ALASKA 506
WHAT REALLY HAPPENED?
25 MARCH, 2000

Any good aviation accident investigator will tell you that in at least 90% of incidents and accidents, the necessary ingredients are present prior to the pilot(s) approaching the aircraft; such was the case with
AK-506. In classic form, the incident was not the result of a single event, but the typical 'chain of events.'

The Captain and the First Officer had flown together all month; they regarded themselves as familiar and as being friends. Each regarded the other as a professional in every respect. It did not occur to them that an occasion for questioning each other would arise.

The crew's attitude, while normally admirable, was to prove another factor in the incident which lay ahead.That attitude conflicted with the teachings of the science of Crew Resource Management (CRM). CRM teaches that anyone can make a mistake, even a highly experienced captain. Thus, CRM teaches all crewmembers to be vigilant for the elusive items. The expression is common, "Test your assumptions."

While the refined teachings of CRM had been published in an "Advisory Circular" by the FAA, the FAA facilitated the event that lay ahead by deliberately 'not getting involved' with CRM at the 'flight line' level.

The FAA had formally refused repeated NTSB requests to insist that the CRM principles be implemented by the FAA in the cockpit itself. The FAA had taken the position that they had published the information in a new Advisory Circular and that was as much as they intended to do.

Despite NTSB warnings and predictions, the FAA refused the NTSB requests - in writing. Most alarming was that ninety-nine fresh tombstones attested to the effect of the FAA's refusal. Eighty-eight were approximately two months old.

Flight 506 from Portland to San Jose was flown with a new B-737-700. It's youth was to prove part of an incident-in-waiting. Small, but important details of it's state-of-the-art functions were missing from the pilots' FAA approved manual. Another occurrence which shouldn't have happened.

The aircraft had been taxiied to the gate by maintenance. However, contrary to maintenance checklist, it had been left with the engine "bleed air" switches in the OFF position. A small but important detail.

Contrary to published regulations and FAA guidance, the local FAA office had approved a deviation to the FAA's own requirements for cockpit safety "checklists." In brief, if an item would be dangerous to overlook, it must be put on a checklist for the crew to ensure that the switch or component was properly set up.

Alaska Airlines had gotten the FAA blessing to substitute a memorized "flow" procedure for the basic cockpit setup. The regulation was clear that checklists were not to be accomplished from memory. The FAA guidance was clear, if an item is critical to safety, it MUST be on a printed checklist, electronic or otherwise.

Most damning - again - was that the FAA had plenty of warning in the form of the Payne Stewart Learjet crash. The "bleed air" switches were found in the OFF position; the aircraft never pressurized. When it crashed, it missed a town by 12 miles.

Still more damning was that the FAA had also looked the other way while the company saved money by not issuing copies of the FAA regulations to the pilots. The pilots were lacking the ability to form a valid question.

When 506's crew got to the aircraft, the First Officer accepted the aircraft from maintenance with the engines shut down and the APU running. The crew set up the cockpit as usual, from memory, using the normal "flow" technique. Each pilot trusted the other to do his job. Unfortunately, the First Officer wasn't expecting the bleed air switches to be in the OFF position and missed their actual position. Given the visual angle of the first officer, both switches being in the OFF position were mistaken as in the correct position.The position of the switches was also missed on the challenge and reply "Before-Start" checklist, the First Officer read, the Captain checked and replied, both pilots had missed the switches being in the incorrect position. The stage had been set.

Flight 506 departed with a normal takeoff; First Officer was the 'flying pilot;' the Captain was the 'monitoring/non-flying pilot.'

Following the takeoff in instrument conditions, the First Officer called for the "After-Takeoff" checklist. Unfortunately, the captain overlooked the position of the bleed air switches in accomplishing the checklist. Further, an illusion deceived him.

The pressurization gauge showed a normal cabin rate-of-climb. However, this was in reality a matter of air escaping from the aircraft through a variety of tiny seals which, by coincidence, gave the expected cockpit indication, as though all things were normal.

The First Officer was hand-flying the aircraft, as opposed to utilizing the sophisticated autopilot. Modern aircraft are sufficiently sophisticated that pilots have to 'make' flying time to maintain their manual flying skills. The First Officer was initially navigating in instrument conditions, concentrating on the flight instruments. The fact that he was manually flying the aircraft demanded a constant instrument visual scan on the forward panel.

As the 'monitoring pilot,' the Captain was conducting the ATC radio communication; ensuring that the First Officer complied with any ATC instructions.

In the background, the cabin was continuing to leak air in the fashion of a rising helium balloon with a small leak.

The air leak was slow enough that no one's ears 'popped' in such a way as to otherwise give an indication that something might be amiss.

At approximately 16,000 feet, things began to happen. First was the sounding of the pressurization warning horn, a steady loud and obnoxious horn; followed nearly immediately by two annunciator lights indicating that the passenger oxygen masks had deployed; the "rubber jungle" was dangling in the passengers' faces. The normal 4,000 foot cabin pressure buffer from warning horn-to-mask deployment was gone.

Immediately, the First Officer initiated a descent. The Captain requested and was granted an initial descent clearance to 14,000 feet, immediately followed by clearance to 10,000 feet. With the aircraft level at 10,000 feet, the autopilot was engaged.

During the descent, a quick scan of the overhead panel betrayed the oversight of the pilots. It was clear to both pilots that the situation could be rapidly corrected. The bleed air switches were then quickly placed to the correct position, the aircraft began to pressurize. It was quite clear that the aircraft was pressurizing normally. The actual condition and the clarity of the situation didn't dictate the procedure for a "Rapid Depressurization" or an "Emergency Descent" scenario; thus, the first officer performed a normal descent. Following procedure, the pilots 'ran' the abnormal checklist; the situation was verified to be corrected.

The Captain asked the First Officer to monitor the ATC radio while he spoke with the flight attendants and made a PA to the cabin. The First Officer asked the captain if he wanted to return to Portland. The Captain said that he needed more information and contacted the flight attendants on the interphone.

Ultimately, the Captain satisfied himself that the oxygen system was still intact and available, if needed. He directed the flight to continue according to the flight plan. Accordingly, trusting in the captain's expertise and judgement, the First Officer climbed to the assigned altitude of 41,000 feet, continuing to San Jose.

Corporate culture was now in command, as opposed to the published principles of CRM. Ideally, in perfect hindsight, either the Captain or the First Officer should have gone to the back to examine the reality. Had they done so, they would have discovered that the passengers had followed the instructions of the automated computerized announcement to pull the masks to their face and breathe normally. The existence of the 'Automatic Announcement' system was not described in the flight manual issued to the pilots. However, it was mentioned in the flight attendant manual.

Unknown to the pilots, approximately half the masks had been used. After 12 minutes, those masks no longer had oxygen available to them. The masks which had not been pulled down were still good. However, it was an embarrassing and awkward situation.

The First Officer was bound by regulation, tradition and corporate culture to obey the Captain. Crew interdependency had been taught by Alaska Airlines and the Captain trusted in the information he was given over the interphone by the flight attendants. In hindsight, that was a mistake; assumptions were not confirmed; corporate culture had negated CRM.

FAR § 121.533 (d) (e) emphatically states that the Captain's instructions are to be followed. The same regulation holds the Captain exclusively responsible for the safety of the aircraft and occupants. FAR § 91.11 makes it almost an act of mutiny to override the Captain.

Enter the question of the legal mandate of CRM. FAA official policy is that CRM is a function of good advice; it is not regulatory and may not be used in the fashion of a violation. A pilot cannot be violated for failing to follow CRM principles. The fact that CRM is part of an airline's training program can be used to support a violation' with respect to establishing a pilot's attitude, in determining whether or not an enforcement action is initiated.

FAR 121.533 is clear that the captain is uniquely responsible for the operation of the aircraft and that his authority cannot be overridden. That's not to say that the copilot cannot be violated for an individual mistake, such as an altitude 'bust.' It does say that the Captain is mandated to ensure that the aircraft is subsequently returned to the correct altitude.

While the current science of CRM encouraged crewmembers to breach culture and traditional relationships to effect safety, the crew of flights 261, 259 and 506 hadn't gotten the proverbial 'latest word.' According to Federal law, they should have. According to the mandate of the same law, the pilots should also have had a professional command of the FAA Regulations.

That package of ignorance produced a considerable corporate savings.

Approximately half way through the flight, the Captain went back to use the restroom. To his dismay, he discovered that the masks had not simply deployed, but had been activated and used by many of the passengers and the flight attendants - their oxygen was gone. He attempted to re-stow a couple of the masks; it was a useless situation. He returned to the cockpit, advising the copilot of the reality. The First Officer immediately initiated a descent to a lower altitude, previously assigned as "pilot's discretion." By this time, they were beyond the halfway point to San Jose; turning back would achieve nothing. In the event of an actual depressurization the terrain behind them was higher.

The crew called the company operations to report their reality. They were advised to keep the passengers on board the aircraft until the ground staff could get names and addresses.

After reaching the gate in San Jose, the captain immediately exited the aircraft and called the company. Maintenance checked out the aircraft. The Captain was advised to ferry the aircraft back to Seattle so that replacement oxygen canisters could be installed. The flight attendants remained in San Jose.

Upon arrival in Seattle, the flight data recorder was removed from the aircraft and the pilots were directed to ferry another aircraft to Vancouver, B.C. and continue flying their scheduled 'pairing' for the next two days. That two days of flying entailed seven revenue flights. A total of nine flights, since the 506 incident. Clearly, the company understood the elements of the 506 incident and did not find significant fault with the pilots.

