Category Archives: Accident Prevention

Procedures to prevent aviation airline mishaps.

MH 370 and UPS 6 near Dubai, 2010: Same Mishap Repeated?

100_3975When UPS 6 crashed near Dubai in the evening of September 3, 2010,  (…/2010-Interim%20R.) ( the crew had been in a battle for their lives for about 20 minutes. Upon first realizing cargo area temperatures were rising and that smoke and fumes were entering the cockpit, the crew made a turn towards a divert field, began a descent to landing, put on their oxygen masks and attempted to quell the fire.  The crew was overcome by the smoke and heat, despite their best efforts and the plane crashed while the crew was attempting an approach to land. Communications with air traffic control were immediately effected by both the use of oxygen masks and the growing smoke and heat in the cockpit. Navigation and aviation back to the divert field were effected by the fire destroying electronic navigation components and flight control components. In essence, the crew was overcome and the plane was overcome by the fire in the cargo compartment. In the end, the plane crashed into the desert sand in the descent the crew had initiated.  The investigation revealed that a fire most likely caused by lithium batteries

About twenty minutes after MH 370 began its flight, the aviation, navigation and communication changed dramatically. Was it due to a fire caused by lithium batteries carried in the cargo hold? Was it due to an explosion or fire related to material brought aboard by terrorists? Though this may be unknown at this point of the investigation, the flight path of the flight, the changes in navigation and changes in communication both verbal and those by automated reporting systems seem to indicate high levels of similarities between these two mishaps.

Does failure of regulatory authorities to comprehend that a cargo aircraft mishap caused by a fire from hazardous cargo could one day lead to the loss of a passenger aircraft hauling the same cargo reveal a fallacy in regulatory logic?  Do regulators reason that until a loss occurs, there is no reason to restrict commerce? But what if the loss of an aircraft due to lithium battery caused fire is a cargo aircraft? Do regulators reason that only cargo aircraft should be restricted from carrying lithium batteries? Should regulators reason that passenger aircraft should also be restricted from carrying lithium batteries?

Are we looking at what is called regulatory two levels of safety, one for cargo flights and one for passenger flights? Is the great fallacy in regulation that passenger flights also haul massive amounts of air freight, and the attempt to create two levels of safety to carve out an exemption for cargo flights in reality results in no level of safety when it comes to carrying hazardous cargo?

Are MH 370 and UPS 6 essentially the same mishap recurring all over again? Was in fact MH 370 a preventable mishap?

Captain Paul Miller in cockpit

UPS 1354, Birmingham Runway 18, August 14, 2013: Is FAA Policy vs Procedures Inconsistency Causing A Severe Safety Risk in Commercial Aviation? “Is the Tail Wagging the Dog ?”


In the last 40 years the US FAA has spent hundreds of billions of taxpayer dollars engineering safety into the nation’s commercial aviation infrastructure. This policy at the FAA has led to great success in achieving an astonishing low commercial aviation mishap rate in the US.  Moreover it has provided an example for Western Europe, Pacrim Asia and the rest of the world to match in building and outfitting highly standardized, major international commercial all-weather airports. Birmingham International Airport in Birmingham, Alabama is one of these airports.

But on the early morning hours of August 14, 2013 at Birmingham International, all of the latest and greatest in hundreds of billions of dollars of technology and engineering was put aside, so that an airfield electrician could change out a few dozen fifteen dollar light bulbs.  When UPS 1354 arrived at Birmingham in the cloudy, dark soup of early morning, the pilots’ heads were swimming in night time induced fatigue.  All that they hoped for was that the local FAA area Air Traffic Control approach controller would vector them onto the final approach course for the amazingly technical all weather runway. They hoped to couple up their fantastically sophisticated jet’s autoflight system to the airfield’s highly accurate electronic glide slope and precision path localizer. They planned to comply with FAA all weather approach procedures and bring their huge  jumbo jet down to the runway along an approach path well clear of trees, mountains and towers. They hoped to land on a well light, precision marked, sharply cut grooved and crowned runway.

But instead, someone at Birmingham, we don’t know who yet, made a decision to invoke a local procedure, a procedure that did not support the most sophisticated FAA instrument approach procedures nor the FAA policy of providing the latest and greatest engineering and technology to commercial flight crew landing huge jumbo jets at Birmingham Airport.

Someone at Birmingham took it upon themselves to take all of this engineering and technology out of service, to shut down all of these highly sophisticated procedures and do so for a considerable amount of time. They did so knowing full well that UPS 1354 would be scheduled to arrive at just this time and in fact was arriving in the area as scheduled. They also knew that the weather at the field held low lying clouds. Additionally, they knew full well that the runway that they would offer UPS 1354 on which to land held only antiquated technology dating back to the dawn of commercial aviation, literally into the 1930’s. Finally, they knew that the descent path for the approach to that runway was directly over hilly and irregular terrain north of the airport, an area unsuited for the installation of any ATC approach modern technology and engineering.

Who was it locally at Birmingham that approved such a procedure that clearly was inconsistent with official FAA all weather commercial operations policy and procedure, and especially so for a cloudy runway at night in the mountains, all while a fully instrumented and safely engineered runway was available and would be consistent  with current FAA safety policy? Where is that procedure written down?

Additionally, how did this conflict between local procedure and FAA policy and procedure for all weather commercial operations come to exist at Birmingham? For that matter how did it come to exist at any international FAA airport? Why didn’t someone either in Birmingham FAA Air Traffic Control Office or the Washington FAA Headquarters Air Traffic Control Directorate or the Commercial Air Safety Directorate question this apparent policy versus procedures inconsistency? Was this an FAA managerial snafu or in fact is this a widespread FAA organizational inconsistency and thus a severe commercial aviation safety hazard?

Was not a very similar commercial aviation safety policy versus all weather procedures conflict involved in the Asiana crash in San Francisco just a few months earlier? In that case, instead of an electrician changing out light bulbs, the airfield’s multi billion dollar engineering and technology instrument approach system was set aside so that bull dozers could move dirt around to build a taxiway.

