Air Safety Investigators: Using Science to Save Lives—One Crash at a Time

By Alan E. Diehl, PhD

This fascinating story explains how aviation crashes are investigated, and what goes on behind the scenes to improve safety. It is also the untold saga of how one maverick scientist battled the bureaucracy to save lives.

Federal officials hired him to prevent an anticipated bloodbath from airline deregulation. He soon introduced innovations, such as Crew Resource Management training, which dramatically reduced airline accidents. However, when he dared expose lies to Congress, officials used the sky marshals to harass him. They then ignored his other programs, which contributed to countless unnecessary deaths -- including JFK Junior's.

Becoming a military safety guru, his important tasks included training Air Force One crews, and going undercover to discover why a mysterious Soviet airliner crash killed an African president.

But he was fired for blowing the whistle on the Pentagon cover-up of the worst fratricide since Vietnam. Congress and other important organizations have often sought his advice on civil and military aviation problems.

• Language: English
• Publisher: Xlibris US
• Release date: Mar 18, 2013
• ISBN: 9781479728954

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Copyright © 2013 by Alan E. Diehl, Ph.D.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Rev. date: 4/9/2013

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CONTENTS

Foreword

Acknowledgments

Introduction

Chapter 1. Their Only Recourse

Chapter 2. The President Is Dead!

Chapter 3. Mrs. Mandela’s Mystery

Chapter 4. The Human Factor

Chapter 5. Joining the Go Team

Chapter 6. Understanding Pilot Error

Chapter 7. A Cavalcade of Crashes

Chapter 8. A Revolutionary Recommendation

Chapter 9. The Definitive Accident

Chapter 10. The Devil in the Details

Chapter 11. Hearing Justice

Chapter 12. Crossing the Rubicon

Chapter 13. Pushing the Envelope

Chapter 14. The Wild Blue Yonder

Chapter 15. Statistical Death Sentences

Chapter 16. Blowing the Whistle

Chapter 17. From Ketchup to Camelot

Chapter 18. It’s the System, Stupid!

Chapter 19. The Systems Approach Comes of Age

Appendix A. Brief Biographies of ASIs and Other Safety Experts Cited Herein.

Appendix B. Ways to Protect Yourself While Flying

Appendix C. Aeronautical Abbreviations, Terms and Definitions.

Detailed Biography of Dr. Alan Diehl

What the Experts Are Saying about Alan Diehl and This Book

DEDICATION

To the victims, Graca and Nelson Mandela—hopefully, you will soon learn what really happened on that African hillside. Jimmy Merryman, now you can understand why your dad hit those trees in Maine. Sylvia Tsao, this is why you and Flight Attendant Janice Brown could not save your son, Evan, at Sioux City. Mrs. Ron Brown this is what they would not tell you about the crash in Croatia that killed your beloved husband, the Secretary of Commerce. To the admirers of John F. Kennedy Jr., this is why he did not get the training that could have saved his life that hazy evening off Martha’s Vineyard.

Ye shall know the truth, and the truth shall make you angry.

FOREWORD

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(Bridgitte Krupke Photo)

Captain John Nance, ABC World News Aviation Analyst.

Despite the regrettable American tradition of slinging the word hero toward highly questionable recipients, true unsung heroes do exist among us; and occasionally, you may have the great luck to meet one (though, at the time, you may not know it). After all, the profile of an unassuming hero is someone who happily labors in obscurity, focused with laserlike precision on a target he or she deems bigger than their own self-interests. That, in fact, is what heroism is made of—selflessness coupled with great courage—and I was lucky enough to get to know and work with just such a gentleman.

It was the dawn of the greatest folly in American transportation history, a mistake of near-biblical proportions which subsequently squandered over forty billion dollars of corporate equity, thousands of lives, and a generation of airline professionals: The airline deregulation act of 1978. The damaging fallout from deregulation is still impacting air travel worldwide, but in the immediate aftermath in 1978 through 1980, one of the greatest concerns deep within the operational airline world (considerations a clueless Congress had pointedly ignored) was what was to become of air safety.

