
The Silent Anniversary: Fifteen Years Since Our Last Major Crash - maxcan
http://www.askthepilot.com/silent-anniversary/
======
NickHoff
The effect of culture should not be underestimated here.

There really is a cooperative spirit among pilots, air traffic controllers,
weather briefers, mechanics, the FAA, etc. Controllers are willing to help
pilots with special requests if able, pilots file weather reports for other
pilots if what they encounter aloft is different from what they expected,
mechanics take pride in their work and are highly regarded by pilots. I
generally take a dim view of regulators, who generally seem to have less
expertise than the people they're regulating. That's mostly not the case here.
I'm libertarian and a pilot - and I like the FAA. Nobody is out to nail you
for a minor technical infraction, but they will yell at you for something
that's unsafe but technically legal. This encourages people to report near
misses, even if casts them in a bad light. The regulations themselves are
generally reasonable, and frankly feel like they were written by pilots,
controllers, and airport operators.

The point is this - regulations matter and budgets matter, but if the culture
is toxic, people will find a way around it anyway. When I see a problem
elsewhere in society - investment banking in the 2000s for example - people
propose heavy regulatory solutions. That may work, but wouldn't be so much of
a battle if the culture were better.

I haven't thought deeply about what "better" means in this context, nor about
how to intentionally change a culture. I'd rather just fly.

~~~
THE_PUN_STOPS
I've often heard it said that FAA regulations are written in blood. Meaning,
if a rule exists, it exists for a damn good reason.

For anyone interested, NASA's ASRS [1] (Aviation Safety Reporting System) is
what the parent commenter is referring to regarding reporting near misses. The
idea is, anyone can submit an incident report with NASA, a neutral separate
party from the FAA, which is placed in an anonymized public database and
cannot be used to justify punishment against anyone involved in the incident.
This promotes transparency and learning from the mistakes of yourself and
others, instead of covering them up. Frequently, the person who caused an
incident in the first place will promptly report it to ASRS, as the FAA looks
favorably upon those who come forward to ASRS on their own and dimly upon
those who do not.

I think more industries could use this kind of transparency in reporting
sketchy situations.

[1]:
[https://asrs.arc.nasa.gov/overview/confidentiality.html](https://asrs.arc.nasa.gov/overview/confidentiality.html)

~~~
markbnj
I often remarked in the same vein to my daughters as they were growing up and
learning to drive. Everywhere you encounter a stop sign, a light, etc., is a
place where people were badly injured or killed on multiple occasions. That
stuff is there for a reason.

~~~
CamperBob2
Obviously that's not even remotely true, so why are you telling your daughters
that?

Don't lie to your kids. They're smarter than you think.

~~~
mrb
Napkin math suggests you are wrong, the grand parent is right.

I can't find the _exact_ stats but in the US there are 2+ million injuries per
year caused by road traffic crashes. We know there are around 300k signalized
intersections [1]. If we estimate non-signalized intersections (ie. those with
STOP signs) to 20x that number, that's 6 million non-signalized intersections.
If 20% of injuries happen at intersections and are randomly distributed across
intersections, then on average there will be 1 injury at a given intersection
every 15 years.

So yeah it is likely that "multiple injuries" have occured at mosts
intersections in the country.

[1]
[http://mutcd.fhwa.dot.gov/knowledge/faqs/faq_part4.htm#tcsgq...](http://mutcd.fhwa.dot.gov/knowledge/faqs/faq_part4.htm#tcsgq3)

~~~
mcbits
Where I live, there are at least a couple hundred stop signs and two (2)
traffic signals. That's probably closer to a typical ratio for suburbs and
smaller towns. I doubt there's ever been a serious accident at most of those
intersections, and certainly not as the catalyst for putting up all the signs.
The major accidents happen on the highways outside of town, during blizzards.

------
maxcan
What wasn't mentioned directly was that since 2009, US passenger airlines have
had a perfect record of zero fatalities, which is mind blowing.