How is it that such inconsistencies exist at FAA? Is this a case of the tail wagging the dog? How is it that the maintenance of light bulbs and airfield construction take precedence over the safe operation of commercial flight? Who at the Washington FAA Headquarters Safety Policy Directorate and the Air Traffic Control Directorate is supposed to be ensuring that local airfield FAA managers are employing procedures that are supportive and consistent with the FAA safety policy? Why are US taxpayers spending hundreds of billions of dollars on commercial airfield infrastructure and operational safety only to have that safety compromised by maintenance and construction and local procedures?

Are we really expecting our international jumbo jet flight crew members to make up for this FAA policy vs procedures failure, at 4am in the morning, in the dark, in the clouds and in the mountains by resorting to 1930’s technology and procedures? Really?

How many more similar commercial airline crashes must occur before the FAA is able to determine that they have policy vs procedures safety inconsistency?

In my opinion, the US National Transportation Safety Board needs to investigate this safety inconsistency, this very severe FAA commercial aviation safety hazard, this severe risk to the US taxpaying public and make a recommendation for corrective action to the FAA before the next similar commercial aviation mishap occurs. In my opinion, they should do so quickly.




The Injury of Pilot Fatigue: Is Fatigue a Stress or a Strain ?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

Fatigue: Is It a Stress or a Strain, that is, an injury? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, a stress for which a good night’s sleep is the common remedy?

That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious and injurious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, damage to the body and mind? If fatigue is an injury to the body and mind, an overstress resulting in a strain, does the body and mind need time to heal back to health from this injury? Is the time of a “good night’s sleep enough time to heal from this injury?

Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep? Is the body and mind being damaged beyond the ability to recover in a day or a weeken

Human beings who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule can be over tired, falling asleep at the switch as the saying goes from fatigue. Yet they are there trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that has not been discussed is does recovery from fatigue take much more time than just one good night’s sleep. If so, why? Is a person somehow injured in my mind and body to the extent that they need to heal? If so, where was the injury, how can a person feel it and how can they measure it? How much time is needed for full physiological recovery of body and mind? Is sacrificing the health of body and mind for a job well understood? If so, are people being separately compensated for both the work done and the sacrificing of the health of body and mind?

There are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.

But there are often more questions about fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired wherever they sit down? Why do older folks struggle often with sleep?  Why do flight crew often feel so tired on weekends that they just want to relax and do nothing stressful, just recover and hope for restful sleep? How and why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?

So, in my curiosity I harkened back to my university days studying metallurgy. We studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.

As students we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is bourne by the material and it springs back into its original being.

In physiology terms, we might say that one all-nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies of human being subjects.

Now back to the metal samples. As we continued to add stress to the metal samples, somewhere down the line we got strain that is no longer elastic. The sample no longer bounces back. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plasticaly, that is, it will no longer spring back into it’s original size, shape and strength. It is deformed into a new shape. It is still one piece, but deformed. It will not now nor ever go back into its original shape. Moreover, if the stress is continually applied, not only does the strain result in a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again does the human body and mind react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep. But what happens to the human body and mind when the stress of sleeplessness is applied continuously and applied over the ability to take this stress undamaged?

Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient in time and regenerative power to cause or allow a recovery? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury? Is fatigue more than a stress? Can fatigue cause a strain or injury?

The answers to all of these questions is neither clear nor well known. But these questions need to be asked. Is fatigue more of a strain at some point than just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient time in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?

Is fatigue more of a strain than a stress?




Titan B733, Chambery France, Loss of Control, Human Factors,14 April 2012: Is Flawed Aerodynamics in UK AAIB Investigation Report?


Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

I believe that there is a basic flaw in the mishap investigation report by the UK AAIB. The flaw is a lack of inclusion of important take off aerodynamics procedures in the investigation, due to referencing solely the events surrounding EFB procedure errors. [Did the board seek the Safety Purpose or the Legal Purpose? See the end of the article for more on that argument.]

Here is the basic flaw in the investigation. The tail scrape occurred because the crew raised the deck angle to take off climb attitude instead of raising the deck angle to lift off angle. This is a mishap due to a misunderstanding of aerodynamics, rather than the entry error in the weight and balance procedure. If pilots reading this article remember this very important point, they will be able to prevent tail scrapes or tail strikes even in the circumstances where there has been an underweight error made in the weight and balance procedure.  Understanding the aerodynamics going on during the take off procedure will allow a flight crew member to easily overcome these errors and not damage the aircraft. Remember any damage on take off could lead to a compromise of the pressure vessel, which could lead to pressurization failures and even structural failure. So in my opinion it is very important that the UK AAIB considers reopening the investigation and delve into take off aerodynamics. In lieu of that happening, I have written this article to cover the important aerodynamics involved.

Take off really requires several steps. The first is the lift off rotation and the second is the rotation to take off climb. With our very powerful engines today, these two steps most often blend into one smooth step since the aircraft accelerates so quickly, even at heavier weights.

But in fact there are two separate steps and if flight crew member understands this, they will be able to both recognize that the lift off attitude, that is the deck angle read on the EADI, will be the same at any weight. By setting this deck angle and waiting for the wing to develop lift equal to weight at the correct speed for the weight, the crew will never drag the tail on the concrete. It is critical to recall that the wing lift is what raises the aircraft off of the runway. The thrust from the jet engines seems like the exhaust from a rocket, but if crew tries to raise the nose to “launch the aircraft into the air” with jet engine exhaust, much like a rocket takes off and if the wing needs more lift to raise the weight into the air, the rotation will not produce lift, but rather only drag the tail. Remember that raising the nose or deck angle up to the climb angle should never be done until the aircraft is airborne, that is wing borne, is lifted off the runway, hence my terminology “the lift off angle.”  So, let us look again at a wing trying to produce lift with an aircraft heavier that it was thought to be.

The wing of the aircraft, any aircraft, flies when it attains the correct lift, a product of  coefficient of lift and indicated airspeed creating a pressure differential spread over the wing’s surface area.  The coefficient of lift itself is based on the shape of the wing and the angle of attack of the wing in the airflow. When the coefficient of lift combined with the indicated airspeed spread over the wing surface is sufficient, the wing will produce a lifting force equal to the aircraft weight, the aircraft will rise up off the wheels and onto the wing and flight will be achieved. This is the lift off rotation from the wheels and onto the wing.