With new airlines popping up like fleas, the Federal Aviation Administration ill-equipped to guarantee safe operations, and the National Transportation Safety Board facing a potential surfeit of human-caused accidents they were ill-equipped to understand, the stage was set for a bloodbath.

Why that bloodbath did not fully occur is one of the hidden success stories of modern aeronautics and in no small measure resulted from the efforts of a single NTSB investigator in the right place at the right time—the author of this book.

The NTSB had traditionally viewed human-caused accidents as something they couldn’t effectively investigate or explain. We can’t get inside a pilot’s head, was the long-standing demurrer. With the threat of an avalanche of inexperienced airlines and aircrews joining an industry that kept crashing airplanes because of human failures, the board had become very uncomfortable with that excuse, and one of their first attempts to rise to the challenge was the hiring of a Ph.D. named Alan Diehl as their first human performance expert.

When the small community of Rockland, Maine, was impacted on the foggy evening of May 30, 1979, by the fatal crash of their local airline’s biggest airplane, Diehl’s dispatch from Washington to investigate the disaster was an unseen stroke of luck. A week into the field investigation, Diehl was on the phone to his boss in Washington with a question few, if any, of the other NTSB staff members would have known to ask: There’s something more going on here. Can I stay a bit longer? Indeed there was more going on, but it took additional weeks of sleuthing to be able to dig past the surface layers of the accident and lay bare a plethora of causal factors, all of which were vital to the understanding of how to keep upstart airlines safe, and none of which would have been understood without a man of Diehl’s background… and courage.

Courage because it took pushing a nonstandard way of looking at air disasters to finally lay open a dead pilot’s mind, exposing what the various factors were that contributed to the accident and what could have been done to prevent it. In Rockland, an oppressive management, an air of tolerance for dangerous rule-breaking, and a macho environment created to encourage cowboyish pilot behavior had coupled with poor maintenance, poor cockpit design, and all but nonexistent FAA supervision to kill seventeen people. Al Diehl’s point—which he refused to back away from—was that every facet of the many human failures in such an accident had to be fully understood and addressed if future iterations were to be prevented.

There were no banners back at NTSB headquarters celebrating this breakthrough, but it was a major turning point, and over the next few years Diehl’s courage (some detractors called it political naiveté) overcame numerous obstacles and traditionalists to pioneer innovative ways of researching accidents. The techniques Diehl pushed into acceptance allowed the rapidly expanding airline and aviation industry to better predict what pressures and factors in their own operations might make a human failure accident more likely. The majority of these folks heretofore had soft-peddled threats such as crew fatigue, management pressure to fly regardless of risk, equipment ergonomics, environmental stressors, and government blunders. Now these impediments were laid on the table—not always to the applause of government overseers.

Nevertheless, what Diehl had materially helped midwife was a historic change in the way not only the NTSB but all accident investigators around the world approached systemic failure in complex human systems: by unveiling the causal role of human failures (not just pilot error) in crashes.

Al Diehl also drafted a host of important recommendations, including one that helped spark one of the most momentous changes in aviation history: the advent of Crew Resource Management or CRM. In fact, his steady hand as a major-change agent and the invaluable nature of his contributions in how human accidents were investigated, and his stewardship of effective countermeasures such as CRM cannot be overstated.

Certainly he did not work alone, nor do it all himself. But without his role as a major catalyst of change and without his indefatigable efforts in disregard of his own career, it would be hard to imagine how the following decade would have avoided a steady increase in major accidents as opposed to the eventual decline of the crashes we actually experienced.

And yes, CRM was and is that incredibly important!

There is a substantial flaw in the structure of the NTSB in my opinion, and that is that when the FAA refuses to implement even the most urgent of its safety recommendations; it is powerless to compel the change having not even standby rule-making authority. Frustrated with FAA intransigence on many levels, Diehl elected to leave the NTSB and join the FAA to work from within—and his timing was propitious.