~~~
mikeash
Especially mind blowing considering that not all that long ago, it was common
to see hundreds of airline fatalities per year, despite much reduced traffic.
If the 1960 level of safety carried through to today, we'd see over three
thousand airline deaths each year.

~~~
imglorp
Furthermore, fatalities are still in the hundreds world-wide, often with the
same equipment flown by US airlines.

This number tells us that the FAA+NTSB, despite some other criticism,
_usually_ has its act together where it counts the most. They iterate on
identifying safety problems and force the airlines to adopt solutions.

~~~
npunt
US airlines often sell their older planes to foreign airlines, which may
account for some of the increased issues those airlines have. Your point still
stands though - culture and processes rule.

~~~
mjevans
You could argue that those planes should be forced to retire instead.

A different perspective might be to require that every 10000 hours of service
see a new mark painted on the hull. This way passengers could be informed of
how much 'age' a plane has had and the regulations could also apply to any
plane which /might/ fly in to the US (or Europe).

~~~
cjrp
The hull's age only tells part of the story though; how well it's maintained,
and the ability of the pilots flying it would need to be factored in as well.

~~~
mikeash
Those are probably far more important. I'd be far more comfortable boarding a
30-year-old airliner with great maintenance and great pilots than boarding a
brand-new 787 with a clueless maintenance crew and pilots who aren't quite
sure which way to move the stick (edit: yoke) to make the houses get smaller.

If you look at the causes of crash, it's usually pilot error or improper
maintenance, occasionally design flaws, but not equipment age.

------
GFischer
Plane crashes have been going down not only in the U.S., but worldwide, which
is commendable.

A bit unfortunate for this to be posted a few days after the Chapecoense crash
shook the world (noted in the postscript), but that was a regional charter
flight, not a major U.S. airline.

Interesting infographic:

[http://www.ibtimes.com/how-many-planes-crash-every-year-
how-...](http://www.ibtimes.com/how-many-planes-crash-every-year-how-many-
people-die-plane-crashes-chart-1560554)

Edit: the Chapecoense crash shows exactly why the FAA's work is so commendable
- disregard of proper procedure and safety measures led to that accident.

~~~
gus_massa
About the Chapecoense crash. From [Portuguese]
[http://www1.folha.uol.com.br/esporte/2016/12/1838707-lamia-j...](http://www1.folha.uol.com.br/esporte/2016/12/1838707-lamia-
ja-havia-descumprido-regra-de-combustivel-em-voo-com-messi.shtml)
Autotranslation:
[https://translate.google.com/translate?sl=auto&tl=en&js=y&pr...](https://translate.google.com/translate?sl=auto&tl=en&js=y&prev=_t&hl=en&ie=UTF-8&u=http%3A%2F%2Fwww1.folha.uol.com.br%2Fesporte%2F2016%2F12%2F1838707-lamia-
ja-havia-descumprido-regra-de-combustivel-em-voo-com-messi.shtml&edit-
text=&act=url)

> _On at least two occasions, the Bolivian company had flown beyond its
> declared autonomy._ [4 hours and 22 minutes]

> _One between Cochabamba in Bolivia and Medellin in Colombia (4 hours and 27
> minutes), and the second between Medellín and Santa Cruz de la Sierra in
> Bolivia (in 4 hours and 32 minutes)._

~~~
wapz
Wouldn't the difference in 5-10 minutes not be the reason for the lack of
fuel, though? I would guess a 4 hour flight would have enough fuel for at
LEAST 5.5 hours if they couldn't land at an airport and had to be diverted to
another one (right before landing).

------
ahupp
"... the first officer of flight 587, Sten Molin, who was at the controls,
overreacted, rapidly and repeatedly moving the widebody jet’s rudder from side
to side,... . The vigor of his inputs caused the entire tail to fracture and
fall off."

I was interested in learning more about this, and it turns out there's an
alternative interpretation that argues he was flying according to best
practices at the time rather than "overreacting":
[http://articles.latimes.com/2005/jan/11/opinion/oe-
garrison1...](http://articles.latimes.com/2005/jan/11/opinion/oe-garrison11)

