One wonders if we are not already at the age of Big Brother, in light of the most recent, albeit, welcome news that the airplane crash that killed three executives of Tesla Motors was caught on audio tape and is now providing assistance to air safety investigators.


On Wednesday, February 17th, Douglas Bourn a senior engineer at the electric car company Tesla Motors, flew his 33 year old Cessna 310 into a high power transmission line shortly after taking off from Palo Alto Municipal Airport in California. Mr. Bourn, an experienced pilot, multi-engine, instrument rated and a certified flight instructor failed to make the required departure turn out over the bay and instead flew the plane into the tower killing himself and the other two executives who were passengers on the flight.

The limited visibility conditions on Wednesday morning may have been an added complication. A pilot who arrived at the airport shortly after Mr. Bourn took off told a reporter visibility was terrible. The NTSB puts it at 1/8^th of a mile. Either way, Wallace Moran, a retired airline captain and F.A.A. pilot examiner who has frequently flown from Palo Alto airports told me, he suspects something else went wrong and limited visibility might have just compounded the problem.

“There are other things that could cause him to go in the wrong direction either instrument issues with the airplane or a medical condition with the pilot, so the NTSB will look at those possibilities.”

What the NTSB has to work with, and this is really a fascinating wrinkle to the investigation, is a series of five audio tapes made from a city wide acoustic surveillance system in East Palo Alto, California. I’ve posted one of them here.

As Police Department Capt. Curt Estelle explained it to me, eighteen months ago the city installed the ShotSpotter recording system. The recording triggers when the sensors detect the kinds of sound associated with gunfire and a report and location information is sent to the police department. “It allows us to respond a lot faster and with a lot more precise location information rather than waiting for citizens to call,” Capt. Estelle told me.

I don’t know what kind of crime problem they have in East Palo Alto, but Capt. Estelle says the department gets about 100 triggering events a month including fireworks which are illegal there. Plane crashes? Capt. Estelle says this is the first.

It was quick thinking on the part of ShotSpotter president James Beldock that resulted in capturing the sound of the crash and putting it together for NTSB investigator in charge Josh Cawthra. Within minutes of learning about the accident, Mr. Beldock checked to see if the system picked up either the engine or impact noise. It had.

This gives Mr. Cawthra an unexpected clue, five recordings of the sound of the airplane as it approached impact and several seconds following, recorded at distances ranging from 600 to 1500 feet. As dramatic as it might be to the lay listener, these recordings should prove illuminating to the specialists in the NTSB sound lab, where Mr. Cawthra said they are now headed.

I was curious to know how a recording system that triggers on certain sound frequencies actually catches the sounds preceding initiation. Mr. Beldock explained it to me yesterday, while I was interviewing him for The New York Times Wheels blog. As it turns out, the system has a “trailing buffer,” which from what I can tell means it is actually always recording.

“You often hear noises right before a shooting and that’s important,” Mr. Beldock explained. A sound determined by the system to be significant, prompts the memory to store the sounds immediately beforehand. Otherwise that memory is constantly recording over itself.

In the midst of the tragedy for Tesla and for the dozens of people in the community who were certainly traumatized by the event, this technological “who’duh thunk it?” provides a tiny bright spot.

I'll grant that math was never my strongest subject, so correct me if I'm wrong here. But after reading the Federal Aviation Administration announcement today that it will fine American Eagle $2.9 million for failing to comply with an airworthiness directive, I got out my calculator to see just what this fine really represents. Transportation Secretary Ray LaHood's characterization notwithstanding, it doesn't sound so "stiff" to me. But first some background.


Over the past few years aviation safety authorities have issued a few directives to both the private and commercial operators of Bombardier aircraft regarding landing gear and gear doors. Suffice to say there have been problems.

Air travelers will be most familiar with the Bombardier, a 70 seat regional jet with a $35 million price tag. American Eagle owns two dozen of them and you'll see them in service at mid-sized airports and throughout the Caribbean.