Deep within FAA headquarters, the individual responsible for deciding whether to let United Airlines (which fielded the first CRM curriculum) continue its fledgling program had all but decided to terminate it. After all, he reasoned, the FAA had given United some leeway in substituting CRM training for other required training, but there seemed to be no metrics the FAA was comfortable using which could validate CRM’s effect, and no understanding that what FAA was essentially asking for was proof of a negative: How did this course help avoid the accidents we never had?

It was Diehl—already tagged as a maverick in the highly structured, iconoclastic world of FAA headquarters—who presumed to do everything but stand on his leader’s desk to avoid that program cancellation. He succeeded, but during the age when rocking the boat was hazardous to your career, others took note.

What the FAA had acquired in hiring Diehl was a dangerous commodity in bureaucracy: integrity. The thought that also blowing the whistle on FAA officials for intentionally misleading Congress might be dangerous did not deter him. And he and a colleague (Dr. William Shepherd) blew the whistle hard. The misinformation was over using infant car seats in airliners, which the airlines had pressured the FAA to reject despite their proven worth.

Diehl and Shepherd’s reward was to be investigated by a cadre of FAA sky marshals illicitly diverted from their security duties and directed to find out not only who had leaked the information to Congress, but also how the miscreants might be vulnerable to firing. When the whistleblowers were unmasked, they were threatened not just with termination, but also prosecution on federal criminal charges—an improper threat that never went further than saber rattling.

Roughly, this was the point at which an NTSB investigator responding to my research on a new book that would become Blind Trust (Morrow, 1986) told me of the Rockland, Maine crash of Downeast Airlines and the man who had changed everything with his investigatory techniques. I found Al Diehl unassuming and immensely helpful when I located his warren deep inside the FAA’s citadel.

After the publication of the book—and being involved in safety as a U.S. Air Force Reserve pilot—I discovered Diehl had been contacted by my own service’s safety center then at Norton AFB in California. Realizing that a man of high integrity unimpressed by internal politics might not be well received in the Air Force’s hierarchical command structure, yet wanting his expertise, I advised him to approach with caution. But I’d be less than candid to deny that I was anything but delighted when he took the position to help my service out of its very embryonic stages of human factor awareness.

Al Diehl was anything but naive about the military. Having served as a Navy psychologist after enrolling in a college Army ROTC program and becoming an Air Force Academy cadet. He had also worked on human factors issues involved in several groundbreaking military projects, including early laser-guided weapons and the AC-130 gunship.

But it was a bit of a surprise when in late 1986 while wrapping up his FAA work, an urgent call came in from his new employer, the Air Force. Could he help, they asked, in a potentially dangerous mission of the utmost national importance?

A Soviet jetliner had crashed in Africa killing the President of Mozambique. The crash occurred in the Republic of South Africa, and its government requested the assistance of our best investigators. Diehl agreed, and a short time after flying to South Africa he uncovered vital and disturbing details on how the Soviets had been operating, and what could have caused the crash. Recognizing the extreme sensitivity of the case, he provided timely reports which were later praised by the highest levels of the Reagan administration.

Months later, Diehl formally reported to the Air Force Inspection and Safety Center to assume his duties as their senior technical advisor, an important job which would become rapidly far more demanding by the many bureaucratic obstacles rolled into his path.

Having come to know him, and still being an active AF Reservist, I was delighted by an invitation to assist my service’s new senior advisor in pushing the acceptance of crew resource management and human factors awareness. Together over the next year we briefed top officials around the Air Force and in the other services. The topics ranged from methods of improving mishap investigations to the benefits military CRM programs might provide. Diehl meticulously analyzed data on the effectiveness of earlier civilian and military CRM programs, which impressed most of our senior leaders, and I lent whatever efficacy the experience of an operational line pilot (then for the Military Airlift Command) could provide.

In fact, I had personally used CRM techniques and helped bring the first programs into the Air Force in 1987 through the offices of the MAC commander in chief, General Dwayne Cassidy. The line pilot point of view added credibility to our argument that these were doable and incredibly important techniques that would substantially reduce our exposure to fatal accidents.