~~~
MaxfordAndSons
IIRC from watching the episode of "Air Crash Investigation" (aka "Mayday") on
this flight, it was a pretty tragic confluence of factors: it was a best
practice on other planes, but not on the A300, but American Airlines training
manual had not been updated to reflect this change, nor did the simulator
models account for this eventuality. Kinda surprised the author of this piece
wrote it up as he did.

~~~
rrmm
If I'm remembering the details of the case correctly, it turns out he did
overreact and that did cause the tail to fail: Certainly the tail did fail,
and the pilot's input caused it.

The important part and the part that has been noted above is the NTSB's (and
the industry's) focus on not blaming the pilot but figuring out why the
situation turned out the way it did, what factors allowed it to happen, and
how things could be changed to insure the same chain of events doesn't keep
occurring.

(Again if I recall correctly), It was the confluence of a few different events
compounding each other and resulting in the accident:

One factor was the airline company sim training on recovery from upsets.
Basically the pilot going through the training could come away learning
entirely the wrong lesson. The simulation was hardwired so that the pilots'
inputs were disregarded until the plane was in an upset and then the pilot
took over. Pilots unfortunately seemed to learn that control inputs before the
upset (which were ignored) affected the outcome, so they might randomly use
large control inputs which were unrealistically ignored in the sim. Pilots
also came out of training with an exaggerated expectation of wake turbulence
because they were unable to control the plane during the early part of the
upset.

An additional problem is that simulators are based from data gathered during
aircraft testing and represents the normal flight envelope of the craft. Using
the simulator outside this regime can result in aircraft responses which do
not simulate the actual aircraft responses.

Another issue was the way the limits of the rudder pedals were handled between
different revs of the A300. Like the steering wheel of a car the rudder pedals
require less and less input to be effective as speed increases. To prevent
overstress on the airframe, the mfr will somtimes shorten the distance you can
physically move the rudder pedals. Another way to achieve this effect is to
change the ratio of rudder pedal movement to actual rudder movement (at cruise
speed, a given movement of the rudder pedal will result in a smaller rudder
movement than at low speeds). The mfr changed from one scheme to the other
between A300 models and additionally lightened the amount of force needed to
move the pedals.

All this added up to a pilot making the same rudder inputs and getting a
vastly different rudder response depending on the revision of the A300 they
were flying.

Finally, I believe there was concern with pilots' understanding of the V_A
speed (one of many V_* speeds that the mfr provides in the aircraft's
operation manual). V_A is the maximum aircraft speed at which you can jam one
of the flight controls to its stops and keep the plane in one piece. Most
pilots the NTSB surveyed didn't realize that this only applied to a single
maneuver/single control input. Putting the rudder pedal to the stops back and
forth repeatedly, even under V_A would allow the energy to build and
eventually cause the airframe to break up.

Full NTSB report:
[http://www.ntsb.gov/investigations/AccidentReports/Reports/A...](http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0404.pdf)

I think the NTSB reports are fantastic reading for anyone interested in the
failure modes of people and machines as well as how to really approach and
investigate difficult problems.

------
nikcub
There's likely no media coverage of the anniversary because only including
major airlines is a very arbitrary cutting off point.

The NTSB lists five major passenger air accidents since 2001:

[http://www.ntsb.gov/investigations/data/Pages/paxfatal.aspx](http://www.ntsb.gov/investigations/data/Pages/paxfatal.aspx)

No agency breaks out "major" airlines from "regional" for the purpose of
regulation or statistics, nor does any other nation. It is purely self-
serving.

What makes this post weirder is while cutting out regional airlines from the
statistics, the _causes_ he attributes with improving safety for the majors
are the same things that regional airlines have also been doing.

~~~
zardeh
Of those 5, 4 occurred in propeller craft. I think that it is relevant to
include that kind of difference. Regional airlines and major airlines do work
differently.

------
blakesterz
"2009: A Colgan Air (Continental Connection) Dash-8 Q400 crashed outside
Buffalo. Fifty people were killed, including the occupant of a house struck by
the plane."

"2006: Forty-nine people perished when a Comair (Delta Connection) regional
jet crashed after attempting takeoff from a too-short runway."