After a main landing gear door flew off an airplane in flight, the F.A.A., in the summer of 2006 ordered all airlines operating the CRJ 700 to inspect the gear doors for cracks as well as loose or missing fasteners. Airlines had plenty of time to do this inspection which the feds estimated would cost about $65 per airplane. Nevertheless, according to the F.A.A. in 2008, American Eagle flew four airplanes with gear door problems on more than 900 flights. Even after discovering the flaws, American Eagle failed to fix the problems in the manner dictated by the directive.

On the one hand, we've got to give credit to the F.A.A. for fining American Eagle. What should be given the fisheye is the size of the penalty and that's where the math comes in.

For ignoring an order that airplanes with a safety problem be inspected and properly repaired and instead putting fare paying passengers on those airplanes more than one thousand times, American Eagle is being asked to pay what amounts to $2461 per flight.

That's why I'm having difficulty accepting Secretary LaHood's statement, "Airlines must know that if safety is compromised, they will be subject to stiff fines." When safety is compromised how about a fine slightly larger than the price of a first class domestic ticket?

It has been my experience that the F.A.A. proposes a fine but at the end of the process, the airline pays far less. I call your attention to the phrase "proposed civil penalty" and the concluding sentence in the F.A.A.'s press release. "American Eagle has 30 days from the receipt of the FAA's civil penalty letter to respond to the agency."

Earlier this month, the F.A.A. proposed American Eagle pay $2.5 million for misstating cargo weights on more than one hundred flights. This isn't like lying about a pound or two when visiting the doctor's office. Determining actual aircraft weight is critical to safety. When asked about this, a spokeswoman for American Eagle told the Washington Post, the paperwork wasn't accurate but the computer tracked weight used by pilots was. As for the F.A.A.'s proposed penalty, she called that "excessive and inappropriate."

The Airline Pilots Association is furious about the probable cause issued by the National Transportation Safety Board in the crash of Continental Express flight 3407, (Colgan Air) and not just because the labor union exists to look out for the best interests of its members. No, ALPA is outraged because in determining what happened to Continental Express flight 3407, the NTSB focused on a symptom and ignored the cause.



Following a hearing on February 2, the board determined that the pilots of the flight, Capt. Marvin Renslow and First Officer Rebecca Shaw, mishandled a stall, and despite the fact that there was time to recover, failed to do so, causing the crash.

The NTSB's hearing was lengthy and detailed including discussion of crew training, fatigue, company policies and hiring practices. But at the end of the day, according to the board's finding of probable cause, responsibility for the accident falls to Renslow and Shaw.

In a statement later, ALPA president John Prater pointed out what should be obvious to the board because its a basic truth in accident investigations; there is no one cause.

"The Board has missed a valuable opportunity to highlight the many factors that combined to cause this tragedy," Mr. Prater said.

The full NTSB probable cause statement follows below, but in summary, the board cites four actions, lapses actually, the crew's failure to monitor airspeed, its failure to observe discipline in the cockpit, the captain's failure to monitor the flight and the airline's operating procedures for flights in icing conditions.

It's a list that heaves buckets of blame on the pilot. Okay, he's not qualified by many measures - the most dramatic being a record of failed check rides and an inability to focus on the task at hand as seen from a cockpit voice recorder transcript that demonstrate this guy's mind was everywhere but on the flight.

The larger question, one that begs examination, is how was he in the cockpit in the first place? How does a succession of first officers work with a pilot who's flying skills and lack of professionalism are so apparent without passing along their concerns? How does his employer fail to note these shortcomings?

John Gadzinski, an airline pilot and fellow member of the International Society of Air Safety Investigators told me once - and I'm going to paraphrase here because truth be told, we were drinking at the time - that an airline's commitment to safety can be easily determined by answering this simple question. Is there a gap between its policies and its practices?