I love my service, but the Air Force—like all other military services—has its share of iconoclastic individuals in high positions who, for their own reasons, sometimes strangle a necessary change in its crib. In fairness, not all our generals were convinced that aircrew members needed to understand how to form and nurture collegial interactive teams versus just being Captain Kirk-class commanders. One such three-star utterly destroyed a pivotal briefing to the Tactical Air Command when… after three hours of winning over TAC’s senior command leadership… Lt. Gen. Joe Ashy sauntered in and dismissed human factor programs—and our briefing as pure B***S***. His destructive remarks unsupported by even a modicum of understanding or exposure to the facts cost the Tactical Air Command over a decade of progress in accident prevention and cost many airmen their lives.

Tragedy after military tragedy, investigation boards would call in Dr. Diehl, and too many times, when major lapses in leadership or failure to install appropriate training programs were shown to have led directly to the tragedy, embarrassed commanders—sometimes at Pentagon level—would shove back, either demanding Diehl’s analysis be expunged from the final accident reports, or ordering him to shut up and return home as quickly as possible. The full and galvanizing stories are in the pages that follow, and they show clearly the desperate need for a thoroughly independent military NTSB reporting directly to the secretary of defense. I say this with sadness because we try to be people of high integrity in the U.S. military, but we are not to be trusted with investigating ourselves when our own systemic failures are involved.

Ultimately, Al Diehl and all his immense experience and understanding of human factors in accident investigation (and the only Ph.D. serving at the Air Force Safety Agency then relocated to Kirtland AFB in Albuquerque) was demoted and reassigned on what I personally know to have been (and communicated clearly to senior USAF leadership) trumped up and patently false charges. Ironically, the demotion came almost simultaneously with a letter of high praise from a member of the senior air staff in the Pentagon.

While the details are in this book, the subscript is that we have yet to figure out how to truly protect those with the courage to stand up and refuse to be silenced, especially when the welfare of our men and women in uniform is at stake. That, you see, has been the history of Al Diehl’s service and alleged insubordination: the refusal to be quiet when flaws need to be spotlighted and corrected. In fact, people are still dying unnecessarily because of our failure to protect such heroes.

It continues to be my high privilege to know and follow Alan Diehl, and I was delighted at the publication of his 2002 book, Silent Knights: Blowing the Whistle on Military Accidents and Their Cover-Ups. In fact, when my own son, Christopher, entered USAF ROTC, I was pleased to find the book required reading for his class—required reading about the courage of integrity and speaking the truth.

Air safety, especially among the airlines, has improved exponentially in the past fifteen years—with the total absence of passenger fatality crashes for the U.S. major airlines for a full ten years by 2012!

Of course, I can’t lay all the credit at the feet of Alan Diehl and forget the major contributions of such people as Dr. John Lauber and so many more first-level pioneers. But you can take this one to the bank: If there had been no Al Diehl at FAA and NTSB, there would have been a much longer and bloodier path to the present level of safety which, at long last, approaches perfection and the Holy Grail goal of zero accidents. CRM was and continues to be a major factor in having saved countless lives, and it is also lighting the way for American medicine and hospitals which are only beginning to understand the need for collegial teamwork and the end of the commander syndrome.

This book lays a deep foundation for understanding all this progress, and it does so through the eyes of a true pioneer, and without question, a true unsung American hero.

John J. Nance, J.D.

Friday Harbor, Washington

ACKNOWLEDGMENTS

I would like to gratefully acknowledge the many people who made this book possible. First and foremost, my fellow air safety investigators, living and dead, who taught me the art and science of conducting aviation accident inquiries. Secondly, the professors, scientists, engineers, and technicians who educated me on what had to be done to understand the cause of these tragic events and how to prevent their reoccurrence. Thirdly, the pilots, flight instructors, and other aviation experts who made me aware of the issues involved in this complex field. Lastly the various individuals who helped me write this book.