The pilots were advised by an ALPA union safety representative to proactively schedule a debrief with the company chief pilot; this was done. It was also learned that the flight attendants filed a complaint with the FAA and the company about the incident. The last two flights were made in the same aircraft involved in the 506 incident, by then returned to service. NASA (safety incident reporting) forms were filed by both pilots.

4 days later, the pilots came to Seattle to debrief with the chief pilot and 'self-disclose' to the FAA. In theory, that self-disclosure could have and should have prevented the filing of a violation. There was no damage or injuries; this was a lesson to be learned. Contrary to the official intent of 'self-disclosure,' the meeting served as a trap for the pilots. The stage for the cockpit-legendary treachery of the FAA was set and lighted.

After nearly two months, the news media learned of the event and broadcast the story. The usual suspects (the pilots) were rounded up. With only one side of the story, the media set their cross-hairs on the pilots. Immediately, the company announced their intention to fire the pilots, while the FAA continued their 'inquiry'.

The media immediately learned the pilots' names, addresses, city of residence and phone numbers. The First Officer was contacted by the media on a phone number only known to the company and the union.

Reactions to Flight 506 are mixed, but the events of that flight - and the aftermath - command attention, questions and action on the part of every pilot and U.S. citizen. The proverbial "stuff" hit the fan in a manner which should shock the entire American society.


THE PRECEDING STATEMENT IS VERY SERIOUS!

READ ON -

Let's return to the fact that the FAA is on record as refusing to promote the safety tool of Crew Resource Management (CRM) at the local (line pilot) level, contrary to the pleadings of the NTSB in the "NTSB Recommendations to FAA and FAA Responses Report Number A-97-5/ 6." Again, the FAA final position was that they had published an updated Advisory Circular and that was all they intended to do.

It is no secret that extremely few pilots ever see these Advisory Circulars. The FAA refusal is contrary to the mandate of federal law; the FAA rationalization directly endangers the public. The recent fatalities glaringly attest to that fact. This is no matter of imagination or opinion.

Locally, Alaska Airlines had three events within 60 days, starting with the 88 lives lost on AK-261. All three of these events had the common trait of Crew Resource Management (CRM) failing. These events epitomized the very fears and predictions of the NTSB as to imminent disaster. Clearly, the FAA wanted no part of the CRM issue at the cockpit level - where it belonged.

Consider also that the FAA knew that the pilots' were not issued the FAA Regulations which contained the essence of the safety standards which the pilots are expected to rely upon.

The resulting marginal knowledge of the FAA regulations left the company operating in a safety 'twilight zone,' an unacceptable state, illustrated by repeated safety-related incidents. That 'twilight zone' was composed of savings / profits. In the words of mechanic, John Liotine, the company announced in 1986 that it was no longer going to 'gold-plate' their aircraft.

In the background of the Alaska Airlines events were numerous other events involving CRM failings. One of these was the crash of American Airlines flight 1420 - eleven dead. The FAA was previously well aware of both the CRM and crew rest issues which created that potential; yet did nothing. The crew rest issue has the appearance of being corrected.

Also in the background was the history of the FAA's removal of Inspector Mary Rose Diefenderfer as the Principal Operations Inspector for Alaska. Her team's efforts to get and keep Alaska safe are well chronicled by the Seattle P-I, Seattle Times and a list of government investigations which affirmed her team's findings. Her reward as a team leader for a job well done was bureaucratic punisment. Her story is bizarre, but not the least bit unique in the FAA environment.

Approximately three weeks after the AK-261 accident (which demonstrated a very debatable CRM failure), a disturbed passenger was boarded on Alaska flight 259, the identical flight as AK-261 from Mexico to San Francisco. Early in the flight, the passenger became known as a safety / security risk. In an identical fashion, that crew also over-flew airports at which they could have landed and deplaned the passenger. Ultimately, the passenger broke into the cockpit, nearly causing the aircraft to crash. To date, there is no known action by the FAA to either hold Alaska Airlines or any employees accountable for the incident. The most recent drunk-passenger incident in Anchorage, aboard another airline, further attests to the FAA disregard for airline compliance with the airport security regulations.

That incident begs the following questions:

1. Given that the AK-259 passenger was known to be intoxicated at the gate in Mexico, why did they board him?

2. On the heels of Alaska 261, why didn't the captain divert or turn back?

3. Was the airline ever investigated for their role?

4. Which FAA jurisdiction investigated that incident, independently of the FBI?

In July, Congress was presented with a damning Government Accounting Office report which detailed the FAA failings on the airport security issue. It's contents is frightening. The GAO refused to publish some of the most current statistics, as they were so alarming. The report also diplomatically illustrated the FAA's deceit.

Within a few weeks of the report's presentation to Congress, two attempted hijackings took place, validating the report. Reality demonstrated that the FAA wasn't doing it's job. An alarming history of security complaints and incidents indicated that the FAA had no serious intention of doing that job.

Looking closer at the Alaska 506 matter:

A. The pilots were not issued, nor adequately taught the FAA regulations. This fact violates not only FAR
§ 121.427 / .415, but is contrary to the guidance contained in the FAA internal policy / procedures document, known as the "8400.10 manual."

B. The FAA failed to enforce FAR § 121.315, regarding the design and use of cockpit checklists. This FAR requires checklists for safety related procedures; specifically prohibiting checklist procedures from being accomplished from memory. The FAA 8400.10 manual reiterates this regulation philosophy. That manual also contains sufficient language to clearly communicate the intention of FAR § 121.315 and the FAA position and methodology to ensure the safest possible operation of aircraft.

While some operators subscribe to the conduct of some procedures, employing a procedural "flow," the FAA guidance continues to direct that critical safety items be contained in some form of a written checklist. Language substitution is irresponsible. Other FAA publications on the design of checklists support this same information. While it is possible to take language out of context, the core information in all related publications is clear as to the intent and desired result - safety only.

C. Partially as a consequence of the inadequate checklist procedures, the AK-506 pilots overlooked the position of the "bleed air" switches during the cockpit setup procedure. The activation of these switches was critical to the pressurization of the aircraft. The result was the failure of the aircraft to pressurize and the unwanted deployment of the passenger oxygen masks.

D. The aircraft involved was a new model to the company, their FAA approved manuals did not contain the necessary information to identify functional differences regarding the operation of the automatic passenger mask deployment. (Ironically, the flight attendant manuals did contain the differences.)

E. According to the pilots' account, following the oxygen mask deployment, the flight attendants led the captain to believe that there was no associated safety matter at hand, although the situation was clearly embarrassing. Combined with his ignorance of the regulations and the pilots' ignorance of specific aircraft systems operation, the captain elected to continue the flight.

F. However, upon their discovery of the unsafe condition, the pilots immediately initiated a descent to accommodate the situation. They also called the company to report the incident.

The events on this flight were AGAIN clearly the result of CRM failings, consistent with the NTSB pleadings for dynamic implementation of CRM by the FAA, not to mention the accuracy of the NTSB predictions. This was the third in a series; cause and effect cannot be denied.

Specifically, the airline's procedures called for the cockpit to be set up uniquely from memory, as opposed to being supported by the FAR required checklist. The memory technique is historically referred to as a 'flow.' While such procedures are commonly used, the FARs dictate that they MUST be backed up by a printed checklist.

The official and well documented FAA treatment of checklist items addresses the appropriate maximum safety aspect. If it would be unsafe to overlook an item, it must be on a checklist. Such items are referred to as "critical" items. For example, it would be unsafe to overlook the engine BLEED AIR switches, it would not be unsafe to overlook the GALLEY POWER switch. In a sentence, all safety-critical items must be on a checklist.

Allegedly, there is another FAA oversight issue in the Alaska Airlines B-737 abnormal checklist which states that in the event of an illumination of the "PASS OXY ON" light (indicates passenger oxygen masks have dropped); check cabin altitude, if normal, no crew action required.


Following are the regulations and policies governing the checklist issue. Additional written FAA guidance exists, supporting the material below. No amount of rationalization can be allowed to openly reduce safety to such an unacceptable degree.

Federal Aviation Regulations


§ 121.315 Cockpit check procedure

(a) Each certificate holder shall provide an approved cockpit check procedure for each type of aircraft.

(b) The approved procedures must include each item necessary for flight crewmembers to check for safety before starting engines, taking off, or landing, and in engine and system emergencies. The procedures must be designed so that a flight crewmember will not need to rely upon his memory for items to be checked.

(c) The approved procedures must be readily usable in the cockpit of each aircraft and crew shall follow them when operating the aircraft.

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AIR TRANSPORTATION OPERATIONS INSPECTOR'S HANDBOOK

(FAA ORDER 8400.10)


Vol. 1

"Should the guidance in this handbook conflict with a Federal Aviation Regulation FAR), the FAR takes precedence."

"A checklist is a mechanical aid used to overcome the limitations of human memory."

8400.10 Vol. 1 p.p. 1-3

A. A primary objective of the personnel developing this handbook is to make it as comprehensive as possible, and easy to use. It is numbered sequentially by volumes, with each volume containing chapters and sections. Paragraphs in each volume are consecutive odd numbers. Even numbers have been reserved for expansion. Pages are numbered within each volume and are so identified (for example, page 25 of volume 3 is shown as 3-25).

B. Where material is only referenced by paragraph number, it can be assumed that the referenced paragraph is within the same volume. If reference is made to material in another volume, it will be identified by volume number, chapter, and section or paragraph number.

