Flight 587 Crash Investigation

This paper examines the disaster of American Airlines flight 587 on November 12, 2001 in New York City. At least 265 people died in this tragedy making its one of the major disasters in modern aviation history. In the immediate aftermath of the accident, there were great fears that this could be another outcome of a terrorist attack on the U. S soil. Official investigations, however, quickly ruled out any terrorist involvement. Findings indicated that the weak wake turbulence caused by an airplane that took off slightly before flight 587 initiated an unfortunate chain of events that resulted in the catastrophe.The final report of the NTSB held the faulty rudder control system design of Airbus A300-600, and the inadequate pilot training program of American Airlines to be chiefly responsible. In addition, the allegedly quirky response behavior of the first officer at the controls of the airplane is considered a critical factor. However, many people, common men and experts alike, are no t convinced of the validity of the NTSB investigations. Introduction On the morning of November 12, 2001, Tom Lynch, a retired firefighter, is on Rockaway Beach Boulevard taking his regular morning exercise march.He watches an airplane complete a banked turn and start towards the ocean. Then, all of a sudden, he sees a small explosion in the fuselage behind the wing. Two more seconds elapse and suddenly there is a second explosion, engulfing most of the plane in flames. It was the American Airlines Flight 587. Two months after 9/11 – this Airbus 300-600 left John F. Kennedy International Airport en route to Santa Domingo, the Dominican Republic. Less than three minutes after takeoff, the aircraft crashed in a blazing inferno in the heart of the neighborhood of Bell Harbor, Queens. All 251 passengers along with 9 crew members perished.Most remarkably, only five people died on the ground. 44 fire trucks and 200 firefighters were rushed to the scene. Soon, the disaster of AA Fli ght 587 would be found not to be due to terrorism, but to mechanical failure. However, in the stark post 9/11 environment of the day, it was difficult for many people to believe that planes could still fall from the sky for reasons unrelated to terrorism. Feelings and fears were especially strong and these were exacerbated this fresh tragic event. As the author S. D. Manning (2003) put it, â€Å"This crash jarred a city (and a nation) still scarred and numb from the agony it has already endured†The Investigation Tonight, American holds its collective breath, Prays this nightmare is due to mechanical failure, Not premeditated design. The sheer irony would shame Kafka – It's not the disaster itself but its cause That bothers us, enslaves us to out TV's; We pray that it’s something man-made, not man. – L. D. Brodsky. (2002). As the aircraft climbed from John F. Kennedy airport, some people on the ground saw an explosion and fire on the underneath side of the aircraft, which was quickly followed by parts falling off the aircraft, including the vertical stabilizer and rudder.During the aircraft's fall, engines came away from the wings. Falling separately, one engine landed on Beach 129th Street the other engine on Beach 126th. The plane then plunged to the ground on the narrow strip of land known as Rockaway, in Belle Harbor at Queens. The plane's tail broke off and fell into Jamaica Bay, more than a mile from the primary crash site. Although a few stray remnants landed here and there, the fuselage and wings pounded into the home on the corner of Beach 131st Street and Newport Avenue. The plane's impact, subsequent explosions, and fire destroyed other homes.The rudder and the tail fin were found first along the flight path, followed by the engines and then the main wreckage. According to the NTSB, the tail fin and rudder of the plane sheared off as it accelerated. The aircraft began a climbing turn over Jamaica Bay when it encountered tu rbulence caused by the wake vortices generated by a Japan Airlines 747 that had taken off just one minute forty-five seconds earlier. Records from the flight data recorder later recovered from the crash site showed that the turbulence had cause movements of flight 587's rudder, part of which, together with the vertical tail fin, became detached from the aircraft.Control of the aircraft was lost and it fell from the sky. This was the second deadliest crash in US history, but it also, â€Å"was the first example where we had an in-flight failure of a major structural component of an aircraft that in fact was made of composite materials,† as NTSB Chairwoman Marion Blakley would assert later. From the outset, the investigation into the loss of the American Airlines aircraft was conducted on the premise that it was an accident. There seemed to be no immediate indication it was anything else, except for the numerous eyewitness accounts of fire and explosion just before the aircraft plummeted.Officials were keen to reiterate that there was nothing to suggest any