This latter group includes John Nance, the author of over twenty books and screenplays himself, who made important suggestions on how best to tell this story and who graciously wrote its foreword. Three editors also made numerous corrections and very insightful suggestions to this manuscript: Jerry McGowan, Doug Hawley and Kirt Hickman, along with my loving and ever-patient wife, Marlyn Schultz-Diehl. Valuable assistance with some of the images was also provided by Dave Straub, Kristine Straub-MacCanon along with Jerry McGowan.

Furthermore, I need to acknowledge the important information sources that I have relied upon over the years and in the preparation of this manuscript, including: Aviation Week & Space Technology, the journal of record for this industry; the International Association of Air Safety Investigators, the most important organization for professionals working in this field; the Aircraft Owners and Pilots Association, the world’s largest pilot member organization that continuously promotes general aviation safety; the Air Line Pilots Association that has provided vital assistance to individuals working to enhance air carrier safety; the Association of Flight Attendants whose members constantly strive to enhance airline passenger and crew safety; the Flight Safety Foundation for its important contributions to this field; and Curt Lewis & Associates whose daily on-line news letter is priceless in keeping abreast on the rapidly changing developments in this field.

I also want to express my deep appreciation to the various members of the Xlibris staff who helped bring this book to the public in a timely and professional manner. Specifically, Tim Fitch, Cynthia Mathews, Joy Daniels, James Calonia and Archie Brown for their many critical inputs to the publication process.

INTRODUCTION

The U.S. major airlines recently passed an almost unbelievable milestone. They went a full decade without a single passenger dying in a crash. The last such accident occurred on November 12, 2001, when an American Airlines Airbus A300 crashed just east of Manhattan, killing 265 people.¹

This book describes how this amazing record came about and why all segments of aviation still need to address safety issues.² It also contends that embracing the lessons learned from our major airlines could result in more outcomes like the one that occurred ironically on the other side of Manhattan several years after that last tragic accident.

When Captain Chesley Sully Sullenberger successfully ditched his USAir Airbus A321 in the Hudson on January 15, 2009, he stood on the shoulders of giants.³ His skills and knowledge were acquired over decades, with the help of many other people.

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(USCG Video Photo)

Airbus in the Hudson.

Sully’s postgraduate education in human factors provided him with insight into the largest single challenge in aviation safety. While flying for the Air Force and a major airline exposed him to superb flight and simulator training.

He, like all modern airmen, also benefited from the work of aviation experts such as scientists, engineers, designers, and accident investigators. While other pilots, who explained how they had averted earlier disasters, undoubtedly facilitated his thinking.

So when birds suddenly disabled Sully’s engines over Gotham, he responded like a champion quarterback, calling an audible and promptly heading for the best emergency landing site. He then pulled off a Hail Mary by setting that high-tech glider down perfectly on a broad river peppered with vessels.

While such miracles are rare, there has been steady progress in enhancing aviation safety in recent decades. This book describes the many struggles involved in achieving those advances.

Much of the success can be attributed to the integration of human performance and systems safety concepts into mainstream aviation. Another significant innovation was the advent of crew resource management. This remarkable training was largely invented by NASA, refined by academia, and eventually embraced by the global airline industry. Such efforts became increasingly important as the pace of technology accelerated.

I was fortunate in being able to witness, and in some cases to help affect, many of these vital developments. And like Sully, I also stood on the shoulders of giants who were my predecessors or contemporaries.

A few of these experts are famous, like aviation news analyst John Nance and consumer advocate Ralph Nader. Others like former NASA scientist John Lauber are well-known in technical circles. But many individuals, who also played critical roles, are unknown except to a handful of colleagues. Somebody needed to describe their vital contributions.

This story is told through the eyes of a working air safety investigator. These dedicated detectives, like crime scene investigators, must race against the clock and long odds to protect the public.

But ASIs know that, because of the nature of aviation disasters, hundreds of lives can be lost from a single mistake on their part. Thus, ASIs diligently try to discover why planes crash so other experts can develop effective countermeasures to prevent future tragedies.

Some of these investigators also confront organizational problems in attempting to change the system—usually by forcing intransigent bosses to do the right thing rather than ignoring critical safety issues. This memoir is an insider’s account of how events actually unfolded in the organizations responsible for protecting everyone who flies.

