Friday, January 25, 2008

FAA History Lesson -- January 25



From the FAA Historical Chronology, 1926-1996...

”Jan 25, 1990: Attempting to land at New York Kennedy airport, a Boeing 707 operated by the Colombian airline Avianca ran out of fuel and crashed on Long Island, fatally injuring 73 of the 158 people on board. On Feb 25, demonstrators drove a procession of automobiles through Kennedy as a protest against air traffic controllers’ alleged mishandling of the flight. The National Transportation Safety Board cited the probable cause of the accident as the crew's failure to manage their fuel load or alert controllers to their fuel emergency. Among the contributing factors, however, the Board pointed to a lack of clear, standardized terminology on fuel emergencies, as well as inadequate traffic flow management.

FAA’s actions in response to the accident included steps to address these concerns and to stress the need for clear pilot/controller communication and for air carriers to be thoroughly familiar with rules and procedures. “


As most of you have already read on Wednesday, in Air Traffic Safety vs. Capacity, I used this accident to highlight the safety implications of over scheduling airports. Avianca 052 was held on three separate occasions during it’s flight to Kennedy (JFK.) The total time in holding was 1 hour and 17 minutes.

Still, the aircraft had enough fuel to make an approach to JFK. However, the weather was so bad that they never saw the runway and had to go around for another try. They didn’t make it.

Like all aviation accidents, there are a number of errors to note. After the missed approach, the captain told the co-pilot (who was operating the radios) to declare an emergency. The co-pilot never did. You could write a book on just the language problems found in this accident. The controllers knew that the aircraft was “running out of fuel” but so was everyone else on this night. From the moment any aircraft takes off, it is running out of fuel.

You can read an analysis of the accident at Aviation Safety Network. There is a link at the bottom of that page where you can download the NTSB’s report if you so choose. I’ll warn you ahead of time, it’s a tough read. It’s 295 pages of mismatched fonts and formats that were scanned into a .pdf file.

The one odd detail I would like to mention is the experience level of the controllers. Of the five New York controllers mentioned (4 controllers and 1 supervisor), all five -- every single one of them -- was hired in 1982. That’s eight years of experience per person. No one with 18 years of experience -- much less 28 years. For the non-controllers out there that aren’t making the connection, PATCO went on strike in 1981.

It’s hard to quantify experience. There’s no telling if it would have made any difference in this situation or not. In the end though, I’d rather have that one old guy -- the one with that nagging thought that something isn’t quite right -- looking at the radar scope too.

By the way, controllers hired in 1982 became eligible to retire last year, in 2007.

I’ll leave you with the comments of NTSB member Jim Burnett about this accident.

” While I can accept the argument that such unsatisfactory service was not causal to this accident, this pattern of substandard service reflects poorly on the ATC system and raises serious safety concerns.

Although the reasons for this pattern of substandard service have not been developed in the report, I suspect that it has little to do, in this case, with the experience level of the controllers and a great deal to do with controller workload under the weather conditions and with the fact that the Federal Aviation Administration flow control intentionally allowed a greater flow of traffic, bound for JFK, into the system than could be safely and efficiently accommodated by the system. “


Don Brown
January 25, 2008

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