Just pulling the nose up at any speed, thereby creating angle of attack above optimal, is therefore never the correct procedure for lifting off of the runway into the first flight on the wing. The angle of attack is created by the deck angle setting the wing angle of attack when the indicated airspeed is achieved. You can not yank the nose up at a slower indicated airspeed to get lift because the angle of attack will be excessive and lift will be less than aircraft weight.  Therefore just pulling the nose up high past rotate angle and into climb angle is never the correct take off procedure. The weight will not yet be lifted onto the wing and therefore further rotation will just drop the tail to the runway and scrape it along at a very fast speed and with a very strong force. This is not good and may do a great deal of damage. This may be hard for crew members to remember especially if their previous training has been on smaller longitudinal axis aircraft such as a trainer. Since transport aircraft tend to be long bodied, the initial lift off rotation and take off climb procedures based on separate deck angles is so important to learn and remember.

The error that this crew made was pulling the plane into the air early at a lower than required indicated airspeed, to a deck angle well above the initial take off angle and up to the higher take off climb angle.

The lift off angle is often low, around 5-8  degrees. Then after the wing is producing lift and lifting the aircraft off the wheels and initially into the air, raising the nose slowly up, further to 15-20 degrees sets the climb angle and the take off climb. There rotation brings the entire aircraft into the air, not just the nose off the ground and the tail into the concrete.

Why was the mishap crew procedure an error? Was it because they may have been “trained” with incorrect practices? Moreover was there another error that this airline made either by teaching or allowing their flight crew to use incorrect and unwritten and unapproved “practices” (set by who knows who), instead of employing the correct, approved and published procedures? In my opinion written Procedures, not generally accepted Practice, is the key to safety and success.

Remember that there is a separate and lower lift off deck angle, the first-part-of-rotation angle, an angle meant purely for lift off of the aircraft from its landing gear and up onto its wing. Once this flight has been achieved, through the production of lift equal to weight by the wing, the aircraft can next accelerate and then climb upward on the wing. These two steps, initial lift off rotation from the wheels and onto the wing and take off climb on the wing, are all really separate aerodynamic events, even if we blend them into one smooth take off rotation procedure due to the rapid take off acceleration of powerful high bypass ration turbo fan engines.
In my opinion, it is a major flaw in aerodynamics to assume that raising the nose at any speed will be sufficient to achieve flight through lift. It appears that this flaw was not identified in the mishap investigation report. If it was in there, I did not find it. The flaw of the airline or the crew members is not uncommon. However, wouldn’t this information from the mishap board investigation identifying the procedural flaw, be of value to other pilots? In my opinion this a major mistake of omission and I believe  a correct accounting of the correct take off procedures should be offered here.

Every flight crew member flying all transport aircraft would be better off if they knew the basics of aerodynamics related to take off, so that they could prevent scraping the tail on takeoff, even in the hazardous event the take off weights are given wrong, calculated wrong or entered in the flight management computers wrong.

Here is the correct procedure in my opinion and in my opinion it is the same or very similar for all transport aircraft:
1. After application of whatever takeoff power  is chosen and as the aircraft approaches rotate speed, the crew should rotate to and then stop the rotation at the lift off deck attitude and do not go any higher. Stop here, hesitate here, be ready to remain here in the event that the aircraft is not yet at the correct lift off speed. If you do this, you will never ever drag the tail of the aircraft even if the weight and balance are wrong.  The speed will continue to accelerate and momentarily will be traveling fast enough for lift off to occur on the wing. If the take off data, the rotate speeds and take off speeds are correct and if the wing camber (flap setting) is correct, the wing will achieve the take off coefficient of lift at take off speed,  as the angle of attack lowers to the lift off angle of attack and the aircraft will lift off the wheels and onto the wing through the production of lift. Again, if the speeds are slow, it will be only by 15 to 20 knots at the most, and with large turbo fan engines, this 15-20 acceleration will take place within a few seconds, in my experience.

2. At that point the wing will lift the aircraft off the ground, because the lift is generated at the correct angle of attack and camber creating the take off coefficient of lift, at the correct indicated air speed. (This is not what is called ground effect, wherein the downwash angle is reduced by close proximity to the ground, thereby reducing induced drag and allowing acceleration and more lift from the aerodynamic force.)

Rather, this is actually the wing producing lift to get the weight of the aircraft up and off the ground. This is a very important step to recognize as a separate event, a separate and distinct part of the lift off take off procedure. It may very well occur at an indicated airspeed above what you may have expected, but not to worry. When the lift is being produced to lift the aircraft into the air, it will occur due to the wing flying at the proper speed and angle of attack. This is how you can overcome a weight entry error and not drag the tail. This is critical training information that every transport pilot should know and be trained on.

3. As the wing lifts the aircraft off the ground and out of ground effect, the feel of pitch control movement will demonstrate an increase in lift as pitch is increased. This is really important and critical to understand. If the aircraft is flying in ground effect and is not at the take off coefficient of lift, any increase in pitch will only result in aircraft longitudinal axis rotation but no increase in lift and will not result in any upward movement of the aircraft due to lift. This is the tell-tale indication that the indicated airspeed is too low for the actual total weight of the aircraft in my opinion and experience. This is trouble and the best thing to do is hold the stick steady, hold the rotation angle steady and wait for more speed.  Many pilots refer to a feeling of a mushy control column in this situation.  Be very careful here and be patient for the aircraft to accelerate to a higher speed. Patience and a light touch on the controls will serve you well at this point. Do not panic and do not yank the nose up, but rather wait, wait for the continuation of acceleration by the engines. Remember that the wing can fly at a range of speeds and weight, but only at the correct angle of attack needed to create sufficient coefficient of lift when the speed is at the minimum for flight and then decreasing angle of attack as the speed increases. So, wait for that correct angle of attack to lower onto the wing before moving the stick back any further.

4. If the situation occurs that the aircraft is airborne solely in ground effect, no further rotation should be attempted until an additional increase of 15-20 knots of indicated airspeed has been achieved. Wait, wait for more speed. At that point the aircraft should be going fast enough at the correct angle of attack to begin to rise from the runway, to lift off out of ground effect. Another take off rotation attempt can now be made. This 15-20 knot increase should move the aircraft closer towards the correct take off speed, the correct angle of attack, the correct coefficient of lift and the correct lift from the wing for flight. Remember that at this point you are not sure what kind of weight error has been made, but you do not need to worry about that at that moment. Just wait for the angle of attack to lower to climb angle of attack, then you can gently raise the nose.


