- File Size: 7202 KB
- Print Length: 380 pages
- Page Numbers Source ISBN: 1479728942
- Simultaneous Device Usage: Unlimited
- Publisher: Xlibris US (November 15, 2013)
- Publication Date: November 15, 2013
- Sold by: Amazon Digital Services LLC
- Language: English
- ASIN: B00BY2DV68
- Text-to-Speech: Enabled
- Word Wise: Not Enabled
- Lending: Enabled
- Amazon Best Sellers Rank: #576,793 Paid in Kindle Store (See Top 100 Paid in Kindle Store)
|Digital List Price:||$3.99|
|Print List Price:||$19.99|
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Air Safety Investigators: Using Science to Save Lives—One Crash at a Time Kindle Edition
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Diehl leads off with the 1989 UAL DC10 crash at Sioux City, circles back to the Turkish crash in 1974, jumps to the American DC10 O’Hare crash in 1972, and then talks about the NTSB breaking off from the DOT in 1974. He touches on Air Mail in the ‘30’s, deregulation of the airlines in 1978, goes back to the Portland CRM recommendation and finally winds up coming back to Sioux City. A whirlwind tour of air crashes, and that’s just the first chapter! Diehl repeats this pattern of jumping back and forth chronologically throughout the book.
After a two chapter detour to discuss his peripheral role in a south African TU134 crash in 1986, he lurches back to 1970 and his work at Cessna. He says Frank Borman was a future EAL CEO in 1986 when he was on the board of inquiry for the south African crash, but Borman was already Eastern CEO then. He says he successfully pushed installation of shoulder harnesses on the new Citation with the help of some Ralph Nader people, and maybe he did. But it sounds like boasting when he talks about praise he received for his work and a Collier trophy Cessna later received in part because of his cockpit layout ideas. The vertical scale instrument tapes he says he introduced were already in use on the USAF C141. He shows us the title page of a 1971 SAE report he wrote to confirm his precedence as a safety advocate. At this point I began to wonder if he was more interested in telling us about aviation safety or in promoting himself. As I read on, I noticed photos of commendation letters and awards he received scattered throughout the book.
I had to shake my head at his story about performing an autopsy on a pilot as a neophyte NTSB investigator in 1977. This was the tragic crash that killed members of the Lynyrd Skynyrd band. He had no training for this and it seems nobody there, including Diehl, had sense enough to handle this procedure properly. Even a rural Mississippi pathologist should have resisted such a practical joke apparently being played on Diehl by his senior colleagues.
Diehl makes an observation on the 1979 Downeast Airlines accident he worked in Rockland, Maine, that I’ve found is still true. He said that after deregulation, which had just happened in 1979, new airlines like Downeast multiplied, but congress did not provide a corresponding increase in FAA staffing levels. There developed a de facto honor system – the government was going to trust the operators to do the right thing. In accident investigations since then, it was often clear the FAA did not have the staff or the strong leadership needed to properly oversee air carriers, particularly those with part 135 certificates. Some did the right thing, but found themselves at a cost disadvantage trying to compete with those who bent or broke the rules.
Diehl says the Downeast final report was the first time the NTSB delved into the effect an operator’s management could have on safety and accident causation. This is supported by Jim Hall’s remarks over twenty years later. If true, this was a very important innovation. Looking at management involvement became a standard and very important practice at the NTSB.
Diehl moved over to the FAA and then on to the USAF Safety Center. He candidly discusses the times he was fired or demoted and the times he blew the whistle or did something else to antagonize senior officials, and claims this was always a matter of conscience. His description of crusty self-interested bureaucrats and hardheaded generals actually rings true, but it’s hard to escape the conclusion that Mr. Diehl had a penchant for picking fights he often lost. Crusaders and grievants often have insight about a real problem, so they are not to be ignored, but they also tend to be extraordinarily self centered and ego driven. I sense a similar pattern with Mr. Diehl.
At the same time, his in-depth explanation of aeronautical decision making (ADM), systems approach to safety (now SMS), the “safety triangle” (accident generation, investigation and prevention), safety programs like ASRS, and the DOD human reliability program have merit. He’s right that in the NTSB’s land of nuts-and-bolts engineers, the human story was and still is a tough sell. (One Investigator In Charge called it “squishy stuff;” another called the human performance division the “division of pilot excuses.”) Whether Diehl was the motive force behind these programs or just an interested bystander when they evolved, he’s told a good story that should engage every person interested in aviation safety.
In this book I would deem to challenge only one conclusion: Dr. Diehl lumps the Colgan crash and AF447 as the result of automation atrophied pilot skills. In the case of the Colgan crash, that is not a bad summation. However, the AF447 crash would fit more accurately into his fight against blaming the dead guys as an investigative tactic and in consonance with his statement in footnote 139 that every aircraft control panel must have an independent source of attitude information. The A330 flight management system, as reported in the preliminary accident report, knew the attitude of the Airbus but didn't tell the pilots. Instead, in a horrible example of non-graceful system failure, it alternated between warnings and blank screens leaving the pilots to guess what was happening in the middle of a violent thunderstorm.
The second noteworthy conclusion lies in Dr. Diehl's recitation of the harassment he underwent in the NTSB, FAA and USAF as he attempted to "tell truth to power". It puts the travesties endured by Thomas Drake, Ed Snowden and the other NSA whistleblowers in their proper place as merely business as usual for threatened bureaucrats lusting after the flood of tax money available in D.C
Learning to master the mechanical aspect of flying is daunting enough, and it is not uncommon for pilots to relax after getting qualified. Dr. Diehl's book smoothly navigates the envelope and panorama that shrouds flying, and makes the case that the art of flying is constantly evolving, and there are so many intangibles that can confront the pilot who must be prepared if he is to survive. The book articulates the importance of crew coordination, safety compromises, weather problems, flying proficiency, instrument flying issues, and crew fatigue.
As an investigator, it appears that skepticism guides his work until all questions are answered.
As I was reading the book, I was able to relate to much of what he wrote. I would have been a better pilot earlier in my career had I had the opportunity to read this highly informative book. One of the interesting aspects of the book is the significance that a crash can have in the political world both domestic and international. I believe the best lesson I learned in reading this book is not to believe every word you read concerning an incident. There is almost always a spin in the report as in the case of Senator John ("catsup") Heinz, JFK Jr., Commerce Secretary Ron Brown, and the President of Mozambique, Samora Machel. Careers can be made or lost as a result of pilot negligence. Most assuredly, this is a five star book.
He puts in the right context different safety initiatives showing how they are linked and, especially, the value of HF approach becomes evident even for people with technical background.