CHAPTER 1. Their Only Recourse

United Flight 232 departed Stapleton International Airport on a lovely Denver afternoon heading for Chicago. July 19, 1989, was children’s day, so dozens of youngsters were among the 296 people aboard the massive DC-10.⁴

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(Don Boyd, Sunbird Photos)

United DC-10 Taking Off.

Captain Alfred Haynes expected this would be another routine flight. But the soft-spoken fifty-seven-year-old knew that in aviation nothing can be taken for granted—hence the adage: Flying involves endless hours of sheer boredom, punctuated by moments of stark terror.

This cliché became all too real for Captain Haynes sixty-seven minutes later when an unrecognized engine problem suddenly threatened the lives of everyone aboard his jet.

Aviation safety has always depended upon the proper functioning of many complex systems and resources. These diverse elements include the design of the aircraft and its subsystems, all of which have to operate flawlessly in a highly stressful environment.

And while mechanical components are important, humans have historically been the most critical items in the safety equation. Human issues involve the knowledge, skill, and judgment of both flight and ground crew members. For a momentary lapse by any of these individuals can be deadly.

Safety also depends on other people—the aircraft’s designers and the Federal Aviation Administration employees, who oversee the regulatory aspects of this complex symphony of systems.

But earlier mistakes by these latter two groups have jeopardized the DC-10’s safety and already claimed hundreds of lives.⁵

The first such disaster occurred on March 3, 1974, after Turkish Airlines Flight 981 departed Paris. As that DC-10 ascended, the air pressure kept increasing inside its fuselage—until a cargo door sprang open. A poorly designed latch mechanism had allowed the ground crew to close this huge door without being able to determine if its locking pins had properly extended into the doorframe.

Human factors experts have always labeled such mistakes as design-induced errors.

The sudden opening of this door at altitude caused an explosive decompression. A massive volume of rapidly escaping air distorted the cabin floor structure. This deformity jammed the cables to the craft’s flight controls and its tail-mounted center engine.

Six passengers died instantly after being ejected through a gaping hole ripped in the fuselage. They were the lucky ones. The rest of the 340 terrified passengers and crew members perished when the jet slammed into wooded terrain, seventy-two agonizing seconds later.

Unbelievably, the manufacturer, Douglas Aircraft, and the FAA had known about this design defect from an earlier DC-10 cargo door opening incident. It occurred when American Airlines Flight 96 departed Detroit on June 12, 1972. But nobody got killed—that time. So little was done to correct this potentially deadly deficiency.

That was not the last time Douglas’s design defects and the FAA’s certification mistakes on the DC-10 caused problems. On May 23, 1978, American Airlines Flight 191 was taking off from Chicago’s O’Hare International Airport when the number one engine violently separated from its left wing, rupturing nearby hydraulic lines.

Hydraulic fluid always was the life-blood of a jumbo jet. And losing this vital fluid allowed the slats located on the leading edge of the jet’s left wing to retract.

These slats had to be extended from both wings hydraulically during takeoffs and landings to generate the increased aerodynamic lift needed at low speeds. But Douglas and the FAA failed to require slat interlocks to preclude these vital control surfaces from moving asymmetrically.

The retraction of the left slats drastically reduced lift generated by that wing, which prevented the pilots from arresting the craft’s violent rolling maneuver. The jet immediately impacted in a nearby field and trailer park.

All 258 passengers and thirteen crew members perished in an instant, along with two other victims on the ground. But they were not the last to die in this tragedy.

Investigators eventually concluded the engine separation problem was caused by mechanics improperly removing the power plant and its pylon together from the craft’s wings. The approved procedure required that the pylon be removed only after its heavy engine had been detached. Removing the pylon and engine together was a cost-cutting shortcut that damaged the wing structure.

Adding to this tragedy, the American Airlines maintenance supervisor who blamed himself for the use of this unapproved procedure later committed suicide. ⁶

However, historically most accidents were blamed on pilot error. And aviators like Captain Haynes knew they could learn to avoid repeating the mistakes of others by studying