In my professional opinion, the mishap crew just over rotated the nose of the aircraft up to the climb deck angle and into ground effect by not hesitating long enough at the lift off rotation deck angle. The coefficient of lift was too low for flight because the speed was too slow for flight and the angle of attack was too high. Therefore the lift being generated was too low to climb, even though it was sufficient to allow rotation of the nose up and the tail down, with the main gear as the fulcrum of the lever.  When the crew rotated the nose up to a higher angle of attack to attempt raise the coefficient of lift and lift, it appears that the crew did not understand the basic aerodynamics related to take off flight in that lift off angle of attack was not yet achieved.

Did not knowing what to do next, when faced with incorrect rotate speeds and take off  speeds at rotation result from the use of “common practices”  in lieu of standard operating procedures? Is scraping the tail the result of rotation to lift off angle or to climb angle?

If the crew had rotated the deck angle to the correct lift off deck angle and then waited for whatever indicated airspeed was needed to produce lift at whatever weight the aircraft was actually at, and not tried to raise the aircraft into the air to climb, by rotating above that deck angle, this mishap could have been avoided, it would have never happened and the data error would have been the only problem the airline needed to deal with. In the same manner future take off over rotation mishaps can be avoided, even when the incorrect take off weight is entered in the EFB or other weight and balance calculation error occurs during preflight procedures.

My guess is that during a career in commercial aviation, many crew members are going to be faced with an incorrect, over-weights or other weight and balance issues due to human error, human factors. But by knowing how to deal with the aerodynamics of take off, and not by just doing a rote “this is how we do it here” practice, they will have the keys to success in any circumstance. In my opinion, during a 40 plus year flying career, you are likely going to see just about one of everything. But if you are prepared by training, you can overcome the hazard and continue to fly safely.

In my opinion this crew and perhaps crew members at other airlines need more takeoff training. This company and perhaps other companies needs more detailed take off procedures. In my opinion this mishap board needs to redo the investigation with a much more detailed investigation of the basic aerodynamics related to take off. I believe that an investigation of errors in the calculation or entry of take off data in the Electronic Flight Book was insufficient to both explain this mishap and explain how to avoid the occurrence of this mishap again, anywhere.

If you were to ask me, this mishap board sought to answer the legal question, who was at fault for the damage and who is to pay. In so doing they failed to answer the Safety Question, “How did this mishap happen and what can be done to keep this mishap from happening again?”  In my opinion, Mishap Investigation Boards,  Accident Investigation Boards should be called upon to serve the Safety Purpose of making commercial aviation safer, and not served the Legal Purpose of finding blame and determining who pays?

Feel free to question any of my arguments. I’d be happy to respond. It is critical that we all learn something from these mishaps through the mishap investigation reports and the Safety Purpose.

You can send me an email: I look forward to your correspondence.


UPS Safety Program: Prevention or Mishap Investigation? What are the Financial Consequences of a Failed Safety Program?

Captain Paul Miller preparing for a coming storm.

Is UPS Airlines now joining the ranks of so many previously safe FAR Part 121 airlines whose safety program looks good on paper, but in the field is no longer functioning to prevent fatal mishaps?

Since 1982, UPS has run UPS Airlines free of fatal mishaps. In fact the few mishaps that have occurred in the operation by and large have not been attributed to flight crew error at all. This has been a substantially safe operation, most markedly from the pilots’ seat. In my opinion, this is a valid reflection of the training program and the safety program that have been working hand in hand successfully.

Now, however, in the space of 3 years, two fatal mishap events have occurred. The two events involved the deaths of four pilots. Additionally the events involved the total destruction of two jumbo jets fully laden with cargo and express packages have brought tragedy and disaster to the front door of this fairly large global shipping company. Has the airline safety program, a program that had been working so well, now failed to prevent two major financial disasters in three years? Are top UPS executives asking the question, “Does the safety program look good on paper but then fail to prevent aviation disasters and the accompanying hundreds of millions of dollars in financial losses?”

The airlines and the pilot union have just completed a three year process involving the GCAA (Dubai civil aviation authority) mishap investigation of the September 2010 fatal air tragedy of UPS Flight 6, a B747-400 freighter, that caught fire inside the cargo area and crashed after takeoff in Dubai, despite the heroic efforts of the crew. (See the article below concerning the report recently released on UPS 6 by GCAA.)

Now UPS once again is visited by tragedy and disaster in Birmingham, Alabama, with the crash of UPS 1354. By all early and outward reports this mishap appears to have been completely preventable. Many people may ask both, “Why and why now?”

Here is the most difficult questions of all for UPS Airlines and its Joint Safety Program with the FAA and its pilot union: Has the safety program been working to prevent mishaps from occurring? Has the Safety Program been serving the safety purpose? Or has the Joint Safety Program become a legal avenue to find blame for the tragedies and losses that are now occurring regularly, without really delineating concrete steps to prevent the mishap from recurring? Is the safety program now serving the legal purpose instead of the safety purpose?”

UPS, its pilot union and its FAA partners are now party to another massive NTSB investigation that will attempt to answer the safety question, “How did the UPS Flight 1354 tragedy at Birmingham’s airport happen and what can UPS, the FAA and its pilot union do jointly to prevent this mishap from occurring again?”

But then the line flight crew member may ask these questions: “Wasn’t the purpose of the Safety Program originally, to prevent this mishap from ever occurring in the first place? Why did that program not work, where was the failure and what can be done now to prevent another fatal mishap from occurring?”

So again the crew member may be wondering, “Has the Safety Program now shifted towards reacting to tragedy and disaster instead of preventing tragedy and disaster? What good is all this attention to the disasters, when at the end of the day two fellow crew members are once again dead?”

Airline operations had been safe between 1982 and 2010. Now losses are occurring. Where has the safety program failed, if in fact it has, and how does UPS return to safe operations?

Perhaps a safety forecast may be useful now in order to develop a new safety plan? Perhaps looking ahead to the safety hazards that the airline faces in the future will allow the airline safety department to create a safety plan to return the airline to mishap free operations.