foul play had been involved in the loss of the aircraft. Coming so soon after the September 11th outrages, another terrorist assault in America would have been untenable and morally damaging. The President had declared war on terrorism. Congress had been actively involved in developing new legislation to contain the threat that al-Qaeda posed to civil aviation operations. The possibility of a terrorist strike seemed a little farfetched in the state of intensely heightened vigilance that the air transportation industry was in during the aftermath of 9/11.Even if there was foul play involved, it could have been more of a sabotage than the explosion of a bomb. Though terrorism was suspected by everyone, it could not be substantiated. The main difficulty of associating the loss of AA587 with terrorism was the manner of its destruction. If the tail assembly did lie at the root of the problem, then sabotage when the aircraft was on the ground appeared a more likely scenario than a suitcase bomb or a suicidal passenger detonating a device on board the plane. Accident scenarios had to be explored first.Marion Blakley said in an interview on CNN Newsnight on the day of the crash: One of the things that we're very committed to doing is to have a full investigation from a system standpoint, mechanical standpoint, looking at the history of this flight, the crew, the human factors that may have been involved. Immediately following the loss of flight 587, a 40-strong NTSB Go Team under the Investigator-in-Charge Robert Benzon was sent to the site of the crash (NTSB News, 2001). As was the norm, their work was supported by other agencies and companies considered appropriate by the board.The NTSB used the American Airlines facility at Tulsa for a detailed examination of the aircraft engines. No evidence was found of a fire, bird strike, or other pre-impact malfunction. The auxiliary power unit ( used to power the aircraft when it is on the ground) was sent to Honeywell, its manufacturer. Nothing wrong was found with the unit. The tail fin and rudder assemblies underwent visual inspection in New York before being sent to the NASA Langley Research Center in Hampton, Virginia.Extensive preliminary tests at Langley sought to identify whether the vertical stabilizer and rudder had had any damage or faults before the accident. None were found. Although the flight data recorder indicated significant rudder movement before the crash, there was nothing to show why this had happened (NTSB News 2002). That both engines separated from the wings as the aircraft fell from a comparatively low height posed another question: Could the engines have been sabotaged, if not by an explosive device, then by some other means so far undetected by the NTSB investigators?â€Å"Investigators suspect a catastrophic engine event as the likely cause of an airline crash Monday in New York,† went CN N. com’s headline on the very day of the accident. However, the primary focus of the investigation eventually shifted to the rudder system. The NTSB team flew to France to work with experts from Airbus Industrie, the aircraft's manufacturer, at their headquarters in Toulouse. The purpose of this visit was to study at firsthand the mechanism of the rudder system and to simulate the pattern of the aerodynamic loads that may have affected the vertical stabilizer during the failure of flight 587.If the investigators could not identify a possible mechanical or structural reason for the accident, they would have been left considering the impossible. Even though they may not have found any terrorist involvement in the loss of AA flight 587, in the absence any other demonstrable reason for the crash, terrorism would be back in focus. Flight History Flight 587 was an Airbus A300-600, Registration Number N14053. It took off from JFK International Airport at 9:14:29 A. M. on November 12 , 2001 in clear weather conditions. At 0915:44.7, the captain Edward States asked, â€Å"little wake turbulence, huh? † to which the first Officer, Sten Molin, replied, at 0915:45. 6, â€Å"yeah. † At 9:15:51, when the plane was 2,000 feet and was over Jamaica Bay, the first officer initiated a series of emergency control inputs and called for the emergency â€Å"escape† maneuver. During the wake turbulence encounter, the airplane’s pitch angle increased from 9? to 11. 5? , decreased to about 10? , and increased again to 11?. At 9:16:01. 9, F. O. Molin was heard on ATC uttering â€Å"losing control.†The airplane crashed 13 seconds later, it was airborne for less than 106 seconds. At 0915:58. 