I'm not sure, maybe "major" has an official cut off number, but 49 or 50
doesn't seem "minor". It's a long way from 260, but it's far from 0.

~~~
el_benhameen
Colgan and Comair aren't counted in the metric because they're regional, not
major/legacy, airlines. They codeshare with the majors, but they're different
organizations.

Tangential: Frontline had a great episode on regional airlines' safety issues.
[http://www.pbs.org/wgbh/pages/frontline/flyingcheap/](http://www.pbs.org/wgbh/pages/frontline/flyingcheap/)

~~~
dingaling
> They codeshare with the majors, but they're different organizations.

Indeed they are organisationally different, but to the passenger holding a
United through-ticket from Smallville to LA there's no difference except one
part of the journey is on a 'tiddly airyplane'.

If they're good enough to carry a major's flight code and livery and do the
grunt work for feeding hubs for them, they're good enough to count in accident
statistics.

Would we accept lower security standards for, say, AWS if that was outsourced
and was only 'branded' by Amazon?

~~~
mikeash
If you include them, the picture is still remarkably safe. How many years
since a regional airline fatality?

~~~
zardeh
7

------
nkrisc
I know perfectly well that a fear of flying is often an irrational, though
very real, fear for many people. But it's exactly the irrational nature of it
that boggles my mind: they should be terrified of driving, but they aren't.

I'm way more comfortable flying than driving.

~~~
jraines
Nervous flyer here.

I tell myself this on a loop while flying and my lizard brain just does not
care. Weirdly, I've flown hundreds of times and this didn't start until I was
near 30.

I think one aspect is not the fear of death, but the fear of being in a
situation of knowing death is certain for minutes as you fall out of the sky.
(Which is a situation I also know is a small fraction of the already tiny
chance of dying in an airplane).

~~~
NullCharacter
Completely agree with you. I fly tons for work, and was just fine until I got
into my mid-late twenties when I started to have horrible anxiety.

And like you, I don't necessarily fear death, but I definitely don't want to
see death coming. More than anything, I fear helplessness.

~~~
gist
When I was a teen (long time ago) I remember telling my dad that I thought it
would be great to take a flight with many stops because that way we got to
takeoff and land multiple times! What fun! A bit later of course it became
exactly the opposite and not just for time travel reasons, price or schedule.

------
slg
I am surprised there wasn't more than a token mention of terrorism. People
like to bemoan airline security and I think there is a valid argument
regarding the effectiveness of the TSA, but this is also the safest stretch
the US airline industry has had against terrorists and hijackers since the
early days of the industry in the 40s and 50s.

~~~
mikeash
I think the current level of airline security is overkill, but I'm always a
little surprised to see people advocating for having _none_. In the late 60s
and early 70s, US airliners were getting hijacked at a rate of once every week
or two. Once basic security screening was introduced, it became far more rare.

Making people take off their shoes and empty their water bottles is a bit
silly, but basic checks for guns and bombs are a good idea.

~~~
throwaway2016a
Keep in mind too, there are also things like air marshals and bullet proof
cockpit doors that can't be opened from the outside and other measures like
that.

Not all the security improvements are at the screening check level.

~~~
mikeash
Very true, I did not mean to imply that _all_ of the new stuff is bad. Air
marshals and solid cockpit doors are both excellent ideas.

------
js2
In no way directly related to this post, but I'm always looking for an excuse
to link to my two favorite airline stories.

1) The Turn -
[http://www.theatlantic.com/past/unbound/langew/turn.htm](http://www.theatlantic.com/past/unbound/langew/turn.htm)

2) The Crash of United Flight 232 talk by Capt. Al Haynes - [http://clear-
prop.org/aviation/haynes.html](http://clear-prop.org/aviation/haynes.html)

------
JHof
Exploiting this aviation-related post to see if any aerospace folks will
comment on my two-month old Ask - Ask HN: Why is the National Airspace System
so dated?
[https://news.ycombinator.com/item?id=12651244](https://news.ycombinator.com/item?id=12651244)

