ANALYSIS: The Boeing Battery Fires

“We do not expect to see fire
events onboard aircraft.
This is a very serious air-safety concern.”

-NTSB Chair Debra Hersman,
at a 1-24-13 press conference

The following analysis concerns the lithium ion battery fires that caused FAA to eventually declare an Emergency Airworthiness Directive (AD), grounding Boeing’s new Dreamliner.

There are four key players in this analysis:

Boeingis the largest commercial aircraft manufacturer in the world. Founded in 1916, they currently have roughly 174,000 employees worldwide. Revenues in 2011 were $69 Billion.
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Boeing’s 787
built mostly from composites, flew its maiden flight in late 2009 and began commercial service in late 2011. A total of 49 had been delivered by the end of 2012. Another 800+ of this $206 Million (+/-) jet are on order. In mid-January of 2013, there was a rapid series of problems: a windscreen crack, two battery fires (one with an emergency landing and evacuation), and a fourth incident (again related to batteries).
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FAAhas formally existed since 1958, and today has an annual budget of roughly $16 Billion. FAA has grown to 47,000+ permanent employees, but there are many thousands of other ‘contract’ employees; in fact, many of these are ‘double-dippers’, collecting their FAA retirement pension while also drawing FAA contractor wages. FAA has promoted the growth of the U.S. aviation industry, while also managing the safety of the U.S. aviation industry. Sometimes (actually, many times) these two functions have become confused. One of the most alarming examples in recent years was when the congressional hearings on 4/3/08 revealed that FAA managers were overriding the work of their inspectors and enabling airlines to fly aircraft years past due for required safety repairs. The hearings drew sharp criticism from members of Congress,link and pressure on FAA to abandon their Customer Service Initiative’.link That original ‘CSI’, begun in late 2003, had FAA trying to act like a business and help out their airline customers), and rename it as Consistency and Standards Initiative’. I kid you not…
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NTSB established in 1967, has roughly 400 employees responsible for investigating not just aviation but ALL transportation accidents: aviation, marine, highway, rail, and pipeline. With an annual budget of roughly $80 Million, NTSB is also charged with producing hundreds of safety recommendations. Nearly all accident investigations are related to aviation; roughly half of the safety recommendations are aviation-related (the others have to do with highway, rail, etc.). FAA routinely either ignores or fails to acceptably resolve a very large percentage of NTSB’s safety recommendations, which become closed by NTSB with a marking of ‘unacceptable status’.


Aviation has always been incredibly harsh and unforgiving

There are more than a few true professionals in aviation. For generations, a lot of careful effort has gone toward improving safety. Mechanical systems have become so reliable, we practically take them for granted. Overall, the present commercial aviation system tends to be reliable and racks up impressive safety statistics. But, on an individual flight, if anything starts to go wrong, there is always the potential that it can rapidly escalate into a full catastrophe. When you really get down to the details, today’s commercial aviation accidents appear to stem from two primary causes: complacency, or technical ignorance. We have modern technologies that layer so much automation into formerly manual processes, it becomes too easy for pilots and controllers to let down their guard. These are people, after all. Give them nothing to do for hours and they will sleep, check out the laptop (maybe watch a movie?), text or otherwise not pay attention. The problem, of course, is that these same systems are not foolproof, and if/when they do fail, the people sitting at the controls may not be able to figure out the problem, let alone recover. In aviation, there often is not enough time.

Here are three recent examples …

Air France, over the Atlantic, on 6/1/09. Nearly four hours after departing Rio for Paris, it’s the middle of the night and they are cruising at 38,000’, in  normal flight conditions. For reasons unknown, key portions of the autopilot disengage. Erroneous readings confuse the pilots who apply corrections which bring the aircraft into a stall. Eventually, they are nose up 35-degrees while descending toward the ocean at nearly 11,000 feet per minute. Four minutes after the disengage, the Airbus A330 impacts the ocean surface, killing 228
Colgan at Buffalo, on 2/12/09. Two fatigued commuter pilots, both with low experience, encountered icing on an otherwise routine flight from Newark to Buffalo. They commented to each other about the icing but failed to take corrective actions. At 10:17pm, while setting up for a final approach, they lost control and dove into a house. There were 50
Comair at Lexington, on 8/27/06. At 6:05am on a Sunday morning, a commuter jet was cleared to depart but took the wrong runway. Fifty seconds later, the takeoff roll commenced, at 6:06:05.0. The aircraft needed a speed of 138kts to rotate and safely takeoff. At 6:06:24.2, the captain called out “one hundred knots”, to alert the first officer he would soon call for rotation. Seven seconds later, at 6:06:31.2, the captain called out “Vee one rotate.” Flight data later showed this call was made early, at 131kts, as they ran out of runway. Both pilots pulled back on the controls to rotate, but tire marks show continued ground contact beyond the runway. A berm was impacted seconds later, and the aircraft went temporarily airborne, before eventually crashing into trees. The sound of the first impact was recorded at 6:06:33, and the recording ended at 6:06:36.2. Forty seconds later, the lone FAA controller in the tower (who was working no other aircraft at the time) observed the fire. He picked up the crash phone at 6:07:17, almost exactly two minutes after he had issued the takeoff clearance. While working in the tower, he had failed to notice that Comair was NOT at Runway 22 when ready to depart, and that Comair then took the wrong runway. He evidently did NOT look at Comair for the next minute, losing his opportunity to save the mistake. The controller also did NOT notice that he had failed to specify the runway number in the takeoff clearance. This oversight was critical due to confusion caused by both the runway/taxiway configuration and an ongoing construction project. There were 49 fatalities; the copilot was the sole


NTSB is the smaller/Better aviation safety advocate

So, the two key federal entities in U.S. aviation safety are FAA and NTSB. The larger of the two has 120-times as many permanent employees, and 200-times the annual budget ($16 Billion vs. $80 Million).