5, the CVR (Cockpit Voice Recorder) recorded the sound of a loud bang. At that time, the airplane was traveling at an airspeed of about 251 knots. â€Å"Hang onto it, Hang onto it,† were the last words of the Captain Edward States, as recorded on the CVR The Crew Background The captain was 42 years of age and the first officer 34. They were hired by American Airlines in July 1985, and March 1991 respectively. The captain had 1,922 hours total flyingtime in military and general aviation before his employment with American Airlines, and 8,050 hours total flying time thereafter which included 3,448 hours as pilot-in-command and 1,723 hours as a pilot-in-command for A300 specifically. His last proficiency check took place on June 21, 2001; and his last pilot-in-command line check occurred on July 31, 2001. He consumed alcohol sparingly and never during a time around his work schedule. According to a colleague, he was an extremely good pilot, very relaxed and competent.The first officer had 3,220 hours total flying time in commercial and general aviation before his employment with American Airlines, and 4,403 hours total flying time, which included 1,835 hours as second-in-command for A300 specifically. Both the captain and the first of ficer had no FAA records that indicated any incident history or enforcement action. One pilot who worked with the first officer, however, described him as being â€Å"very aggressive† on the rudder pedals after a wake turbulence encounter. Except for that, his overall skills were described as excellent, and â€Å"well above the norm. †The 5M ConceptThe 5M concept is a risk assessment tool used to graphically illustrate how the dynamic interaction of the man, the machine and the media (that is, environment) converge to produce either a successful mission or if unsuccessful, a mishap. Man-category encompasses aircrew members, their training, selection, proficiency, habit patterns, performance, and personal factors. Factors under â€Å"performance† heading include awareness, perceptions, saturation, distraction, channelized attention, stress, confidence, adaptive skills, and fatigue (physical, motivational, sleep deprivation, circadian rhythm, klutz).â€Å"Persona l factors† include job satisfaction, values, families/friends, command/control, discipline (internal and external), and communication skills. The Machine-category encompasses the various design, maintenance, logistics, and other technical data related to the aircraft. The Media is the environment in which aircrew fly and includes factors and forces that are related to climactic, operational, hygienic conditions. The fourth category is the management. Management regulates standards, procedures, and controls.The interaction between the 4M’s Man, Media, Machine, and Management determine the desired outcome, or the Mission. When outcome fails to meet anticipated goals, these 5 M’s must be thoroughly reassessed (Civil Air Patrol). The Shell Model The factors that affect the outcome of each flight can be assessed under the SHELL Model: Software, Hardware, Environment, Liveware (outer ring) and Liveware (inner ring). Software is what makes the system work, and includes guidelines, regulations, operation specifications, and company policy and procedures.Hardware is the physical equipment that is necessary for a flight to operate. The category â€Å"Environment† relates to the broad external context that can affect the flight or the pilot, and includes factors such as weather, g-forces, and ambient light. Liveware represents the human factors. The outer ring includes air traffic controllers, flight service briefers, dispatchers, other crewmembers, pilots of other aircraft, flight attendants.The inner ring is the most important part of the SHELL model and includes various variables affecting the competence and performance of the pilots (Shields 2002). The NTSB Findings The NTSB officials very early on in the investigation suggested the cause of the crash might be due to wake turbulence from an aircraft that departed earlier. However, many experts doubted that the light turbulence from such an encounter would register on the scale of the type o f extreme turbulence that aircraft undergo from atmospheric disturbances such as in the vicinity of thunderstorms.Commercial jets are built to withstand forces up to 2. 5 G-forces, while the turbulence that hit the plane was one tenth of a G-force — barely strong enough to be even noticed (Dyer 2002). The Board then suggested that the composite vertical stabilizer may be faulty. However, this does not address the numerous reports of reliable witnesses, such as policemen and firemen, concerning fire and explosions coming from the aircraft before the vertical stabilizer ripped from the aircraft.Finally, after three years of investigations, National Transportation and Safety Board stood by its wake turbulence hypothesis. However, it was only a triggering event. The report, under the heading â€Å"Probable Cause† placed most of the blame on the first office for his â€Å"unnecessary and excessive rudder pedal inputs. † It goes on to say, â€Å"Contributing to these rudder pedal inputs were characteristics of the Airbus A300-600 rudder system design and elements of the American Airlines Advanced Aircraft Maneuvering Program† (NTSB 2004).The NTSB's conclusion was that the cause of the crash was the tail separating from the fuselage, which happened as a result of pilot placing loads on the tail that exceeded its ultimate limit – which in turn