Mishaps are terribly costly in both human terms and financial terms. The losses from these two mishaps at this time have most likely surpassed half a billion dollars. From a financial perspective alone, a safety forecast and a safety plan would be a wise strategy.

Winter Storm

UPS 6 Sept 2010 Dubai Crash GCAA Final Report: What Is the Cost of the Mishap? What Recommended Corrective Actions Will Prevent this Mishap from Occurring all over again?

100_4203What is not written in the just released GCAA Final Report of the September 2010 crash of UPS Flight 6? Was the report written for legal purposes or safety purposes? What wasn’t learned from the reading of the report? Was anything learned from the report that would have prevented this mishap, that wasn ‘t already known before the mishap? How does the line pilot become more safe as a result of this three year long exercise in investigatory procedure?

Is it possible that many people may ask these questions and feel that the report did not answer these questions? Here are a set of questions that may be on the minds of many people:

1. How did the cargo get on the plane, who put it there?

2.  How did it catch fire?

3. Why was this situation allowed to occur?

4. Were not all of the elements of this mishap known well ahead of time; did this accident happen once before and didn’t an investigation look into all of the essential elements of this mishap once before? Were not all these questions asked once before?

5. Why is it that this mishap happened again?

Again, these may be questions on the minds of many people who have read the GCAA Report and did not find all the answers to questions related to this mishap.  To look deeper let’s unwrap a few layers of information about the events related to this mishap.

First, the business of UPS is the main concern. According to their own published and filed financial reports, UPS created approximately $3.5 billion in operating income based on revenues of about $50 billion in 2010.  That is a return of about 7% or seven cents on the dollar for 2010 and about eight cents for 2011. So, this is good business return in this industry and appears consistent year after year.

Let’s consider the costs associated with crashing a fully laden B747-400 freighter and killing two crew. The plane is about $200 million. The cargo onboard guestimate is variable, but a fair estimate is between $50 million to $600 million, so let’s round off to $100 million. The crew death costs together all told about $2 million. The costs of a thorough three year investigation is about $5-6 million. Add this all together and the number is somewhere in the neighborhood of $308 million, and again since these are only estimates, the numbers could vary by plus or minus 10%.

Okay, now let’s figure based on seven cents to the dollar, how much business UPS has to conduct in order to have $308 million created as an operating income. The number is about $4.4 billion. Worth repeating: in order for this company to have enough money to go out and buy a B747, load it up with cargo, crash it, kill the crew and pay for a three year investigation, about $4.4 billion worth of business has to be conducted that results in $308 million in operating profits.

So what is the costs of a crash? How many people do you have to have out there working, selling service, moving packages, maintaining the operation, making things happen, so that at the end of the year they have all created $4.4 billion in revenue?

Asked another way, what is the comparison between the $4.4 billion and the annual revenue created by the entire company working the entire year of 2010, the year of the mishap? Comparing $4.4 with 2010 revenue of $50 billion, gives a number of about 9%. What does this mean? It means the mishap squandered the work of about 9% of the company’s entire work for one year. Again this is worth repeating. The UPS 6 mishap squandered about 9% of all the work done by all the UPS employees for the entire year.  That is a pretty big number in scale to any management goal and certainly a number acceptable by few responsible managers.

Put in another way, a company with 330,000 employees, where the work of 9% is wasted in a mishap, that would calculate to the work of about 29,700 employees wasted for one year.

While this is what happened, that set of numbers is not to be found in the GCAA report of UPS 6, nor is there any similar accounting of the costs of the mishap.

What was learned from the GCAA report that was not already known? The report identifies batteries of the lithium group carried as cargo to have been the source of the fire on board UPS 6.  But it was already known that lithium group batteries may initiate fires in cargo. It is already known that few methods of extinguishing are available to crews operating cargo aircraft and since there are no additional fire fighting crew members on board, any fire extinguishing that is going to be done, has to be done by flight crew members only. This means that either the crew keeps flying and no one fights the fire, or someone fighting the fire is not flying the airplane. But again, this was already known.  I am not sure what is in the GCAA report of the UPS 6 mishap, that was not already known? The report delineates the progress of the fire, the inability of the crew to complete a return to land, wherein the fire either diminished the systems needed to complete the flight or disabled or even destroyed them. Humans need oxygen to breath, the fire both filled the cockpit with smoke and caused the oxygen system to fail, just when it was needed most.

What was new in the report of the UPS 6 mishap that we learned? I am not sure that I found any thing new, anything that was not already known before. A cargo fire may render the cables controlling flight controls inoperable and do so rather quickly. That was not known, but is now. This is interesting because this aircraft is used for long overwater crossings regularly, wherein there is no divert field available without a transit time of two or three hours, meaning an immediate ditching, a ditching within 20 minutes of fire indication would be needed to complete any overwater ditching under controlled flight.

How is the line pilot safer as a result of the GCAA report? That appears open to discussion and to be determined. More fire suppression is good. Smoke hoods are good. All this is good, but preventing the event from recurring is the actual goal of the GCAA three year investigation. Other than chronicling the event per se, what else did the report do for safety of the line pilot? It is not really that clear.

Will the actions recommended in the GCAA report, if taken, prevent another similar mishap? If so, how would they? Will the actions keep Li group batteries off of aircraft? If so, how so? How much time will the next crew to experience a fire airborne have before they are overcome? Does this GCAA serve the safety of the line flight crew member? Did the report serve the safety purpose of mishap prevention for the benefit of the line pilot and the company or did the report serve the legal purpose of collecting the evidence for lawyers, regulators and administrators?

You are invited to read the report one more time and determine these answers for yourself. What additional questions come to your mind? What recommended corrective actions do you think need to be enacted in order to keep this same mishap from happening all over again? How can this mishap be prevented?

Captain Paul Miller preparing for a coming storm.

Asiana 214, Fatigue and In-Flight Crew Meals: Postprandial somnolence, or getting sleepy after you eat.