C. Figures and tables have been kept as close to the pertinent text as possible. Where they are lengthy, they have been placed at the back of the section so as not to create large breaks in the textual material. Figures and tables will be identified numerically by volume, chapter, section, and the figure or table number. For example, the first table in volume 1, chapter 2, section 3, will be identified as table 1.2.3.1., and the second table will be table 1.2.3.2.

Directive and Guidance information.

A. Directive information is information that is considered directive in nature and will contain terms such as "shall," or "must," and means the actions are mandatory. "Shall not" means the action is prohibited. The use of these terms will leave no flexibility, and their direction shall be followed unless otherwise authorized by Headquarters.

B. Guidance information is information considered guiding in nature and will contain terms such as "will," "should," or "may." These teams indicate actions that are desirable, permissive, or not mandatory, and allow flexibility.

Checklist Format.

POI's shall ensure that operators present checklists to flightcrews in a practical and usable format. POI's should use the following guidance when evaluating aircraft checklists for proper format.

A. Paper checklists should be protected either by plastic lamination or by being printed on heavy, folded pasteboard stock.

B. Nonnormal, alternate, and emergency checklists must be in a format that allows crewmembers to quickly and accurately find the correct procedure while the crewmember is under stress. To expedite the referencing of these checklists, a tabbed manual or other quick reference format is recommended. When a paper checklist is required on the airplane, the methods used in an electronic checklist and the associated paper checklist for referencing a particular checklist shall be sufficiently similar to minimize flightcrew confusion or inappropriate flightcrew response. The methods for accessing electronic checklists may determine the format used to reference checklists in the paper version.

Policies for Managing the Accomplishment of Checklists.

POI's must ensure that the appropriate sections of the operator's manuals contain the specific crewmember responsibilities for monitoring, verifying, and managing the accomplishment of checklists. These responsibilities should appear either as policy statements or as specific directives. POI's should use the guidance that follows when evaluating an operator's policies for the accomplishment of checklists.

A. Objective of Policy Statements and Directives.

The primary objective of the operator's policy statements or directives is to standardize crewmember interaction. These statements should include, but not be limited to, the following items:

- Flightcrew responsibilities for maintaining aircraft control, analyzing situations, and for requesting the appropriate checklist in nonnormal and emergency situations

- The specified crewmember responsible for initiating each checklist

- The specified time when each checklist is to be initiated

- The specified crewmember responsible for accomplishing each item on the checklist

- The specified crewmember responsible for ensuring that each checklist is completed and for reporting that completion to the crew

- Crewmember responsibilities for bringing to the attention of the pilot-in-command (PIC) and the rest of the crew any observed deviation from prescribed procedures

B. Methods for Managing Checklist Accomplishment.

The following subparagraphs each contain a discussion of recommended methods an operator may use for managing checklist accomplishment. These methods are not all-inclusive and may not meet all of the operator's needs. POI's shall not interpret these methods as the only ones that are acceptable. ...........

........ item(10): All checklists, except the after-takeoff and after-landing checklists, should be accomplished by one crewmember reading the checklist items and a second crewmember confirming and responding to each item. POI's shall ensure that critical items on the before-takeoff and before-landing checklists are confirmed and responded to by at least two crewmembers.

Criticality of Checklist Items.

Checklist items can be ranked in criticality according to the potential effect of the crewmember failing to perform the action. Critical items are those items which, if not correctly performed, have a direct, adverse effect on safety. Noncritical items are "housekeeping" items or systems management items, which for operating practices must be routinely accomplished during a specific phase of flight, but if omitted would have a minimal effect on safety. An item may be considered to be critical on one checklist but noncritical on another checklist. For example, a flightcrew's failure to set the flaps while accomplishing the before-takeoff checklist has had extremely adverse consequences. A flightcrew's failure to retract the flaps while performing the after-landing checklist, however, has had little effect on safety.

The operator and POI shall analyze each phase of flight to identify critical items for that phase of flight and to ensure that all critical items are included on the checklist.

Aircraft Sophistication and Checklist Design.

The degree of technological sophistication in the design of the aircraft directly affects checklist items. In older aircraft, the flightcrew must manually select and monitor most items. In technologically advanced aircraft, the same items are accomplished and monitored by automatic systems that relieve the flightcrew of these tasks. Checklists for technologically advanced aircraft tend to be shorter and simpler than those for older aircraft. POI's shall ensure that the operator's aircraft checklists are based on a careful task analysis of the operational requirements of the specific aircraft.

Fleet Standardization.

POI's shall ensure that operators standardize checklist items and the sequence of items to the extent allowed by individual aircraft differences across all aircraft in the fleet. Checklists for technologically sophisticated aircraft are typically shorter and simpler than those for older aircraft. The items on checklists for technologically advanced aircraft, however, are normally present on checklists for aircraft with older technology. POI's shall require operators to evaluate the feasibility of placing common checklist items on checklists with standard titles for all aircraft (such as before-start, before-takeoff, or before-landing checklists). Items should appear in a standard sequence to the degree possible. POI's should not normally approve placing an item on a checklist that is not required for that specific aircraft solely because the item is required in other aircraft of the fleet. POI's may make exceptions, however, when the operator provides adequate justification.



Returning to the AK-506 incident -

Allegedly, (as of 25 March 2000) the Alaska Airlines pilot's B-737 emergency/abnormal "Quick Reference Handbook" reads -

---------------------------------------------------

Abnormal Checklist, Warnings Systems, Miscellaneous, Doors -

"PASSENGER OXYGEN" - ON

Condition: The PASS OXY ON light illuminated indicates the passenger oxygen system is activated.

Check cabin altitude. If normal, no crew action required.

------------------------------------------


As a practical matter, there should be a fairly extensive procedure, starting with verification that the masks have, in fact, been deployed, determination as to whether or not they have been used, etc.

The Abnormal Checklist left the 506 crew at a loss for detailed guidance.

Following the Alaska flight 506 incident, the copilot openly testified that he couldn't answer as to the captain's actual conversation with the flight attendants over the interphone. He and the captain stated that they relied on the input of the flight attendants, per the interphone conversation. Both pilots cite the fact that the company puts the pilots through combined CRM training as much as practical with the flight attendants. The intent is to teach reliance on the other crewmembers to do their job as professionals.

While the copilot asked the captain if he wanted to return to Portland, the captain made the decision to continue; hence, the copilot was stuck with it, as he had no information other than what the captain gave him and because they had flown together, no reason to question his judgement. Except for sudden emergencies such as an impending midair collision, the copilot is required to defer to the captain's judgement, per
§ 121.533(d)(e) and § 91.11.

Therefore (by all that is right), either the FAA is promoting mutiny, or they need to walk away from their approach to this case - quickly.

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§ 91.11 Prohibition against interference with crewmembers.

No person may assault, threaten, intimidate, or interfere with a crewmember in the performance of the crewmember's duties aboard an aircraft being operated.

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§ 121.533 Responsibility for operational control: Domestic air carriers.

(a) Each domestic air carrier is responsible for operational control.

(b) The pilot in command and the aircraft dispatcher are jointly responsible for the preflight planning, delay, and dispatch release of a flight in compliance with this chapter and operations specifications.

(c) The aircraft dispatcher is responsible for -

(1) Monitoring the progress of each flight;

(2) Issuing necessary information for the safety of the flight; and

(3) Canceling or redispatching a flight if, in his opinion or the opinion of the pilot in command, the flight cannot operate or continue to operate safely as planned or released.

(d) Each pilot in command of an aircraft is, during flight time, in command of the aircraft and crew and is responsible for the safety of the passengers, crewmembers, cargo, and airplane.

(e) Each pilot in command has full control and authority in the operation of the aircraft, without limitation, over other crewmembers and their duties during flight time, whether or not he holds valid certificates authorizing him to perform the duties of those crewmembers.



In the Emergency Revocation order, the language was both false and misleading, contrary to DOT procedures and criminal law. Under DOT procedures, the act of affixing a signature to a document certifies the accuracy of its contents and that the information is neither false nor misleading.

In order to use that procedure, the FAA has to establish that an open threat to the public exists, per the Compliance and Enforcement Program manual, FAA Order 2150.3a. The pilots had been grounded for 3 1/2 months. After 3 1/2 months, where was the threat / emergency? There was none. Given the FAR requirement for a background check, they couldn't find another flying job; there was simply no risk or danger.

The Emergency Revocation order stated that the oxygen supply to the passengers had been depleted, it hadn't; it was obviously diminished. There was no attempt to ascertain whether or not sufficient oxygen remained to meet the test of the appropriate FAR.

In an Emergency Revocation, that's an irresponsible assertion to make. The basic issue involves the number of oxygen canisters which were actually used / replaced. According to the media quoting Alaska Airlines, they replaced approximately 50% of them. That is far from 'depleted.'

Under DOT rules, the signature on the revocation order was a legal certification statement having the effect of sworn testimony. How could anyone sign such a document, when the facts were so obviously wrong? Further, Title 18 of the U.S. Code prohibits the presentation of known false or misleading information. To do so is a felony - pure and simple.

Normally an Emergency Revocation is used when the airline intends to support a pilot and continue using him/her, pending the violation outcome; this can often take years. In these pilots' case, they'd been grounded and terminated. There was no valid basis for the Emergency Revocation, whatsoever. Again, another airline couldn't use them if they wanted to, because of the background check requirement of the regulations. There was no emergency.

CONSIDER THE POLITICAL REALITY -

FAA National Headquarters is known to be keenly aware of all problems which the aviation community lives with. The FAA headquarters is reported to be in a state of election-year paranoia about it. They know that undeserving individuals are getting the shaft at the hands of the Federal power-geeks, Bob Hoover style.