Colgan repeatedly states that safety is a top concern and yet, here's the gap. Colgan claimed to have a policy prohibiting pilots from overnighting in crew lounges yet it was a well known fact that commuting pilots did just that. Colgan claimed use of personal electronic devices was prohibited and yet the 24-year old first officer on the flight not only felt free to send text messages but when she did so, the captain failed to say anything to her about it.

Sterile cockpit? We'll that's not just a Colgan "policy" its an F.A.A. requirement. On the night of the crash, Flight 3407 had an hour-long taxi out at Newark Liberty Airport while waiting takeoff. Virtually the entire time was spent in conversation, but only sixteen minutes of talk was about the flight.

Its just not believable that this kind of cockpit behavior was unknown to Colgan. Getting to the heart of why that was the case is entirely relevant to determining why this plane crashed. Its bigger than Mr. Renslow and Ms. Shaw. Its bigger than Colgan too. There's a crisis here, but you'd never know it by reading the probable cause statement.

Sure, its recognized by the safety board to the extent that it plans two public events, one to study pilot training and standards and another to look into "code-share" operations.

Whether the effect of future discussions will be as effective as something more comprehensive emerging within the powerful emotional atmosphere of a crash hearing remains to be seen.

In discussing the danger of Mr. Renslow's loquaciousness, NTSB member Robert Sumwalt said he squandered time he did not have. Waiting too long to address the problems in the regional airline business risks the same fate.

PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

As the National Transportation Safety Board begins its hearing today into the cause of the crash of Continental Express flight 3407, I draw your attention to the list at the end of my comments, which I assembled after reviewing the accident database for all regional airline accidents in the United States over the past 10 years.

There were eleven accidents, eight of which included injuries or fatalities. During this same period there were three accidents involving large airline operations. (September 11 terror attacks excluded)

Regional jets and turbo prop aircraft account for about 40% of commercial aviation in the United States, but these carriers are involved in a disproportionate share of accidents. The carriers who contract for these services, American, USAirways, Delta, Northwest, Continental and the Federal Aviation Administration itself say regional airlines are held to the same level of safety as large airlines.

Continental was operating the Colgan flight from Newark to Buffalo under a lift agreement with Continental. "Prior to entering any agreement we conduct due diligence to make sure they comply with government and safety regulations," Continental spokeswoman Julie King told me after the Colgan crash, "But because they are a part of the oversight system, the F.A.A. is really their oversight."

Regional airlines operate under “fee for departure” agreements with nearly all the large carriers. These agreements provide narrow profit margins that in turn create pressures to delay maintenance, hire low-time pilots and flight attendants and other economies that impact safety.

Some of these issues are expected to come up at the hearing which is being held just two weeks shy of the first anniversary of the crash. That the board will examine not just the factors that directly contributed to the Colgan disaster, but those that haunt the regional aviation industry in general is a good thing.

Make no mistake there is a larger problem.

List of regional airline accidents since 2000

1. Colgan Air 2.12.09 Fatalities 50 N200WQ (Continental Connection)


2. Pinnacle Airlines 11.13.08 Injuries no fatalities N8698A (Northwest Airlink)


3. Shuttle America 2.18.07 No fatalities N862RW (Delta Connection)


4. Comair 8.27.06 Fatalities 49 N431CA(Delta Connection)


5. Flying Boat Inc. 12.19.05 Fatalities 20 N2969 (Chalk's Ocean Airways)


6. Executive Airlines 5.9.04 No fatalities N438AT (American Eagle)


7. Corporate Airlines 10.19.2004 Fatalities 13 N875JX (American Connection)


8. Pinnacle Airlines 10.14.04 Fatalities 2 N8396A (Northwest Airlink)


9. Air Midwest Airlines 1.8.03 Fatalities 21 N233YV (USAirways Express)


10. Colgan Air 8.26.03 Fatalities 2 N240CJ (Ferry flight)


11. Peninsula Airways 10.10.01 Fatalities 9 N9530F