The more factors I consider, the fewer seem likely until I consider the human factor of fatigue. Automation? He was flying a B747 prior, plenty of automation there. San Francisco? Not all that different from dozens of international airports in the Pac Rim. CRM? Things didn’t go bad until the last few miles. New captain, new instructor? Happens everyday at every airline. Cultural paralysis? What? These airlines fly safely all around the world daily. Airmanship? The guys have thousands of hours flying the heavy machinery. Sure, the B777 is different from a B747, but the pilot monitoring was a B777 instructor, trained and qualified.

So why did they just stop flying, lose situational awareness, lose internal communications and CRM all at once? It seemed. like someone had whacked them in the head with a stick, like they ‘d had been incapacitated,  like they were barely conscious?

What is the one factor that would interrupt motor skills,cloud judgment and block action? Only one common factor comes to mind, the human factor of fatigue.

If culture was cause, then every flight operated by this culture would crash. But that is not what the facts tell us, since pilots from this culture operate hundreds of flights safely everyday, everyweek, everymonth, everyyear. Therefore logic tells us that culture is NOT THE CAUSE.

Since most commercial aviation mishaps are related to human factors, such as fatigue, which is highly incapacitating to all humans, regardless of culture, flight crew fatigue would be one of the first places to investigate in my opinion.

If we look at the many aircraft mishaps over the years, the demographics of flight crews involved cuts squarely across every cultural line. Any attempt to “culture-bait” this investigation in my mind is an attempt to divert us from the truth. And I personnaly do not like looking in the wrong direction for truth.

Let me ask any of you who are non-flight crew persons, how many of you who are office type persons spend 14-16 hours at your desk each day? Consider this hypothetical situation  because probably you have at least once spent 16 hours at your desk.
At the end of this theoretical 16 hr day, how good were your decisions, how clear was your judgment, how swift were your actions and how clear were your communications?

Fatigue can shut down the best parts of our brains. Why do we have such a hard time understanding that putting pilots in charge of a flight with 38 or more computer modes after a 14 hr day and 200+ peoples lives is not such a great idea?

And one further question, when did the crew eat their last meal before reassuming their duties on the flight deck? Did the after meal fatigue, the tendency for many of us to nod off as our digestive systems go to work, put the crew members into a food induced fatigue?

This is just my hunch, I have no facts to check this out.
Sometimes, when a crew grabs some rest, after they arise, they may eat a meal.
If after eating, they moved up to the flight deck and took over flight duties for the last 1 1/2 to 2 hrs, it is possible that the crew got hit with very human post meal drowsiness. Even with a few cups of strong coffee, many if not most people I flew with  were certainly affected.
I have never seen this addressed in any FAA reg, SOP or safety note. But it is certainly very common. I know of at least one B747 incident on record where the crew ate and fell asleep, the autopilot disconnected and the plane went out of control.
We will see, again this is  100% speculation.

I just ate my lunch. I think I will take a nap now.


Asiana 214: Cultural Issues, Fatigue or a need for better Stabilized Approach and Go Around Procedures?

IMG_0922_2Culture issues, fatigue and other human factors of every type are and will continue to be amongst the most serious safety hazards, risks or challenges for the foreseeable future in commercial aviation.

In the very open cultures of North America there may be a tendency to see cultural issues not only as a non-typical factor, but one that affects flight crew members in other regions of the world. Previous mishap investigations have shown this human factor issue for the most part affecting flight crew members not from North America. But I would argue from a safety viewpoint, where communications is the key to success, we in North America are vulnerable and have to remain alert for cultural issues in our operations. Why? I would argue that our demographics are far from homogeneous. Culturally we have on the flight deck old and young, male and female, military and civilian, conservative and liberal, uptight and loosey goosey and many other opposites on various cultural scales.  There is often a cultural demographic out there that could trip up our communications.

Now let’s look at fatigue. Fatigue is highly dangerous, much more so than even the most ardent and zealous safety advocates realize. Fatigue can cripple the parts of even the most mature, well trained and seasoned brains of our most experienced flight crew members and catch everyone by surprise. Furthermore, as Murphy’s Law tells us, fatigue will affect us at the worst possible time. The night express package delivery and the international segments of our industry are a fatigue prone operation. Long haul flights over many time zones, all week long-all night operations are knitted into these human factors. It doesn’t take much more in life to toss even the best of us off our planned sleep-rest schedules. Typical life events such as family harmony issues, health of aged parents, the teen years of our kids-who knows what will affect us next week? We are all vulnerable. But because of our humanity we are also our own worst judges of how we are doing. The person in the mirror can not always judge the right thing to do when tired.

The whole spectrum of other human factors, such as crew communications, ATC comm, being caught by surprise with an unusual circumstance, all of the other Human Factors out there, we are all very liable to be exposed because as flight crew members, our group is very human. Yes, the typical flight crew is very polite and diplomatic but at the same time very dynamic, very capable and are mostly well rounded people. I never ceased to be impressed with what a fine group of people I have had the pleasure to know and fly with around the world. But that means that we are VERY HUMAN, and thus very vulnerable. The great success of our superb FAA ASAP program, the wonderful reactions of our crew members to the insightful FOQA data reports and the success of our flight training is dependent upon us all being good and open communicators. Good communicators tend to be involved with people on and off duty: it is our strength but at times may be our weakness.

Having said that, in my opinion, three things, all interrelated, are the best approach to our most typical human factors safety risks: procedures (SOP), training based on procedures for operational competency and lastly good communications.  This is where Asiana is going to have to go to get well from this tragic mishap, in my humble opinion.

The recent Flight Safety Foundation European Advisory Committee Go Around Safety Conference was three years in the planning and preparation. Unstable approaches turned out to be the main topic of the conference. I was very happy to have been a participant in the steering committee at EAC that brought this conference to fruition. But now we and the airlines all over the globe will have to roll up our sleeves and work hard on this safety issue. We have to get stabilized approach procedures written and better trained. We have to make a Go Around part of the approach procedure when we do not achieve and maintain the stabilized approach procedure.  Let me repeat by saying this has to be a written SOP, not a criteria or policy, and we have to train to this procedure.

What was learned in the remarkable seven papers researched for, written for and presented at the Go Around Conference, was how poorly flight crew members globally react to unstable approaches. Researchers found that only 3-4 per cent of the time do flight crew members who were flying unstable approaches, employ the go around procedure. The rest, that is right, the other 97% of pilots continued to fly the approach to a landing. Out of these landings is where we have the runway excursions off the end and side and as we saw with Asiana 214, a landing short of the runway.