FAA has a proven track record: an ever-growing budget, hundreds of cases where managers and regulated airlines are NOT held accountable, a very high percentage of NTSB Safety Recommendations that are NOT complied with or are ‘closed, unacceptable’, and as compared to other federal agencies, an inordinately large number of damaged whistleblowers. FAA also has a huge amount of clout with members of Congress, by virtue of FAA money doled out each year to projects within all the congressional districts (the largest such fund, drawn primarily as a tax on airline passengers, is the Airport Improvement Fund that distributes nearly $4 Billion annually).

By contrast, NTSB carries a slingshot to FAA’s flamethrower. But, the more important contrast is that NTSB is fit and vigorous and appears to be ethical, while FAA is one donut short of a coronary occlusion. In recent years, NTSB has become increasingly impatient with – and is speaking up more about – FAA’s failures. Thus, when Comair happened at Lexington, Hersman was a new NTSB member and met hundreds of grieving crash victim relatives. She had to stomach the careful construction of a report that could-not/must-not allow the FAA air traffic controller to tell his whole story. The controller knows what happened, and one of the less considered tragedies of Comair is that he now has to carry that fact concealed for the rest of his life. He deferred to the controllers union, NATCA, which quickly jumped in and took charge, representing ATC and working hand-in-glove with FAA to make sure the blame was nebulously reassigned. The official NTSB record declared the controller was distracted doing administrative duties. In truth, the counting of fourteen paper strips at the end of an ATC shift takes ten seconds, max. To her great credit, Hersman (and one other Board member, Higgins) submitted a ‘concurring’ opinion that effectively laid out the need to start adding FAA to the list of those held accountable. When Colgan happened, NTSB hammered home the need for FAA to quit delaying on fatigue issues, as they had for decades. Then, in early 2011, when a supervisor at Reagan National airport fell asleep around midnight and two commercial flights had to land without landing clearances, NTSB jumped forward and did a thorough It seems highly likely, given the politics of Washington, that there were at least a few in FAA who cried ‘overreach’ at the time, and begged the White House or allies in Congress (yeah, the ones with ‘most-favored-grant-recipient status) to hold NTSB back. Why? Because NTSB was ‘doing well’ what FAA would have ‘well concealed’.

And what does FAA have to do with the burning batteries?

It comes down to a fear that FAA is not really performing its ‘certification’ duties. Patterns similar to the Dreamliner certification occurred a few years ago, with rushed certification of the Eclipse 500 VLJ (very light jet).link FAA Administrator Marion Blakey disregarded concerns raised by her certification employees, and helped accelerate the Eclipse into production, with a big certification media event at Oshkosh in 2006. Within two years, Eclipse was bankrupt, the limited fleet was experiencing dangerous incidents, and a 2008 Congressional hearing held by the House Aviation Subcommittee revealed just how far FAA had drifted from its core safety mission.

It is this simple…

Good people like Debra Hersman do not want to have to face crowds of people who have lost a loved one, people who sense (or even know, with the angry clarity that often appears where grief collides with bureaucratic coverup) that an effective FAA would have prevented this disaster. NTSB has given cover to FAA in the past (two that come to mind are Piedmont 22 link in the early years, and Korean Air 801 link in the 1990’s), but those were different times, and NTSB was just a young waterboy. Changes at FAA in the last two decades are forcing a new reality: NTSB must come of age. Through their long pattern of dereliction, FAA has relinquished the safety authority they should no longer have. So, let’s assign it to NTSB. Give Hersman and her team as much authority as they can handle. Give NTSB the full resources they need to manage air safety.

What others are saying:

“…outsourcing of the certification processes to the actual beneficiaries of the process is incompatible with the purpose and intent of testing and certification…”

“…the weasel words you will find in the history of the Eclipse certification debacle came from the same FAA administrators that ‘facilitated’ rather than thoroughly and independently examined the early stages of the 787 project…”

Ben Sandilands’ ‘Plane Talking’ blog, on 1-19-13

“… Now watch out because she’s looking at the Dreamliner problem not just as something that needs to be found, fixed and flown, but maybe even illustrative of a bigger problem of FAA oversight of airplane certification. But here’s a safety professional willing to see a potential safety problem and acknowledge it for what it might be without mincing around. What does it take to have more like her? …”

Christine Negroni’s ‘Flying Lessons’ blog, on 1-24-13

“… In a detailed Bloomberg news account, the NTSB chair also said the plane’s design should have prevented the spate of recent lithium-ion battery meltdowns that have grounded the Dream. Are Hersman and the NTSB second-guessing the Federal Aviation Administration’s approval of Boeing’s plan? If so, it could spell trouble for the 787. Rule of thumb when the NTSB and FAA clash? The NTSB wins. …”

Joe Copeland’s‘TheDailyTroll’ blog, on 1-24-13