wouldn’t be difficult to incorporate this during heavy maintenance when the aircraft is stripped and the insulation blankets are coming out anyway. It might add a week to its turnaround servicing. Each type would need a different design but the mod kits could be "off the shelf" components [switches, relays, junction boxes etc]. The design and incorporation costs would come out of litigation between the aircraft manufacturers, FAA, airlines and wire-makers. Each entity must bear some responsibility for the current situation. It only remains for the courts to apportion blame and the insurance companies to force the issue.

Quest: So you think that this will likely be the outcome recommendation of the crash investigator’s findings for SR 111?

Answer: No, because it’s likely that the Swissair report will be inconclusive. It’s a difficult investigation because of the loss of DFDR data and the disintegration and the fact that they’ll only ever recover about 50% of the debris. No-one will be surprised when it comes in as an "undetermined" cause or is generically classified as a fire of unknown origin suspected to be due to an electrical fault. That way it’s easier for the insurance companies and the courts and the airlines, manufacturers and the FAA. It’s easier for all in the industry if it’s a "once-off" accident. It will be an actuarial blip rather than an otherwise defining event, were blame to be laid at the manufacturer’s door. Of course Swissair will, in the short term, quietly sell off all their MD11’s to a third world operator or cargo-carrier at a bargain price, buy some Airbus A340’s and put it all behind them. Everything will quieten down until the next one.

Quest: You’re hinting that there have been others?

1996 Resignee from Head of NTSB after

Gore Commission

FAA vs NTSB

FAA sensitivities

Design Concepts

Fly by wire flaws

Dollar cost of Safety

Kapton? What’s that?

The third man

Public Concerns

Author, Author!

A Report’s Value?

Litigation

Collusion or

Consultation.

Leadership

Quest: Has the Gore Commission achieved any real progress in making US or global airline flying safer for passengers?

Quest: Is the FAA guilty of complacency and bureaucratic lethargy or is it just a fact, that post-deregulation, their functionaries are too thinly spread?

Quest: Would it be correct to say that generally the NTSB comes up with sensible recommendations but that the FAA filter them through economic realities and the residual outcomes are therefore often unrecognizable and ineffectual?

Quest: How might the revelations of the Swissair accident affect FAA attitudes and bring about needed change?

Backgrounder: There’s a school of thought that says that the ultimate responsibility for the Swissair crash lies with the manufacturers. They built an airframe that eliminated the need for more than two pilots due to its heavy reliance upon computerized electronics and that was therefore very economical to operate. Unfortunately for that to be a viable concept they had to decree that total electrical failure was an impossibility. We now know that the impossible happened.

Quest: It would seem that triple redundancy and fault bypass are in reality myths when it comes down to basic electrical component failure. Ms Schiavo, what’s to say that any of the fly-by-wire glass cockpit aircraft in use today could not be similarly crippled and crash due to the built-in vulnerability of their computerized electronics and electro-hydraulic flight-control systems?

Quest: In an ideal world, where passenger safety was the indisputable, uncontested bottom line, would all the Kapton wiring and flammable sound insulation come out as a result of an FAA directive?

Quest: In the real world, where there is a finite dollar cost limit on safety measures, what is more likely to happen in the aftermath of SR 111?

Quest: Were you aware of Kapton being an issue when you were in office?

Quest: Was the elimination of the third man in the cockpit ever an issue for the FAA or did they simply accept that the Human Factors "pilot error" cause factors were best dealt with by making much of the operation robotic?

Quest: Do you think that a large enough cross-section of the traveling public will ever become concerned enough about safety that they will become a significant factor in the safety equation – or will the dollar cost of a seat continue to be their only consideration?

Quest: If there was to be a book about the Swissair crash, Kapton wiring, flammable insulation, glass cockpits, computerised systems, two man long-haul operations, inappropriate smoke checklists and poorly sealing smoke-masks and goggles - all as an outcome of deregulation, would you be the person to write it?

Quest: The ramifications of the accident report for SR 111 upon families’ litigation against airlines, manufacturers or even the FAA itself – how much does this influence the content, the timing and the conclusions of investigator’s reports?

Quest: The La Motta family has filed a lawsuit claiming $125M damages, another Greek family is believed to be suing for over a $1billion. Under the new laws removing the limits on passenger claims theoretically the families of all 229 victims could tie up the courts forever. Depending upon the venues, a finding in favor of one will be logically a finding for all. The total cost may push hull and passenger liability premiums beyond the reach of airlines and manufacturers. Ticket prices would rise astronomically. The next crash tied to the same cause [say, for argument, Kapton wiring] would have a pre-ordained litigation outcome. Was this ever discussed by the FAA? Will it prove to have been cheaper [in the long run ] to have run a safer operation from the beginning?

Quest: Could one presuppose that the Canadian TSB will have consultations with the FAA before the preliminary findings and, eventually, the final report is released? Would they normally seek such a consensus?

Quest: In your view is the Jane Garvey/Tom McSweeney team a good choice for the way ahead at the FAA?