There are plenty of other stats about how many approaches are unstable and how many mishaps resulted from all this flying in the following references published on Eurocontrol’s Skybrary: see for the many details.

But for us, we involved in the safety business, the most important thing for us to get behind and to make changes globally, everywhere that there is a commercial aviation operation, is that only 3-4% of crew flying unstable approaches Go Around.  Our great success in safety so far I have no doubt is related to the idea of a stabilized approach procedure (SOP). Notice I did not use the term policy. It is a procedure, this is a critical term here. Now we must integrate the Go Around as part of the stabilized approach  procedure when we do not achieve the stabilized approach.

Remember that ‘cultural issues’ are a very common human factor everywhere, but the safety risk is the inteference to communications and the interuption of the achievment of procedures (SOP). My recommendation continues to be SOP, training and communications as a common approach to human factors safety risks. Train, train and train until flight crew are as well rehearsed as any professional should be. We have done so well globally in commercial aviation safety. But now we must make a change that will improve safety to an even higher level. I know that each safety manager at each airline knows where to go now with this safety effort. We are the fortunate ones to be in a position to make this important safety change.

Good luck and let’s get to work. Best wishes, your friend in safety, Paul Miller

Asiana 214 Mishap, SFO, July 6, 2013: Stable Approaches & Go Around Procedures

Captain Paul Miller in cockpit

Captain Paul Miller

Stabilized Approaches must be part of an Standard Operating Procedure (SOP) and not just a criteria, policy or even best practice.  Procedure means that it is a written set of steps and explanatory notes. Procedures are trained by the airline, checked by the FAA and continually verified, reviewed and updated by the FAA and the airline. Part of a stabilized approach procedure must include a verbalized communication of the aircraft state and progress at several points in the approach and a verbal command to continue the approach or to Go Around as the aircraft passes these points, if the procedural steps are not achieved.

One of the most important things we learned in the recent June 18, 2013 Flight Safety Foundation (FSF) Go-Around Safety Conference, sponsored jointly by EuroControl, European Regions Airline  Association (ERAA) and the European Advisory Committee and the International Advisory Committee (EAC and IAC) of the FSF, in Brussels, addressed the idea of a criteria, policy or best practice as opposed to an SOP.

See the conference link at  for more details.

It is one thing to have a 500ft or even a 1000 ft stabilized approach criteria.  It is quite another thing to have an SOP to which all flight crew members are trained, a procedure  that says if the crew does not accomplish a stabilized approach by 1000 ft or even 500 ft, the pilot monitoring, the flight crew member not flying, shall say verbally “GO AROUND,  APPROACH UNSTABLE.”  Then, as written in the SOP, the pilot flying (PF) procedurally initiates the Go Around (GA), as per trained, as briefed and published as well  as cleared by air traffic management procedures.
Even now, even with a stabilized approach criteria or policy at 500ft or 1000 ft and a even with a no fault GA policy, wherein the crews’ motive for going around is not called into question, air lines still need to have an SOP, a written operating procedure. The SOP must require crew members to verbalize, “1000 feet, APPROACH STABLE, CONTINUE,” or “1000 feet, APPROACH UNSTABLE, GO AROUND.” The SOP must define action, not just policy or criteria. It must require prescribed actions for the flight crew to do at that point of decision. This is not a talking point, a time for discussion or observation-this is a time for action.

Why is this important now? So, it has actually always been important.  However, now we need to understand what happened to Asiana 214 and learn from it. Having seen the video of Asiana 214 approaching San Francisco International (SFO) runway 28 Left, one thing is quite noticeable. The approach appears very flat and very low in altitude at a considerable distance from the stone wall at the waters edge. In lieu of the standard three degree glide slope, the aircraft appears to have essentially leveled off at 100 or 150 feet 1/4 to 1/2 mile from the seawall. This is not good, but also this did not happen in the blink of an eye. This was a developing situation, to which the crew did not report their state nor did they take action.

Keep in mind that the designated normal landing area on any runway is between 500 feet and 1500 feet down the runway. Add onto that, the stone wall at the waters edge appears to be approximately 1000 feet from the end of the runway.  So the aircraft landed approximately 2000 feet short of the intended point of landing, that is, the normal landing area on the runway. This means that the aircraft had descended approximately 50ft and 100ft  below the normal 3 degree glide slope. This deviation did not occur 4 or 7 seconds from landing, but possibly 1/2 mile or more from the end of the runway. This very large deviation was neither reported nor reacted to initially as it occurred, but only just a few seconds prior to impact. By apparently not having a reporting and Go Around procedurally ingrained by training, the crew was left to determine where they were by their own criteria or judgment and then decide on a course of action and then to take that action: too much to think about in too little time and space, in my opinion.

If and when the aircraft passed 1000 feet in altitude or even 500 feet in altitude during the final approach, this would have still been a considerable distance from the runway. In this mishap the aircraft had to have been well below glide slope and thus very unstable at that point, a factor observable from the flightdeck and measurable against the requirement for a stable approach.

So did the airline have a procedure (SOP) that required the crew to verbalized stable or unstable and continue or go around? If so, why did the crew continue the unstable approach? Did the crew notice the unstable approach? Why was there a hesitation to act? Was there a procedure in place to which the crew had been trained? Or rather was there merely a criteria and a policy only in place? Can you see the difference between having a a trained GA SOP and having only a policy or only a criteria? A policy or a criteria gives talking points.  An SOP gives action required.

Early reports from the NTSB identified that the airspeed decreased from a landing target of 137 knots down to about 109 knots. Remember that normal target speed is 130% of the stall speed at that weight or 1.3 times the stall speed. So this decrease of 28 knots is a considerable change. But remembering the laws of aerodynamics, the aircraft nose attitude had to slowly pitch upward as the speed decreased. This means that the plane went from a normal landing attitude to a very high nose up attitude, again something very noticeable from the flight deck, another clue that the speed is unstable.