The reported D.C. awareness illustrates the concerns, nigh-unto-paranoia, at the D.C. Beltway level. However, the harsh reality is that the FAA managers attend meetings in D.C., then go back to their local region, essentially with the philosophy, "To hell with her, we have to live with these carriers, she doesn't." Thus, the tail is once again wagging the dog.

Call it "managerial compartmentalization." The local FAA people don't get fired with a new administration; that's the difference. Their loyalty is extremely local. They know that leadership can be replaced overnight, the field people can't. They only have to wait out the election, then it's business-as-usual.

Perhaps they know something Al Gore (their current 'boss') doesn't know.

HERE'S THE RUB -

The copilot of AK-506 allegedly filed a violation against the company and individuals involved with the FAR deviations. He specifically requested that the case be handled exclusively by the Western-Pacific Region. In his complaint, he allegedly cited the FBI as already investigating the Seattle FAA office (a fact).

However, following a reported FAA meeting in D.C to discuss effecting the FAA's Public Relations, its own compliance with law, regulations and FAA procedures, the Western-Pacific region transferred the copilot's violation complaint to Seattle. This action was the reverse of committments which had just been made to Jane Garvey, herself!

The FAA Compliance and Enforcement Program manual (FAA Order 2150.3a) is specific as to the mandate to follow its guidance in terms of "must-follow." The manual also dictates that the enforcement personnel know it's contents. Further, the essence of the pertinent Federal Criminal Code is published within that manual. Therefore, there is no excuse for any of this to have happened.

IT GOT WORSE - FOR THE REST OF US:

While we are led to believe that the NTSB and FAA are enemies, the NTSB Chairman, Jim Hall, abruptly changed the rules; the FAA loves him.

As of mid-July, an Emergency Revocation now gives the certificate holder two days hours to file a request for review of the Emergency Authority. You can't get a phone call in to the typical FAA-savvy attorney in that time! According to an FAA type, "It's intended to be delivered Friday evening - Hint! Hint!" Considering the complexity of modern life of an airline pilot, in particular, two days CANNOT be considered reasonable.

NOTE: A previous description of the above cited the appeal process in error - that remains at ten days (Author's sincere apology).

Among other cases, the Alaska 506 saga clearly demonstrates that the FAA is so out of control that they no longer need to establish reasonable public risk to invoke the Emergency Revocation authority. Obviously, the NTSB is going to back the FAA.

According to the same FAA source, the agenda is to exclusively hold pilots responsible, so as to avoid costing the deep pockets of the airlines. This crew is again a classic example - illegal checklist; FAA approved, etc.

If you're NOT a pilot, your challenge is to entertain this question - "If they do this to airline pilots - and get away with it, who is next?" That's no small question and an issue of fact; not opinion or paranoia. If you're smart; be afraid - do something about it. Ask a teacher or a nurse how their life has changed in the past few years. Ask a doctor what 'managed care' means to him / her. If you don't already know the answer, you're in for a terrible surprise.

FURTHER DOCUMENTATION

"NTSB Recommendations to FAA and
FAA Responses Report Number: A-97-6"


On February 19, 1996, a Continental Airlines, Flight 1943, a Douglas DC-9-32, N10556 landed wheels up on Runway 27 at the Houston Intercontinental Airport, Houston, Texas. The airplane slid 6,850 feet before coming to rest in the grass about 140 feet left of the runway centerline. The cabin began to fill with smoke, and the captain ordered the evacuation of the airplane. There were 82 passengers, 2 flight crewmembers, and 3 flight attendants on board the airplane. No fatalities or serious injuries occurred; 12 minor injuries to passengers were reported. The airplane sustained substantial damage to its lower fuselage. The regularly scheduled passenger flight was operating under 14 CFR Part 121 and had originated from Washington National Airport about 3 hours before the accident. An instrument flight rules flight plan had been filed; however, visual meteorological conditions prevailed for the landing in Houston.

Recommendations:

A-97-6. Require all principal operations of 14 CFR Part 121 carriers to ensure that crew resource management programs provide pilots with training in recognizing the need for, and practice in presenting, clear and unambiguous communications of flight-related concerns.

Responses:

FAA LTR DTD: 4/22/97

In accordance with 14 CFR Part 119, effective March 20, 1997, air carriers are required to provide crew resource management (CRM) training to their flightcrews as part of their FAA-approved training programs. The POI's evaluate, approve, and oversee their 14 CFR Part 121 air carriers to ensure that their CRM programs are in accordance with the guidance provided in Advisory Circular (AC) 120-51B, Crew Resource Management. Specifically, Change 2, Appendix 3, provides guidance on communication skills. I have enclosed a copy of Change 2 to AC 120-51B for the Board's information.

I consider the FAA's action to be completed on these safety recommendations, and I plan no further action.

NTSB LTR DTD: 8/26/97

Although AC 120-51B, Change 2, Appendix 3, does not explicitly address the type of "clear and unambiguous communications of flight-related concerns" intended in Safety Recommendation A-97-6, the Safety Board believes that Line Operational Simulation (LOS) training could, depending on the content of the FAA-approved LOS scenarios and the criteria the instructor pilots and/or the check airman use to evaluate the quality of the crew communication exhibited during the LOS scenario, satisfy the intent of this recommendation. Pending receipt of additional information on the content of LOS scenarios that will be approved by POIs in accordance with the guidance contained in AC 120-51B, Change 2, Appendix 3, and the associated POI-approved instructor and check airman evaluation criteria, the Safety Board classifies Safety Recommendation A-97-6 "Open-Acceptable Response."

FAA LTR DTD: 6/18/98

The FAA has reviewed its position in response to these safety recommendations and will revise Advisory Circular (AC) 120-51B, Crew Resource Management, to address the need for air carriers to establish policy that crewmembers who appropriately question another pilot's decision or action and are following appropriate crew resource management techniques will not encounter negative consequences. The FAA will also revise AC 120-51B to address the importance of training pilots to recognize the need for presenting clear and unambiguous communications of flight-related concerns. It is anticipated that the revision to AC 120-51B will be issued in August 1998.

I will provide the Board with a copy of the AC as soon as it is revised.

NTSB LTR DTD: 10/21/98

The FAA has stated that it has reviewed its position in response to these safety recommendations and will revise Advisory Circular (AC) 120-51B, "Crew Resource Management," to address the need for air carriers to establish a policy ensuring that crewmembers who appropriately question another pilot's decision or action and are following appropriate crew resource management techniques will not encounter negative consequences. The FAA has also stated that it intends to revise AC 120-51B to address the importance of training pilots to recognize the need for presenting clear and unambiguous communications of flight-related concerns.

The Board believes the FAA should address these actions in a flight standards information bulletin (FSIB) to provide guidance to POIs. Pending publication of the FSIB, Safety Recommendations A-97-5 and -6 are classified "Open-Acceptable Response."

FAA LTR DTD: 12/11/98

On October 30, 1998, the FAA issued AC 120-51C, Crew Resource Management Training. A copy of the AC is enclosed. Paragraph 12(a), "Communications Processes and Decision Behavior," addresses internal and external influences on interpersonal communications. Paragraph 12(a) emphasizes that external factors include communication barriers, like rank, age, gender, and organizational culture, and that internal factors include speaking skills, listening skills, decision making skills, conflict resolution techniques, and the use of appropriate assertiveness and advocacy. Paragraph 12(a) also stresses the importance of clear and unambiguous communication in all training activities involving pilots, flight attendants, and aircraft dispatchers. Paragraph 12(a) emphasizes that the greater one's concern in flight-related matters, the greater the need for clear communication.

I consider the FAA's action to be completed on this safety recommendation, and I plan no further action.

NTSB LTR DTD: 3/1/99

On October 30, 1998, the FAA issued advisory circular (AC) 120-51C, "Crew Resource Management Training." In response to Safety Recommendation A-97-5, the FAA cited paragraph 10(b), "Get Commitment from All Managers, Starting with Senior Managers," which emphasizes that it is essential that every level of management support a safety culture whereby communication is promoted by encouraging appropriate questioning. Paragraph 10(b) also emphasizes that it should be made perfectly clear in pilots' manuals and in every phase of pilot training that appropriate questioning is encouraged and that there will be no negative repercussions for appropriate questioning of one pilot's decision or action by another pilot. The FAA also cited paragraphs 2(e), 2(f), and 2(g) in Appendix 3, which provide the same guidance for check airmen, first officers, and captains.

In response to Safety Recommendation A-97-6, the FAA cited AC 120-51C's paragraph 12(a), "Communications Processes and Decision Behavior," which addresses internal and external influences on interpersonal communications. Paragraph 12(a) emphasizes that external factors include communication barriers such as rank, age, gender, and organizational culture and that internal factors include speaking, listening, and decision making skills, conflict resolution techniques, and the use of appropriate assertiveness and advocacy. Paragraph 12(a) also stresses the importance of clear and unambiguous communication in all training activities involving pilots, flight attendants, and aircraft dispatchers and emphasizes that the greater one's concern in flight-related matters, the greater the need for clear communication.

The Safety Board appreciates the changes the FAA has incorporated in AC 120-51C and we believe that the information in the AC will meet the intent of these recommendations, if followed. In its October 21, 1998, letter the Safety Board stated that the FAA should address these actions in a flight standards information bulletin (FSIB) to provide guidance to POIs. The Board suggested using an FSIB to address these actions because although the AC contains advisory material consistent with the intent of the recommendations, it does not "require all POIs to ensure...," as recommended. We continue to believe that it is important for the POIs to ensure that carriers are adhering to the information in the AC. Therefore, we request the FAA to consider issuing an FSIB or Flight Standards Handbook Bulletin that would have the POIs ensure that all carriers take advantage of the new information in the AC. Pending further response, Safety Recommendations A-97-5 and -6 are classified "Open-Unacceptable Response."

