Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, November 13, 1994 TAG: 9411140092
SECTION: NATIONAL/INTERNATIONAL PAGE: A-1 EDITION: METRO
SOURCE: New York Times
DATELINE: LENGTH: Long
Only after the jet had landed safely and the ground crew had discovered the fuel situation did the captain acknowledge that there was no engine problem. Behind schedule in Washington, workers had neglected to refuel the plane, and the pilots had not checked the gauges before takeoff.
The error and attempted concealment from federal authorities was one of a number of safety and training lapses uncovered in a New York Times examination of USAir undertaken after a USAir Boeing 737 crashed near Pittsburgh Sept. 8, killing 132 people.
The crash, the worst aviation disaster in this country since 1987, was the fifth for USAir since 1989, the worst record of any major American airline in more than 20 years.
After the September crash, federal officials and USAir executives rushed to defend the safety of the airline. The Federal Aviation Administration said that USAir met all its safety requirements. USAir executives said that its accidents were not connected and that there was no reason to draw negative conclusions about safety. They strongly denied that financial troubles had had any impact on safety.
``When it comes to safety, we are well within the mean range, and better than some,'' Seth E. Schofield, USAir's chairman and chief executive, said in an interview. ``The reality is that if I thought the airline was unsafe, I would ground every plane.''
But a less reassuring portrait of the nation's sixth-largest and busiest airline emerges from thousands of pages of federal safety records and court files covering the past five years that were examined by the Times.
For example, the Flight 565 fuel scare was not an isolated incident. Records show nine instances in which USAir planes left the gate without enough fuel since the airline eliminated two pre-flight refueling checks 16 months ago. The cutback was made to save time, despite concerns expressed by the FAA.
In addition, interviews with safety experts and the analysis of court files and documents obtained through the Freedom of Information Act, which provides public access to government records, found the following:
Despite USAir's insistence that its five fatal accidents since 1989 are not connected, failures by pilots to follow federal and airline regulations were factors in two crashes at La Guardia and pilot actions are under scrutiny in a third, the crash of a DC-9 during a thunderstorm in Charlotte, N.C., on July 2.
A national team of FAA inspectors last year found more than 40 deficiencies in USAir's flight operations and training programs for its more than 5,000 pilots. One problem involved falsely certifying that a captain had completed training to avoid the violent downdrafts known as wind shear.
USAir is more than $2 billion in debt and losing $2 million a day, causing some employees to feel pressure to keep planes flying. In one incident, a USAir maintenance supervisor said he had tried to save the company money by allowing a plane to fly, even though a mandatory warning system was inoperative. In another case, USAir violated FAA regulations by permitting a plane to fly for 13 days without proper repairs to a dented and cracked wing flap.
Concerned by the Charlotte crash, FAA officials met Aug. 29 with USAir executives to discuss improving safety and training. Although USAir and FAA officials described the session as friendly, others said the airline had been put on notice to strengthen its training and safety programs. Ten days after the meeting, the USAir 737 crashed near Pittsburgh.
Jim Burnett, who served nearly a decade as a member and chairman of the National Transportation Safety Board, the independent federal agency that investigates accidents, said there might be a connection among three of the five USAir crashes.
``From the issues of pilot training and cockpit discipline, you could potentially have a connection between three there,'' said Burnett, now a lawyer in Arkansas. ``The NTSB members are failing to do their job if they fail to look at those lines and see if they make a picture.''
With hundreds of flights every day, no big airline is immune from mistakes and even accidents. Yet the American airline industry is still regarded as the world's safest. In fact, a person is about as likely to be killed by lightning as to die in an airplane crash, according to statistics from the National Safety Council.
It is precisely because the large carriers' overall performance is so good that USAir's record has attracted such attention. Everything from pilot training to the effect of mergers on airline safety has come under federal inquiry. And the FAA has increased its scrutiny since 1992 because of USAir's crash record and its financial condition. In addition, NTSB officials have indicated that they are examining USAir's management culture in the search for a possible explanation for the series of crashes.
In a letter Friday to the New York Times, James T. Lloyd, USAir's executive vice president and general counsel, said:
``Because of this intense regulatory scrutiny, and because of our own determination to check, recheck and report every aspect of our operations, it is possible to look through the tens of thousands of reports that accumulate over time and build a picture that distorts the fundamental truths. Any time you have millions of takeoffs and landings and 45,000 employees, and you put them under a microscope, you will find some irregularities. But this does not mean the company is lax, and, in fact, it means that if there is a problem, we find it and we fix it.''
USAir was a small regional carrier when it bought Pacific Southwest Airlines and Piedmont Aviation in 1987 and merged them into a single, international airline by mid-1989.
Along with the wave of mergers came new safety concerns as airlines struggled to integrate different training and safety procedures into a uniform system.
Indications of problems at USAir came abruptly, in the form of an accident and a highly critical inspection report before the end of 1989.
On Sept. 20, 1989, a USAir 737 ran off a runway into the East River during takeoff at La Guardia, killing two people and injuring 21.
The National Transportation Safety Board blamed pilot error for the accident. The board said the captain had failed to detect a misaligned rudder and had not followed the airline's policy of using the autobrake, a computerized braking system that might have stopped the plane before it went off the runway. The board also said he failed to exercise his cockpit authority when the problems developed.
Burnett, then a board member, urged his colleagues to name USAir as a contributing factor in the crash because the airline failed to provide a properly trained crew. But the other members thought the evidence was not strong enough.
Three months after the crash, questions about USAir's pilot training were raised in a report prepared by a special FAA inspection team. The inspectors found that retraining sessions offered too little challenge and had unrealistically low failure rates - 15 failures among 1,700 pilot evaluations, less than half the industry rate, according to safety experts.
Questions about pilot training arose again after a second accident at La Guardia 21/2 years later. On March 22, 1992, a USAir Fokker F-28 crashed into Flushing Bay on takeoff, killing 27 people. The probable cause, the safety board said, was ice on the wings, which reduced the plane's speed and made it harder to control.
But the board also said pilot mistakes had contributed to the accident. And earlier this year, a federal judge in Cleveland ruled that USAir was negligent because of the failure to detect the ice in the 1992 crash.
The USAir jet had been de-iced 35 minutes before the attempted takeoff, about 15 minutes after the effectiveness of the de-icing fluid had lapsed. Evidence indicated that the pilots had not returned to the gate for another de-icing because they had not wanted to lose their place in line for taking off.
The pilots had checked the wings for ice only by looking out the cockpit window, which did not provide a complete view. Further, the NTSB said, the captain contributed to the crash by reducing the takeoff speed below the approved level.
As a result of NTSB criticism, the FAA imposed stricter de-icing standards on the industry. USAir said it had upgraded its de-icing procedures since the accident.
Yet federal records indicate that USAir has continued to have difficulty following de-icing procedures. In the most recent incidents, the FAA discovered two cases last March in which USAir personnel failed to follow the procedures. The inquiries came after callers alerted the agency's aviation safety phone line, which investigates complaints from the public and industry.
In a third call to the safety phone line earlier this year, a USAir captain complained that USAir crews in Charlotte were not properly inspecting aircraft wings for ice in stormy conditions, the same issue that arose in the La Guardia de-icing crash. A follow-up FAA inquiry said the captain's concerns were valid and that the agency was working with the airline to improve procedures.
In another call on June 6, less than a month before the Charlotte crash, a USAir pilot complained that another USAir captain had taken off that evening from Philadelphia International Airport in a heavy thunderstorm with lightning and ``a potential for a wind-shear situation.'' FAA records show that the caller's concerns about the weather were borne out and that the incident remains under investigation.
by CNB