In regard to the safety of regionals vs. the major airlines that the article's
author is writing about: I can see why the statistics are separate. Even
though, according to the FAA, we're all under the "same standard", in
practice, this isn't the case. As long as the paperwork looks the same,
though, we're "safe". Also, within the industry, some pilots tend to think of
themselves as shouldering the responsibility of safety, however, I sometimes
think we're safe despite the pilots. Engineers of aircraft, airspace,
arrival/departure/approach procedures, airports, ATC systems, etc. are
silently keeping you safe. That the FAA is able to manage all of these
elements is quite impressive. Still, its massive bureaucracy can be quite
Vogon-like.

~~~
rplst8
I think a lot of software engineers would be blown away at how strict software
standards are for avionic systems. Like 100% modified condition/decision
coverage for all software tests, strict. No pointer math and no dynamic memory
allocation, strict.

[https://en.wikipedia.org/wiki/Modified_condition/decision_co...](https://en.wikipedia.org/wiki/Modified_condition/decision_coverage)

~~~
gurneyHaleck
Being a party to lackluster software development on a regular basis, I
somewhat pine for projects this strict.

As part of my daily routine, feigning surprise at the fact that, given a tree
of decisions, I'm only permitted to code for the ones that make money, simply
to find that "Quality Testing" reveals the 500 other permutations will
inevitably result in thrown exceptions with hideous, glaring error messages.

" _WHOOPS._ "

~~~
rplst8
This sort of thing is exactly what some of the software development processes
are all about.

When I was in a CMMI training class 10 or more years ago, the instructor we
had said basically that much. By instantiating a process, it takes the mental
weight of knowing (or checking) if everything is correct.

No one builds cars that way - why should we build anything that way. The
processes should catch the inevitable human errors.

------
throwaway729
Does anyone know what this is referring to?

 _> We’ve engineered away what used to be the most common causes of accident_

~~~
sowbug
I'm not enough of an experienced pilot to authoritatively answer, but here's a
guess at some items.

* Sterile cockpit: a rule that pilots avoid any distracting activities during critical parts of flight (mostly takeoff/landing, flying around busy areas).

* Crew resource management: a shocking number of major commercial accidents have involved either confusion in the cockpit or one pilot who knew something was wrong but didn't feel he/she had the authority to say something. Tenerife is a very sad example. CRM is a set of procedures that specify how concerns are brought to the PIC (pilot in command) in a way that's unlikely to make things worse. Basically, it's an escalation procedure that is recognized on both speaking/listening sides as something that needs to be paid attention to.

* Checklists: Not sure if this is new, but it is completely routine in flight to consult standardized checklists for everything, whether ordinary takeoff/flight/landing or emergency situations. It's thus a lot less likely you'll make a stupid mistake in flight like running out of fuel because you forgot to switch tanks. (Actually people still run out often, but the out-of-fuel checklist includes ensuring you've remembered to switch away from the empty tank, meaning people don't crash planes with half their fuel anymore.) There is no cultural shame in consulting checklists; in fact my (limited) experience is that most pilots would question the judgment of someone who didn't use checklists. This is a bigger deal than you might think because most aircraft incidents are fundamentally attributable to human error.

* Better weather technology, both for prediction and real-time assessment.

Flight 1549 (the one that landed in the water with no deaths and just a couple
serious injuries) is a good example of the first three. You can listen to the
cockpit recording to see them all in action.

When the birds hit, the pilots were already 100% focused on the critical
takeoff portion of the flight -- zero distractions that could have delayed
reaction time.

The copilot immediately got out the POH (plane's owner's manual containing
tons of checklists) and started all the restart procedures while the captain
reflexively put the plane in the maximum glide position to extend range.

Then right as they're lined up for the river, Sullenberger asks the copilot
"Got any ideas?" While this might sound like comical desperation, it's
actually good CRM in action -- after they'd tried the checklists and were in a
somewhat stable descent, the captain solicited feedback from the second-in-
command, just to make sure they hadn't overlooked anything else.

Anyway, I'm sure my list is far from complete. Someone more knowledgeable can
continue it.

~~~
WalterBright
Checklists in aviation started in 1939, I think. Airplanes had gotten
complicated by then and pilots would routinely forget to set things up
properly for takeoff, etc.

Checklists have been incredibly effective in improving safety. It's a crying
shame that they are not used elsewhere, like for surgical procedures. Doctors
need to give up on the idea that checklists insult their competence.

Also, the health care industry could learn a great deal from the aviation
industry about eliminating human error. The health care industry just wings it
as far as I know, and hospital deaths due to stupid mistakes are legion.