FAA LTR DTD: 7/22/99

On October 30, 1998, the Federal Aviation Administration (FAA) issued Advisory Circular (AC) 120-51C, Crew Resource Management Training. Paragraph 10(b), "Get Commitment from All Managers, Starting with Senior Managers," emphasizes that it is essential that every level of management support a safety culture whereby communication is promoted by encouraging appropriate questioning. Paragraph 10(b) also emphasizes that it should be made perfectly clear in pilots' manuals and in every phase of pilot training that appropriate questioning is encouraged and that there will be no negative repercussions for appropriate questioning of one pilot's decision or action by another pilot. In addition, Appendix 3, paragraphs 2(e), 2(f), and 2(g), provides the same guidance for check airmen, first officers, and captains. This information addresses Safety Recommendation A-97-5.

In response to Safety Recommendation A-97-6, paragraph 12(a) emphasizes that external factors include communication barriers, like rank, age, gender, and organizational culture, and that internal factors include speaking skills, listening skills, decision making skills, conflict resolution techniques, and the use of appropriate assertiveness and advocacy. Paragraph 12(a) also stresses the importance of clear and unambiguous communication in all training activities involving pilots, flight attendants, and aircraft dispatchers. Paragraph 12(a) emphasizes that the greater one's concern in flight-related matters, the greater the need for clear communication.

The FAA considered its action to be completed with the issuance of the AC. On March 1, 1999, the Board classified these safety recommendations as "open unacceptable" stating that while the information contained in the AC meets the intent of these safety recommendations, the Board was concerned that air carriers would not use this information unless prompted by the principal operations inspectors. The Board asked the FAA to issue a flight standards information bulletin directing its principal operations inspectors to remind air carriers of the availability of the AC and to ensure that they take advantage of the information contained in the AC.

I have reviewed the Board's concern and do not believe it is necessary to issue a bulletin in this case. The availability of the revised AC was widely publicized. Air carriers, as a matter of good operating practice, are familiar with this information and are using the guidance in the AC as a foundation of their crew resource management training. I believe that, in this case, issuing an information bulletin to call attention to the existence of the revised AC is an ineffective use of the bulletin process.

I believe that the FAA has addressed this issue completely, and I plan no further action on these safety recommendations.

NTSB LTR DTD: 2/23/00

On October 30, 1998, the FAA issued Advisory Circular (AC) 120-51C, "Crew Resource Management Training." Paragraph 10(b), "Get Commitment from All Managers, Starting with Senior Managers," emphasizes that it is essential that every level of management support a safety culture whereby communication is promoted by encouraging appropriate questioning. Paragraph 10(b) also emphasizes that it should be made perfectly clear in pilots' manuals and in every phase of pilot training that appropriate questioning is encouraged and that there will be no negative repercussions for appropriate questioning of one pilot's decision or action by another pilot. In addition, appendix 3, paragraphs 2(e), 2(f), and 2(g), provide the same guidance for check airmen, first officers, and captains.

Additionally, Paragraph 12(a), "Communications Processes and Decision Behavior," emphasizes that external factors include communication barriers, like rank, age, gender, and organizational culture and that internal factors include speaking skills, listening skills, decision-making skills, conflict resolution techniques, and the use of appropriate assertiveness and advocacy. Paragraph 12(a) also stresses the importance of clear communication in all training activities involving pilots, flight attendants, and aircraft dispatchers and emphasizes that the greater one's concern in flight-related matters, the greater the need for clear communication.

On March 1, 1999, the Safety Board classified these safety recommendations "Open-Unacceptable Response" because although the information contained in the AC addressed the issues of concern in these safety recommendations, the Board was concerned that air carriers would not use this information unless prompted by POIs. The Board asked the FAA to issue a flight standards information bulletin FSIB) directing its POIs to remind air carriers of the availability of the AC and to ensure that air carriers take advantage of the information contained in the AC.

After reviewing the FAA's reply, it is evident that the FAA disagrees with the need to address this critical issue through the use of the POI program. The Safety Board believes that without reinforcement by the POIs, some airlines may not have these important issues addressed in their CRM programs, and pilots could still feel intimidated or fail to make their views heard during critical phases of flight. The purpose of this recommendation was to direct that POIs inspected airline CRM programs to ensure that these policies were present in their CRM program. Since ACs are advisory only, the FAA's actions have failed to address this recommendation. Therefore, Safety Recommendations A-97-5 and -6 are classified "Closed-Unacceptable Action."

---------------------------------------------------------


Can anyone realistically question how the recent accidents and incidents happened?

Here's how it works -

Clinton issued Executive Order 12866. This order mandated the consideration of costs in the enforcement of regulations and in regulation enactment. That order was prostituted to effect the public endangerment which we are now witnessing. Rationalization provided by the Executive Branch of American government has effectively nullified public law.

Gore refers to this as, 're-inventing government.' Very clever!


Here's the catch -

Section 9 of that order clearly stated that the order did not have the effect of negating existing public law. Hence, the FAA's safety mandate is still in full force and effect - however, now on a selective basis.

Money talked; safety walked. For all intents and purposes, the lobbyists effect the policies; effectively bypassing the law itself.



In the aftermath of the AK-506 incident, the crew discovered their scope of friends. The number turned out to be small and diminished with time. The copilot, in particular, fell prey to his share of the pilot-cannibal types on the ALPA electronic bulletin board. Human nature is unfortunately characterized by predictable negativity.

The copilot quickly discovered that the myth of union brotherhood obscured the fact that 'unity' was largely a function of money matters at the juncture of contract negotiations. Some attacks were incredibly arbitrary and self-serving. Naturally the bulk of the attacks were contained in the unspoken argument, "Making him look bad makes me look good." "Shutting him down makes me look powerful." Amazingly, the continuing safety issues seemed to mean nothing. The attacks were adolescent at best.

Prior to the 506 incident, the copilot had taken a strong position on behalf of the union membership to enhance the airline safety. It was ironic that he fell victim to the very issue he attempted to promote.

Perhaps the most bewildering aspect of the FAA action against the pilots is that after facilitating the basic problem, the FAA violated every 'norm' known to pilots by ignoring the 'NASA report' and the policy covering 'self-disclosure,' AFTER TWO MONTHS; then only after the media publicized the event.

A local FAA action might be understandable. However, the NTSB is clear that there was no emergency - hence, no authority for the violation. Why, then, has the NTSB even agreed to process the violation?

While some might argue a case against the captain, it should be clear in anyone's mind that the first officer was totally compelled by law, regulation and policy to abide by the directives of the captain.

The violation against the first officer, in particular is glaring evidence of the corruption involved.

The biggest mystery of all is that the FAA corruption of the AK-506 incident is known to all the offices involved in Washington D.C.. Yet nothing has been done, other than to effectively strip every pilot of his or her rights as a pilot, following the first officer's appeal to the NTSB.

In reality, the FAA and NTSB have reacted with a vengence, following Bob Hoover's re-certification.

All this corruption (not limited by any means to the AK-506 incident) by the very people who raised their right hand swearing to defend the Constitution of the Unites States, against all enemies, foreign and domestic.


In the wake of the 506 incident, the copilot quickly discovered his isolated condition, becoming keenly aware that his will to survive was largely a function of his personal resourcefulness. The payroll "B-scale," left him little to survive on. The ALPA "Hostage Funds" designed to assist pilots who were attacked by management for union activities were unavailable to him. The material, above, is the result of his resourcefulness; his attorneys have learned from his resourcefulness.

There were the 'self-serving' who consciously refused to see the safety aspect of the crew's fight. Eighty-eight fresh tombstones seem to have no meaning to them. Ironically, approximately 30 of those tombstones identify former co-workers.

Over time, the 506 pilots' peers have come to grips with the potential which the fate of the AK-506 crew holds for all the Alaska pilots. Slowly, the detractors have been held accountable by their peers. A non-union assistance fund has been started by one pilot. Nobility has taken hold; results will illustrate it's effect.

Perhaps the spirit of the Alaskan frontier is starting to show itself among the Alaska Airlines employees who have begun to keenly sense their isolation from management; reminiscent of the Alaskan pioneers, isolated by distance from "....the lower-48."

Time will tell.

The 506 crew's issues are those of every airline pilot, particularly those of the Alaska Airline's pilots. The 506 crew now fights for not only their jobs and licenses, but also for the safety issues which affect the welfare of the pilots at Alaska and the very economic health of the corporation.



IN THE MEANTIME....

While the pilots were fired for their alleged failure to follow procedure and lying to the company, recent depositions (approx. 8 Sept, 2000) of the flight attendants indicate the exact reverse, complete with sworn testimony as to the company and FAA complicity in effecting the falsifications used to terminate the pilots and induce the violation proceedings. The obvious and constant motive is to cover up the factual account, cited above.

In a sentence, the sworn depositions revealed one vitally important fact, THE PILOTS TOLD THE TRUTH!

A second important fact was also revealed in the depositions; the FAA knew that the pilots' account was factual from the very beginning!

A third fact has also been revealed; the question as to whether the passenger oxygen supply was diminished to a dangerous / illegal level has yet to be resolved. As a consequence, the FAA cannot account for their initiation of any enforcement action against the pilots, let alone their application of the FAA's Emergency Authority, used to revoke the pilots' certificates.