was an outcome of pilot’s rudder movements. He put excessive pressure on the rudder pedal in response to the wake turbulence caused by the JAL flight that preceded them. But why did the pilot move the rudder pedals as aggressively as he did? This became an issue of great controversy.The NTSB report dwells on the previously observed tendency of the first officer to place inappropriate pedal inputs, which in tandem with two other reasons, the deficient pilot training system and the defective Airbus rudder control system, resulted in a colossal disaster: The Safety Board’s investigat ion determined that three main factors influenced the first officer’s rudder use during the accident sequence: a tendency to react aggressively to wake turbulence, as evidenced by his responses to previous wake turbulence encounters; his pilot training, including the training he received at American Airlines regarding wake turbulence, upset recovery, and rudder pedal use; and the characteristics of the A300-600 rudder control system. (NTSB 2004)These findings resulted in a mammoth row between Airbus and American Airlines is –– with Airbus contending that the first officer’s inappropriate response caused because of his improper training by American Airlines, and the American Airlines contending the Airbus’ rudder pedal system unusually sensitive.The NTSB RecommendationsThe NTSB report discusses several safety issues relevant to the Flight 587 disaster, focusing on characteristics of the A300-600 rudder control system design, A300-600 rudder pedal in puts at high airspeeds, aircraft-pilot coupling, flight operations at or below an airplane’s design maneuvering speed, and upset recovery training programs. Airbus Industrie and American Airlines have acted upon industry-wide amendments to ensure safety of operation of aircraft.American Airlines continue to operate the Airbus A300, Airbus are confident of the structural and functional integrity of their plane – although many AA pilots and those of other airlines sought transfer to supposedly much more stable Boeing airplanes in the wake of the disaster. Conclusion New Yorkers may be resilient, But they have their breaking points, And they must be getting close to them. Like all of us, they want to believe That something like a shorting wire, Exploding fuel tank, or malfunctioning turbofan Is the reason at least 265 perished in Queens. – L. D. Brodsky. (2002).The biggest unresolved issue in this entire tragic episode of Flight 587 crash were the flames and the ex plosions noted by over 50% of over 400 witnesses. In its report, the NTSB attributes them to either an â€Å"initial release of fuel† or the â€Å"effects of engine compressor surges. † Both of them could have been caused due to out-of-control motion during the airplane's precipitous descent. However, one must remember that the airplane had just took over and was not at a great height, and most importantly that the witnesses observed the fire before anything else happened.In effect, the fire could not have been set off during the descent and as a result of the descent. Most of the witnesses are unequivocal about it and stand vehemently by their testimony to this day. Many quarters have felt that the NTSB prematurely declared the crash to be an accident and hastily concluded that the tail separation was the initiating event without adequate analysis of all the evidence, and especially without giving proper credence to witness testimony – and later went on to bols ter its convenient preconceived notions.Today, claims of NTSB cover-up and conspiracy theories pointing to terrorist involvement abound around this subject – making the tragedy of flight 587 a lingering mystery.References:Brodsky, L. D. (2002). Shadow War: A Poetic Chronicle of September 11 and Beyond, Volume Two. St. Louis, Missouri : Time Being Books Civil Air Patrol. Civil Air Patrol Guide to Operational Risk Management. Retrieved 3 March 2007 from www. orwg. cap. gov/Safety/CAPguidetoORM. pdf Dyer, N. (2002). The Mystery of Flight 587?What Caused the Crash of Flight 587? Science World. Feb 25 2002. Retrieved 3 March 2007 from http://www. findarticles. com/p/articles/mi_m1590/is_10_58/ai_83667600Manning, S. D. (2004). American Dream, A Search for Justice. New York : A&M Publishing NTSB News (2001).American Airlines Flight 587. National Transportation and Safety Board. 12 November 2001. Retrieved 3 March 2007 from http://www. ntsb. gov/events/2001/AA587/default. htm   NTS B News. (2002).Fourth Update on NTSB Investigation into Crash of American Airlines Flight 587. National Transportation and Safety Board. January 15, 2002. Retrieved 3 March 2007 from http://www. ntsb. gov/Pressrel/2002/020115. htm NTSB. (2004).Aircraft Accident Report. National Transportation and Safety Board. October 26, 2004. Retrieved 3 March 2007 from http://www. ntsb. gov/publictn/2004/AAR0404. pdf Shields. J. (2002).SHELL Model. Josh's Little Aviation Place on the Web. Retrieved 3 March 2007 from http://people. aero. und. edu/~jshields/CRM/shell_model. htm