Rounding off for argument sake, a stall speed of 100 knots, with a 30% buffer gives a landing speed of 130 knots. The stall warning stick shaker come on 5-8 knots above stall speed (or more correctly stall angle of attack).  So the crew was not flying the aircraft just a little slow; the crew was flying substantially slow, dangerously slow and into the region of rapidly rising induced drag.  The crew appeared to be unaware of the rapid decay from 137 knots to 109 knots right into the stall. I wonder if the subject of the region of reverse command in swept winged aircraft was part of the Asiana B777 training program? Again, there may be a reliance on subjective values such as airmanship, in lieu of a set of written procedures, approved, trained and checked. But all flight crew of swept wing aircraft must have a very good understanding of the region of reverse command and the grave consequences of allowing the aircraft to enter into that part of the flight envelope. Yet, how many commercial pilots can recount the danger of the region of reverse command? Does the FAA require it?

Remember it is not uncommon for many crew to add 5-7 knots to give a margin above the minimum target speed. So that would mean many pilots would be flying at about 142 knots. The aircraft landed 30 or more knots slow. This would require a significant increase in angle of attack and nose up position, which was seen in the video at the last moments. This high pitch attitude rapid change is another major deviation from a stabilized approach procedure.  This deceleration should have been recognized immediately as it occurred initially below 137 knots and the nose high attitude should have been corrected by the crew or the crew should have commanded a Go Around. The GA SOP should have been initiated as soon as the airspeed fell below the target speed. The correction would have been to add substantial power and lower the nose slightly.  The value of a written stabilized procedure is that this procedure is trained over and over again until the crew is exceptionally skilled in close to the hand eye coordination needed when a lot is going on.

As it happened the aircraft was well below glide slope and very slow below landing target speed. Both of these serious deviations from the stabilized approach requirements occurred well before the aircraft arrived at the sea wall. The deviations began more than a half mile out and increased as the flight approached the sea wall. The crew began a discussion during this period, but did not take action during this period. This is the danger of having a criteria and/or a policy in lieu of a well trained GA SOP.

Not having a well trained Go Around SOP based on deviations from Stabilized Approach is a severe risk to safety. Not having a training program that covers the aerodynamic principle of the region of rising induced drag and does not address corrections is a severe risk to safety as well.

Concerning the Instrument Landing System (ILS) electronic glide slope for runway 28 left being inoperative, I would ask very serious questions of the FAA and the airport authority as to why they chose to temporarily decommission this system and why the decommissioning lasted for such a long period of time. This puts a burden on the crew members in the cockpit. This is what many people call the tail wagging the dog. Why have all this expensive ILS technology, engineering, equipment and training, if in the end all of it is deferred to a construction company that is laying concrete? Whose decision is that? Either the ILS is important and we had better damn well keep the system up and operating, or it is not important and we should train pilots to do visual landings. But the FAA and airport authorities want the argument to go both ways and always be in their favor. I do not agree with this tail wagging the dog theory. If the runway is “under construction,” then close the runway and allow the construction crews to do what has to be done. Do not close all of the vital instrumentation and just keep the concrete portion of the runway open for revenue generating purposes. This is not fair to the flight crew and this is most certainly not fair nor safe to the flying public, which by the way is also the paying public. Again the least of all parties in this case is the concrete construction company. Therefore it ought to be they who accommodates the operation, not the operation that accommodates the concrete company.

Decommissioning the ILS  requires the crew to build an artificial glide slope in the flight management system, using runway data and alternate procedures. This would have been a good training opportunity for the crew to build that approach within the aircraft flight management system. This could have been done as part of the preparation for the approach. Again though, was this Asiana SOP?

This is a standard and written procedure in the B777 flight manual. If that procedure was not done, the next guide to a usable runway glide slope would have been the precision approach path indicators known as PAPI mounted along side the runway. The PAPI  will indicate to the crew when they are below the glide slope, an illumination of four red lights to the left side of the landing area of the runway. We are not sure from reports that the crew was using the PAPI to assist them in the landing.

One last thing, as the initial operating experience instructor pilot sitting in the right seat should have said when things got far out of hand, “Okay, I’ve got it,” and flown the aircraft back into safety, again as a procedure for being the person in command. But the actions taken were to order a Go Around to the pilot flying, but too late for any reasonable reaction from the pilot flying. He should have taken the plane and done the Go Around when he saw that things were out of hand.

A lot going on here to discuss, no? I think so. We all would be better off tomorrow if we all tried to understand what happened to Asiana 214 today. We should see many ways on how our own airline could be made safer from the discussion of the mishap of Asiana 214.

Stabilized Approach Procedures, Go Around Procedures and substitutes for ILS procedures all must be part of the skills sets of B777 crew members and for that matter all commercial flight crew members no matter what aircraft they are operating.

Lithium-Ion Aircraft Batteries as a Passenger and Cargo Smoke/Fire Risk

100_3975In fact three aircraft have been destroyed by fires caused by lithium ion batteries, one in 2006, two in 2010. But the FAA, NTSB and other government and official agencies categorize safety as related to passenger safety or a cargo acft only hazard and of no interest to passenger airline safety, such as the current FAA and EASA Cargo Carve-out Exemption of new Flight Duty and Rest Regulations. However, by summarily ignoring the distinct ties in safety that nevertheless may validly exist between cargo airlines, passenger airlines and their respective pilots safety, FAA, EASA and others may have gravely missed the most valuable of all safety principles, that of early warning.

The early warning evidence in this case was the two cargo fires caused by lithium-ion batteries.  The fire dangers of lithium ion batteries have been amply noted, the information on this hazard has been widely available and mishap reports by FAA and EASA have identified a clear and present danger since at least 2006.

Instead of keeping lithium-ion batteries away from commercial aviation however, FAA, EASA and others have made a clear choice to allow industry lobbyist lawyers to influence safety decisions when it came to lithium ion battery carriage regulation and by that same process, have kept the safety experts themselves at arms length.

No greater illustration of inverted safety logic is present in aviation government regulatory administration today than this example.

When will the FAA, EASA and other government aviation safety agencies place aviation safety experts in charge of making important public safety and industry regulatory safety decisions?

When will the direct, clear connection in commercial aviation safety between passenger and cargo airline operations be recognized by FAA, EASA and others? It is obvious that attorneys themselves appear unable to make that connection. Wouldn’t the industry be better served by placing safety experts in charge of safety decisions and regulations?