Another fact was revealed at the depositions; the passenger oxygen masks dropped within seconds of the sounding of the cabin pressure warning. That testimony not only corroborated the pilots' statements, it also revealed the probability of a distinct certification problem in the particular series of pressurization controllers.

While notified of the details, Washington D.C. continues their silence, indicating no interest in the violation of the pilots' Constitutional rights or the continuing FAA criminal corruption.

The amazing fact is that the pilot' and company 'self-disclosure' should have served as it's intended act of honesty, revealing elementary and easily corrected problems. The FAA had every opportunity to take the factual position that the event was totally inadvertant, no one was ever endangered and that an investigation was underway to correct certain possible oversights. It was always that simple!

Yes, Lord Acton, "Power corrupts; absolute power corrupts absolutely!"

Although the FAA acted with blatantly illegal swiftness against the pilots when it became clear that their 'secret' was exposed (two months of silence), they have only acknowledged the receipt of the violation complaint, which was subsequently filed against the company by the first officer.

Despite these issues illuminating major safety matters demanding immediate correction to prevent a 'next occurence,' there is no known action in that direction. It is unforgivable for the FAA to so blatantly abandon their safety mission.

Conversely, the FAA instead concentrated on putting another airline, ProAir, out of business. With a "100% surveilance" effort, more than 300 unwarranted 'investigations' revealed no significant findings worthy of a revocation action. Yet the surveilance continued until the FAA achieved their nefarious end.

Against the obvious need for simple and inexpensive changes indicated by the AK-506 incident alone, there is no excuse for the politically selective action / inaction of the FAA. If reasoning alone is not enough, the fatalities in the background should compel the FAA to action toward effecting safety.

In addition to other accidents and incidents, the American 1420 and Alaska 261 accidents glaringly testify to the fact that the FAA knew that the obvious problems existed; yet did nothing. The FAA action in the AK-506 incident tells only one story; they still intend to do nothing.

In the most recent depositions, the FAA inspector handling the 506 investigation essentially testified that he didn't have the slightest idea what constituted an "emergency" in the context of the violation which he investigated. He also testified that he didn't have a reliable shred of evidence that the oxygen supply was actually depleted to a dangerous degree, nor whether the aircraft was actually airworthy.

The inspector testified that in his mind, FAR 91.7's provision that the Pilot In Command (captain)is responsible for determining the airworthiness of the aircraft, also applied to the Second In Command because the term "solely responsible" wasn't used in the wording, therefore he could safely imply that others are also responsible for airworthiness inflight... or on the ground for that matter (i.e. ground personnel). Further, the inspector stated that it was the copilot's responsibility to argue with the captain all the way up to the cruise altitude, stressing the need to return to Portland & not contiune the climb.

It should be noted that the violation in question correctly asserted the operation as being conducted under FAR 121. The classic treatment of this regulation by the FAA is that FAR 121 acts as a restriction to FAR 91, hence FAR 121.533 (d)(e) was the controlling regulation. That regulation is crystal clear that the captain is soley responsible.

Either the "expert" inspector was testifying to his own incompetence; or his thinly veiled deceit.


Ironically, the essence of the inspector's testimony in this regard was the implication that CRM application was mandatory. Again, contrast such a position against the official FAA position that material emanating out of Advisory Circulars is prohibited from being treated as the basis for enforcement!

He did testify that he prepared the statement of a party offering essentially 'hearsay' evidence, upon which he relied. He also testified that he prepared the flight attendant's joint statement for their signature.

The major question is, why - after 3 months - didn't he examine the aircraft Maintenance Logbook, which would have immediately answered numerous obvious questions? Why not determine airworthiness before and after the incident flight? Further, why didn't he examine the mandatory reports made directly to the FAA? What happened to the depleted cannisters (hazardous material tracking required)? How many canisters were actually replaced? The canisters are serial numbered; were they being tracked? Was there enough for 10 percent of the passengers as described in FAR 121.333? 50 percent? More?

While sworn as an 'expert witness,' after six hours in deposition, the FAA inspector, with 10 years experience, could not establish any valid information which was sufficiently reliable as to warrant ANY action taken against the pilots! It is well worth questioning exactly who is calling the shots. The suspect history of the Seattle FAA office is too extensive to evade that question, in particular.

The inspector's testimony left one major idea; the AK-506 case was a 'dirty' investigation in it's best merits. Clearly, the FAA was conducting a wannabe 'sting' operation. As in the CS-985 case, their employment of FAA procedures and regulations was selective - to an extreme. The typical observer would stand back and say, "They can't do that!" As in CS-985, they did.

The inspector also testified that no changes had been initiated at Alaska Airlines since the event. Against the background of one fatal accident and the AK-259 'air rage' incident, such is unbelievable!

Depositions also indicated that one of the flight attendants had "legally" recorded the joint meeting with the same FAA inspector in a joint meeting with company officials. However, that tape was 'accidentally' destroyed after the revelation of its existence in previous depositions.

Later depositions of the Chief Pilot and Director of Inflight (flight attendants) affirmed the depositions of the flight attendants. In essence, their depositions containing the expected 'memory lapses,' added little, however, their testimony re-affirmed the caseto the benefit of the pilots.

Returning to the core of the matter, the depositions re-illuminated the fact that the allegations in the Emergency Order against the pilots failed to cite any factual history, thus an emergency could not, in any reasonable manner, be determined.

Instead, the allegations, which should have been considered in the exclusive context of a routine investigation, possibly an enforcement matter, were used as the basis for an emergency revocation. The pilots' appeals were filed according to the new "Hoover Bill" procedures of 49 U.S.C., section 44709, challenging the facts and the definition and existence of an "emergency."

Alaska 506 is exactly the type of case the new procedures were intended to cure, i.e., one where the FAA has exagerated its authority, for unstated reasons, attempting to cover that action by arbitrarily and capriciously declaring the existence of an "emergency," thereby unduly punishing the certificate holder.

The FAA action goes beyond clever verbiage, as their false claims clearly fall within the venue of a Federal Felony. As in the Air Mike CS-985 case, the commission of felonies is nothing new to the FAA. The CS-985 case, complained to all pertinent office in Washington D.C., also demonstrates the FAA's Teflon coating, relative to investigation and punishment.

The FAA's apparent immunity from investigation and prosecution is additionally demonstrated by the Mary Rose Diefenderfer case. While the FBI is known to be investigating her matters as well, the FAA was so highly confident in their position as to proceed and continue with the action against the pilots.

Additional protection of the FAA abuses is further demonstrated by the counter-violation filed by the first officer of Flight 506. Despite his pleas, the jurisdiction was transferred to the very people whom he complained about. The essence of the treatment in that violation complaint is, "Sheriff, investigate thyself."

At the core of these pilots' appeals is the career and personal future of the pilots. However, there is far more involved in this matter. There is additionally a genuine issue of highly preferential treatment of the indisputable FAA double standard which permits the FAA to enhance the economic welfare of Alaska Airlines, Inc., to the unfair detriment of the pilots. Contrary to any concept of integrity or morality, the FAA is employing their emergency authority as a discriminatory punitive and enforcement tool.

The FAA's treatment of the pilots stands in stark contrast to its treatment of Alaska Airlines, itself. During a two-year investigation of Alaska's maintenance practices, highlighted by the fatal Flight 261 tragedy of January 31, 2000, the FAA, through the local Seattle office of the FAA, worked diligently with Alaska Airlines to develop a new maintenance plan. Approximately three months ago, the FAA announced that it accepted the plan and that no certificate action would be taken against Alaska Airlines.

As the Seattle Times illustrated, the actual revision of those manuals PRECEDED the FAA announcement that there was a concern in the matter.

Again, the Flight 506 pilots had legitimately filed the NASA ASRS reports and had demonstrated their honor by self-disclosing the events of the flight in a timely fashion. No enforcement action was warranted, as opposed to corrective action, which remains to be achieved.

Comparing the two situations, there was no "emergency" and no action was taken to punish the Alaska Airlines employees and shareholders in a situation that was radically beyond any potential enforcement issues presented by the pilots of Flight 506. The Alaska 261 tragedy, alone, had a legacy of 88 fatalities.

The 'air rage' incident a few weeks later reinforced the call for the re-examination of safety procedures at Alaska.

The FAA has a long history of being able to engage in totally arbitrary actions, prostituting the "emergency" provision in section 44709. The FAA is the only federal regulatory agency (distinguished from the authority of bodies such as the IRS) with such draconian powers. The Hoover Bill was intended to halt those abuses. This is such a case where the line should be drawn. Indeed, if it the line is not drawn at this juncture, the Hoover Bill is destined to become a virtual joke in aeronautical history.

In the context of the FAA's application, there is no pertinent definition of the term "emergency," other than to associate it to "safety in air commerce or air transportation." The dictionary defines the term as, "a serious condition or occurrence which happens unexpectedly, demanding immediate action" or a "condition of urgent need, requiring action or assistance."

The legislative history of the new review provision confirms that the elements of urgency, immediacy, and a lack of foreseeability are prerequisites to a determination that an emergency exists. The Hoover Bill, named after the aerobatics pilot who had his medical certificate revoked by the FAA on a capricious "emergency" basis, last was introduced as S.722 on March 25, 1999. On the senate floor , Senator Inhofe (Oklahoma )stated that, "the FAA has begun to use an exceptional power as a standard practice." He added, "At my request, the General Accounting Office (GAO) did a study of emergency revocation actions taken by the FAA between 1990 and 1997. The most troubling result of the GAO study is that during [the] time frame studied, 50 percent of the emergency revocations were issued four months to two years after the violation occurred. In only 4% of the cases was the emergency revocation issued within ten days or less of the actual violation. In fact, the median time lapse between the violation and the emergency order was a little over four months (132 days)." Cong Rec. S3450 (March 25, 1999).