~~~
andrewaylett
There's a movement towards checklists in healthcare, and the UK NHS is picking
them up, as I understand.

I'm currently reading The Checklist Manifesto by Atul Gawande, a surgeon.
Devops shouldn't be life-or-death, but I'd still like to learn and improve.

------
sean_patel
> Some will argue that it’s unfair to gerrymander statistics in this fashion,
> separating airlines into categories of convenience. However, it’s necessary.
> Regional carriers, for instance, can have substantially different cultural
> and operational environments than their legacy carrier affiliates. It’s the
> majors that set the standard, and it’s only fair that we measure from there.

Yes. It is gerrymandering, and no you can't wash your hands of the regional
carriers' crashes and deaths after you've stamped your 'trusted' name and
brand on their flights.

I am appalled at how they callously dismissed those plane crashes since 2001
like this.

> To be clear, there have been a handful of tragedies involving regional
> carriers and freighters... in which dozens died.

Really? 'dozens died' is ok, but 100s died is not? Are we cattle?

~~~
rplst8
> Really? 'dozens died' is ok, but 100s died is not? Are we cattle?

Yes. Some people are choosing to pay less for a little more risk. The market
should allow for that in the fringes. The vast majority of flying happens on
the major carriers, so having stricter standards for the majority of your
flying passengers is the right way to approach safety.

------
throwaway4891a
Also: Air Crash Investigation / Mayday / Air Disasters is an interesting
series if one is interested in real-world, root-cause engineering analysis.

------
chinathrow
RIP to the freight dogs though:

"2013: A UPS flight crashed on approach to Birmingham, Alabama, killing the
two pilots."

~~~
chinathrow
Why the downvote? UPS is a major airline - even if they only transport cargo,
humans still had to give their live.

Also, "freight dogs" is the gentle term for the pilots in cargo planes.

------
rl3
This would be why I always tell people to fly major U.S. legacy carriers if
possible, or their western equivalents (e.g. British Airways, Qantas). As a
general rule, major carriers from countries that have a pool of predominantly
native English speakers to hire from.

~~~
jpatokal
Actually, only two of the world's safest airlines hail from the US:
[http://www.telegraph.co.uk/travel/news/The-worlds-safest-
air...](http://www.telegraph.co.uk/travel/news/The-worlds-safest-airlines-
revealed/)

And 6 of the top 10 are not from English speaking countries (ANA, Cathay,
Emirates, Etihad, EVA, Finnair).

~~~
rl3
_Actually, only two of the world 's safest airlines hail from the US_

The list you just cited includes Alaska and Hawaiian on that list, for a total
of four US carriers. My original statement was in context of major legacy
carriers, so I could understand you excluding those—however, each of the
airlines you cited has a comparable—if not smaller—fleet size to that of
Alaska Airlines.

Also, keep in mind that major US carriers have underwent major consolidation
in recent years:

US Airways and American Airlines

United and Continental

Northwest and Delta

> _And 6 of the top 10 are not from English speaking countries (ANA, Cathay,
> Emirates, Etihad, EVA, Finnair)._

If you total the fleet sizes of each of these, you end up with 907 aircraft.
American Airlines alone operates 952 aircraft.

Moreover, many of the airlines you listed tend to hire Western pilots formerly
of major legacy carriers—captains in particular—in order to meet high PIC
experience requirements.

-

It's also worth mentioning that AirlineRatings.com[0] (the source of the list
you cited) currently assigns Malaysia Airlines a safety rating of 5/7, despite
the fact they managed to lose two 777 hulls (MH370, MH17) only months
apart—one of which was perfectly preventable (don't fly over active war
zones?).

The same site affords Asiana Airlines a similarly lofty rating of 6/7, despite
a 777 hull loss (Asiana 214) due to its pilots being unable to perform a
simple visual approach in ideal conditions at SFO. A truly stunning display of
incompetence that belied a terrible training and safety culture at the
airline.

Of course, going by safety records alone, I'm sure both airlines looked great
on paper about five years ago.

[0]
[http://www.airlineratings.com/safety_rating_per_airline.php](http://www.airlineratings.com/safety_rating_per_airline.php)

------
rplst8
One word. DO-178B.