The only solution to the blatant power abuse was to grant certificate holders the right to an immediate review of an emergency revocation "to determine whether or not a true emergency exists." S.722 was finally enacted as section 44709(e)(3).

However, the permitted time frame of the appeal (two days) for review of the FAA application of their emergency authority is arbitrarily far too short to effect universal relief in the application of this right. For the moment, it's the best relief available.

The NTSB has never has defined the term, "emergency" because it did not have jurisdiction to establish a specific definition. Thus, the courts have historically treated the issue on a factual basis, individually examining situations alleged to constitute an "emergency." As an example, any significant delay between the investigation and the issuance of the Emergency Order obviously indicates a lack of urgency, unless the delay can be otherwise justified by the requirement of time to responsibly complete a complex investigation. [Go Leasing, Inc. v. National Transportation Safety Board, 800 F.2d 1514, 15__ (9th Cir. 1986). Similarly, a "pattern of repeated conduct evidencing a disregard for regulations directed to safety" can, in certain circumstances, constitute an emergency. Nevada Airlines, Inc. v. Bond, 622 F.2d 1017, 10__ (9th Cir. 1980)]

Such considerations are consistent with the FAA's directions to its inspectors: Emergency certificate actions may be taken only when clearly needed in the public interest.

The issue ultimately demands that the definition of "emergency" also has to rely on common sense. It is necessary that the situation described in the revocation order be examined to establish that the situation is, in fact, so immediate and compelling that it warrants overriding 'due process' for the sake of safety. Conversely, it must also be examined to discover whether or not the authority application is a fraudulent method for the FAA to override due process. In cases such as this, legal precedents and common sense beg to be applied against a history which betrays the following:

- The FAA failed to establish any factual basis for the violation in question.

- The FAA was complicit in the event by virtue of their negligent oversight of Alaska Airlines policies, procedures and training.

- The FAA was complicit in the event by virtue of their negligent oversight of Alaska Airlines recent pattern of accidents and incidents.

- The FAA failed to initiate ANY action until after the media publicized the event; approximately two months after the fact.

- The FAA action was in concert with Alaska Airline's announcement of their intent to terminate the pilots, also immediately following the event being publicized by the media.

- To date, the FAA has failed to take any corrective action to amend the obvious processes which precipitated the event in question.

- The FAA has relied upon no consistent information or statements which would compel this action; or any enforcement action against the pilots.

- While the FAA has been on notice of the negligible (possibly false) merits of their allegations, the FAA has taken no steps to re-access this action with respect to diminishing or withdrawing their complaint.

- While the FAA has been on notice of certain safety violations by Alaska Airlines emanating from this incident, the FAA has taken no appreciable steps to either investigate or correct these the allegations.

- The allegations do not identify a violation of the FARs, let alone an "emergency." The pilots are essentially being punished for having appropriately complied with FAA certified and accepted procedures.

- The FAA now seeks to revoke the licenses of the pilots in lieu of more appropriate enforcement action against Alaska Airlines.

From any perspective, there was no emergency in any sense of the term.

The FAA's efforts have maliciously slandered and libeled the integrity of the pilots of flight 506 by asserting that the pilots operated an aircraft "in a careless or reckless manner."

The FAA emergency order fails to describe a factual violation. There is simply no basis for asserting that there was an urgent situation compelling such extraordinary action to protect the public.

The Emergency Order makes the assertion that the pilots presently lack the qualifications to hold a certificate. The assertion would clearly be far mor appropriate against Alaska Airlines.

In glaring contrast, the FAA additionally exercised their emergency authority, without merit in the case of ProAir, Inc. This case was also an event of preferential treatment against the safety history of Alaska Airlines.

- Alaska Airlines is under criminal indictment for allegedly having failed to assure the continued airworthiness of its airplanes and the safety of its operations;

- Alaska Airlines manual system was discovered to be insufficient;

- Alaska Airlines does not have an adequate training program, evidenced by the pilots actions and the content of their FAA approved and accepted manuals.

These issues were essentially identical to those cited in the FAA's press release, regarding ProAir's operating certificate emergency revocation, along with the particularly false comment that Pro Air failed "to correct these discrepancies after being notified by the FAA."

For such statements to be made from Washington D.C. is unforgivable.

The allegations against the Flight 506 pilots are not only incorrect, they are quite obviously politically driven, in favor of Alaska Airlines flight operations management. In the greatest clarity, the allegations are uniquely regulatory rationalization, bordering on criminal fraud. In no manner should such unsupported conclusions be used to rationalize or justify the existence of an emergency.

The pilots are entitled to be treated according to responsibly determined facts. They do not deserve such extreme rationalization. By any reasonable standard, the FAA is compelled to fairly determine whether or not the pilots actions on flight 506 were so extreme as to create an event so urgent that an "emergency" existed.

The fact that no one within the FAA felt that an emergency existed until approximately 3 1/2 months after the event, with no changed circumstances and no significant investigative fact-finding processes, is the most powerful indicator of the reality.

Correctly, the average person would ask, "Then WHY is this happening???" The question is both fair and pertinent. The answer is simply, "dollars." The Alaska 506 case and the ProAir case have one common denominator with the CS-985 case, the attention and APPROPRIATE 'heat' are directed away from the 'protected' company.

As of the end of September, 2000, how far along is the change program in all areas of Alaska Airlines, following the force-fed re-writing of their manuals? Have deadlines been set or attained? If one word in what you've been reading is true, the answer is that the changes have not been effected to an acceptable degree. The remaining question is, will they be?

Once again, contrast the treatment of ProAir. There's something desperately wrong in this picture.

In the background also is the violation filed by the first officer. A reasonable person would conclude that the FAA will stall until they can invoke the "stale complaint rule." Afterall, this isn't about safety; it's about protecting the profits of Alaska Airlines.

The NTSB heard the cases of the pilots, with the final decision (pending possible appeal), rendered on the 28th of September, 2000.

During the presentations, the defense attorneys repeatedly cited the pilots' compliance with the FAA approved training and the associated checklist, which clearly stated "..no further crew action required." It's difficult to ask for stronger language.

In response, the FAA rebutted the position, claiming that the end of the appropriate checklist is not the end of the expected pilot action. One has to ask the root of that conclusion, as there is nothing available to the pilots to arrive at the same idea. Clearly, the FAA's position was not focused on safety; only power.

The FAA's position was paradoxical, against the known history of the fatal AK-261 crash. That crew went far beyond the checklist, as opposed to concluding that their actions were as complete as possible. In contrast to AK-506, the pilots of AK-261 went the extra mile for the company; at a terrible price.

The obvious conclusion is the demand for an institutionalized policy / philosophy which states, "If any abnormal or emergency checklist fails to resolve the situation, land as soon as possible."

The captain's certificate revocation was upheld. To be brief, the judge stated that the captain did not exhaust all means available to ascertain the true reality of the situation, hence he was reckless in that regard.

The first officer's case was modified to a 4-month suspension. The judge honored the fact that he had openly questioned the captain. However, the judge essentially based his finding on the ability (failure) of the first officer to discount the captain's opinion or decision, and to independently verify the reality to his own satisfaction.

The first officer's defense attorney, acting in concert with the ALPA attorney, delivered an eloquent summary on behalf of the pilots; the first officer, in particular. He cited the fact that the pilots were acting in willing compliance to their FAA approved training, without exception. He went on to say that if the FAA desired a higher standard than that which the pilots were responsive to, then it was far more appropriate for the FAA to analyze the event in the context of the scope of the FAA's own standard, imposed on the pilots. The attorney appropriately protested the FAA counsel's offensive and inaccurate description of the first officer 'sitting there like a bump on a log.' He illustrated the copilot's right to rely on the captain's judgement, having first openly questioned the reality of the situation and the decision against returning to Portland.

During the testimony, the flight attendants accounts differed widely. However, all three claimed that two flight attendants went to the cockpit. Within the scope of that testimony, the two flight attendants affirmed that they had not advised the crew as to the expended status of the passenger oxygen system, during the alleged visit. Given the empassioned testimony as to their personal fear of danger during the flight, one has to seriously wonder how the flight attendants could NOT bring up the obvious issue, if they in fact went to the cockpit. The pilots, conversely, were adamant that the flight attendants had not entered the cockpit as described.

One of the key discrepancies in the flight attendant testimony, was that two of the flight attendants cited the aft interphone being picked up in response to a chime signal from the cockpit. That testimony corroborated the pilots' account. The lead flight attendant was adamant that he initiated contact with the cockpit. Had that been factual, a cabin chime would not have been heard.

The details of the flight attendant testimony differed significantly. However, the testimony depicted the issue of the interphone communication as casual or quizical, at best, regarding the status of the passenger oxygen supply.

The first written statement of the flight attendants, which failed to describe any cockpit visit, was mysteriously treated as insignificant. A reasonable person is left to wonder why a statement made within 24 hours of the event would be treated as insignificant, as it obviously contained the most fresh memories. The later statement crafted with the assistance of the FAA inspector was treated as the only credible statement.

In contrast, the pilots' account was constant and detailed with respect to the complexity from the beginning to the end.

Against the mandate implied in the pilots' case, there was no address of a similar responsibility shared by the flight attendants, despite the intended content of the Alaska Airlines CRM program. The CRM program at Alaska is known as "ICE," Integrated Crew Environment.

Bewilderment is the appropriate reaction of any Alaska Airlines pilot. The Alaska "ICE" program calls for the inter-dependence of crewmembers, based on the assumption that the crewmember is competent in their job. To overtly question or blatantly distrust the other crewmember is to be considered unprofessional.

In the current world of 'politically correct,' any pilot would be wise to fear a reaction to his/her questioning of a flight attendant. Unfortunately, the AK-506 matter demonstrated that progressive thinking is not inherently productive. Resorting to comic relief, it may be said that the pilots got 'iced.'

The NTSB outcome sent a clear message to pilots as a whole; "Test your assumptions." Paradoxically, that message is consistent with the principles embodied in the science of CRM. The message staggers the imagination, as the FAA had taken such an adamant stand against the NTSB appeals for their implementation of CRM at the cockpit level. The FAA's apparent underlying message being, "We won't seriously facilitate CRM, but we'll gladly prosecute a CRM failure."

It is oxymoronic, nigh unto humorous, that the FAA would turn to the NTSB to prosecute an NTSB issue, which opposed the FAA. The pilots learned an important lesson, "Trust not - suffer not." Against the number of FAA personnel who are appropriately to be respected and admired, this one case betrayed the potential treachery of the agency which continues to insult the aviation community with expressions which essentially say, "Trust us." Bad move.

If there was a single 'highest injustice' in this case, it was contained in the appropriate demand on the pilot's for the highest standard of safety, yet the FAA is virtually immune from the same Federal Statute. Selected airlines mysteriously seem to share that same immunity. Most alarming is the number of gravestones which continue to be erected as a consequence of this immunity.

The greatest tragedy of the outcome of this case is that it was consistent with the sabotaged efforts of Mary Rose Diefenderfer and her FAA team. More tragedy is reasonably guaranteed by the fact that there are no indicators to suggest that the gravestones and subsequent events count for anything, except reduced expenses.

The most chilling part of this case is that the FAA established a new norm - the justified snitch. Given the effective precedent - "copilots will be jointly battered" - it is naive to think that first officers will not make regular visits to the chief pilot's office to complain about the decision making of captains.

Their complaint is valid, "The FAA will not only grab my license at will, they'll distort anything into a termination procedure. The FAA publicity blitz will force you to fire me for visiting the lav. Look what they did to that CS-985 captain; they can lie about anything! The FBI can't even keep them honest; this isn't just a local thing!"

In the background of this case - and others - is that the FAA inspectors themselves do not control the disposition of the case. While the inspector makes the recommendation as to disposition, the decision can be overridden in the office. In the 506 case, Tweedly Dum (description appropriate) sat through the hearings to witness his power in action and was obviously very pleased with himself.

Perhaps the most offensive event was the FAA inspectors joyous leap in the air after the Captain's case was closed and most had left the hearing room. That event gave new meaning to to the joke, "I'm from the FAA, trust me."

From this time forward, the relationship between captains, first officers and FAA inspectors has taken a new turn. Enter the proven and deadliest ingredient of all - personality conflict.

The testimony of the FAA during the hearing was almost stunning. The FAA introduced a company CRM policy which was dated after the AK-506 event. The document cited the generic CRM policy in terms of flight crews; flight attendants implied. The policy demanded that the crewmember assertively communicate their concerns clearly until they were sure their point was firmly established. Yet the FAA said nothing about flight attendant responsibility, even though the flight attendant testimony (and associated depositions) clearly established that their actual response to the situation ran contrary to the CRM policy entered into evidence. No, the matter isn't about safety.

The FAA presented a medical doctor who convincingly testified as to the deadly effects of decompression at an altitude of 41,000 feet. Amazingly, his testimony essentially implied that in a realistic situation, the passengers stood little chance of survival in the best of conditions at that altitude.

With a minimum of deduction, on a full flight, if the flight attendants were caught working in the middle of the aisle, they would be essentially doomed, unless they stole masks from the passengers getting back to their seats or to a portable oxygen bottle. Imagining the descent angle of a 'high-dive,' any standing passengers or the the flight attendants would be in dire peril.

Later an FAA certified flight surgeon affirmed that obvious suspicion, estimating ten seconds or less to get a mask on. He cited the improbability that the masks, even if successfully donned would be effective safety devices, given the probable realistic time it would take for the aircraft to get to a safe altitude.

Being realistic, in the chaos of an explosive decompression, in particular, the required time (again, being realistic) is extremely unlikely to be available. The effectiveness of the passenger masks, even if successfully donned wouldn't likely be sufficient to ensure survival in the event of an unexpected decompression at 41,000 feet. Clearly, flight at such an altitude is unsafe for passengers or cabin crew, yet it is an FAA certified operation - don't ask; don't tell.

The recent history of bizarre 'air rage' events speak to a radically higher probability of such a decompression event. The liklihood is far more than hypothetical. Computer proability statistics are insufficient basis for certification in this arena.

The June 2000 GAO report to Congress on airport security adds the potential of a terrorist attack to that probability. In glaring evidence of that assertion is the fact that the most current statistics are held as a secret, as the threat is estimated to be so high. There is nothing paranoid or exagerrated about such a fear.

Ironically, flight attendants now fall under the auspices of OSHA. With a simple reality check, only a dreamer would expect any intervention for the flight attendants. Chauvinism aside, one has to ask the obvious question,"With the flight attendants incapacitated, who is going to attend to the passengers?" A realist would demand, "Show me anyone who actually cares. If they did, we wouldn't be here."

Behind the scenes of this event lurk the requirements of Title 49; parts 300 and 805. These would lead any reasonable person to expect nearly identical functions and restrictions as found in a court of law. Yet that doesn't and didn't happen on the argument, "This is a 'regulatory' environment."

The "Ethics in Government" requirements mysteriously fade into the symbolic darkness of these hearing rooms. Despite all rationalization, one cannot help but wonder how such events can be created and perpetuated by those who raised their right hand swearing to uphold and defend the Constitution of the United States against all enemies, foreign and domestic.

Something just doesn't make sense.

Following the announcement of the captain's fate, one mind in that hearing room wandered back to the nation's Capitol, the symbol of prejudice extinction. The image within a cultural museum entered his mind, showing a gateway to eternity with a sign overhead which read, "Arbeit Machs Frie." The museum slogan was, "Never again." That same mind silently muttered, "Maybe not the same way; maybe not to them."

Mysteriously, the 'power-trip' continues.

The bizarre behavior of the FAA continues, unabated by law, regulation, policy or reason. Beyond "power-addiction," no one has an explanation. There has never been as much as an accusation, let alone a shred of evidence that anyone in the FAA is taking any money. One can only ponder the addicting effect of personal power with bewilderment. Denial is a waste of time.

Given that the presented issues are not limited to the single FAA office, but have been broadcast throughout the nation's Capital; there are appropriate and legitimate fears.

While the strange internal politics of the Seattle FAA office have been investigated by the NTSB and reported to the FBI; it's still "...business-as-usual;" emphasis on 'business.'

The never-ending nightmare is the fact that only the victims of such events seem to care.


RECENTLY - The 506 case took on a renewed fire; the FAA, in it's lust for absolute power, appealed the ruling against thE first officer of AK-506; they want nothing less than absolute power - revocation; nothing less. A four month suspension for questioning, then following the captain's directive (per regulation and policy) simply wasn't enough. WHY???

The hearings were dramatic enough, but again, told one story. The pilots were foolish to believe that the FAA certified training was the mandate. It turned out to essentially be a 'sting-in-waiting,' effected at the whim of the FAA.

On October 8th, an article in the Los Angeles Times by Eric Malnic cited a nearly secret meeting of the top FAA officials in a Holiday Inn meeting room in the Washington D.C. area. The meeting was strange in itself with all the offices in the world in Washington D.C. available. In that meeting, the FAA heads discussed the miserable state of affairs in the agency. Yet they left the meeting to perpetrate more of the very same treatment which they acknowledged as being totally unacceptable. Malnic was able to get them to admit even their subsequent failures as being factual. Still, no change except for the worse.

While Malnic's article did an excellent job of focusing on the continuing reality of crew fatigue, even hidden from Malnic was the crew fatigue factor in the Gander DC-8 crash, the Houston DC-9 belly-in and the Air Mike CS-985 incident. The obscuration of these events testify to the clever ability of the FAA to hide major factors in incidents and accidents. There is still more to that story.

The immediate history (i.e., Alaska 506, Pro Air and Sun Pacific, CS-985, etc.) following that 'secret' meeting in Washington tells one message - someone outside the Federal Government is actually calling the shots.

Remember that this is an election year; political embarrassment is not allowed. Whether it is a single agency or the entire government, "subversion" is the only appropriate term. Challenge yourself for another explanation. Al Gore is all too well informed; it's his show as Vice President alone. Given the media attention to the airline industry, burden, ignorance and chaos are not a viable answers. Selective windfall profits offer the enduring answer; at the risk of passenger's lives. Notice that nothing is changing, despite the undeniable risk illumination.

Outstanding in this case also is the lack of support of the company, even after depositions revealed insufficient evidence that the pilots had lied. The facts behind the crafting of the statement which the company relied on were far too suspect to reasonably be considered as a basis for termination.

Debate aside, considering the Alaska Airlines history of egregious errors by pilots causing damage to aircraft with no termination - something continues to be very wrong in this picture.

At this juncture, it's appropriate to refer to the continuing saga of the ProAir case, as it is a nearly identical case of power addiction.