"We are the protagonists of our stories called life, and there is no limit to how high we can fly."
PHD. MBA. MHS. Type rated on A350, A330, B777, B747-400, B747-200, B757, B767, B737, B727. International Airline Pilot / Author / Speaker. Dedicated to giving the gift of wings to anyone following their dreams. Supporting Aviation Safety through training, writing, and inspiration. Fighting for Aviation Safety and Airline Employee Advocacy. Safety Culture and SMS change agent.
“Any landing you walk away from is a good landing”
might be wrong.
I’m surprised that anyone survived this crash, but I am not surprised that this event happened. This was not an “if” but a “when.” This was a training issue that resulted in pilot error. Fast, no flare, they slammed into the runway. But if we don't properly train pilots to land in strong winds, or how to identify when to go around, or how to do so, because that might cut into executives profit, then we failed these pilots.
Why has Nobody Interviewed the CEO
Captain James Graham?
Endeavor Air CEO James Graham
Substandard Training
In 2008 Delta and Northwest merged. In 2009 they formed a single operating certificate. In 2010, I experienced my first Delta training checkride, where the instructor did not give the federally required oral. He sat in the back of the simulator and texted instead of paying attention to the “new to” A330 pilots. He did not even give a debrief. He falsified training records. Why? Because as he said, “At Delta we have the power to do what we want.” He soon became a line check airman.
Meanwhile, in another Delta simulator a different instructor is telling Delta pilots, “Stop asking questions, be the monkey, hit the lever, get the banana.” Delta even provides answers to the written tests, computerized now, for rote memorization. To pass the test however, sometimes you have to answer incorrectly, because the test is wrong. Their training manuals for years said the Airbus A330 had a stick shaker. It does not.
Pilots who flow up to mainline Delta and cannot pass this training are allowed to return to their same captain position, at Endeavor. While I can only attest to facts of Delta’s substandard training to first-hand experience and trial testimony, I only have hearsay as to how bad Endeavor’s training is. The FAA will have to investigate that. But there is the problem.
Effort to Improve Safety
In 2014 I returned to school to earn a doctoral degree in aviation focused on Safety to figure out what the hell was going on at Delta. I learned of SMS and realized that Delta’s processes were violating Federal Regulations, and that substandard training led to the lack of understanding that resulted in accidents. During my defense, a professor said, “What do you think they will do now?” as a result of my findings. “They” being management and the FAA. But the FAA already knew, and management refused to invest in training and the FAA looked the other way.
In 2015 I heard Delta’s CEO, Richard Anderson at the time, speak on safety and reporting that conflicted with the Delta culture. Therefore, I requested a meeting with senior executives, Captain Steve Dickson and Captain James Graham to discuss my concerns. In 2015, Graham put in writing that he planned to send me into a psychiatric evaluation after our meeting went through. In 2016, four months later, Graham and Dickson met with me. Two months after that, they enacted the hit to have me removed, in the exact manner Graham had said that he would.
Safety Concerns
During trial, March 20, 2019, Captain James Graham, Delta’s SVP of flight operations at the time, not only perjured himself on multiple accounts during trial, but he proudly testified, “And Flight Operations, specifically, our ASAP program now has, for the year 2018, we were just over 25,000 reports that were brought forward from our pilot group!” That is not a metric to be proud of.
In my report to captains Dickson and Graham, I expressed my deep concern that pilots could not fly based upon what Captain Dempsey, Delta’s Chair, Human Factors Working Group, told me. He had departed an airport heading to Atlanta, but he lost his auto flight system on takeoff. Dempsey continued to fly to Atlanta, but requested a block altitude, meaning the pilot is unable to fly a specific altitude so they need more airspace. He also flew into RVSM airspace, an altitude that requires an autopilot due to close separation of 1000 feet from other traffic. Upon arrival, Dempsey declared an emergency because ATC refused to provide a block altitude for their arrival phase. He used the emergency card for something that was not an emergency. The Training Department used this as an example of “workload management” and created a training video telling pilots to declare an emergency if they, too, lose their auto flight system.
The problems with this video were many. The FAA and office of inspector general were working to convince pilots to hand fly due to an endemic loss of hand-flying skills. However, this training video stated that hand-flying was an emergency procedure. The worst part of all this was I reached out to Dempsey about this event, and he told me that, “Delta as a group, cannot fly Level 0, nor can we fly Level 4, so says ASAP.” Level 0 is when there’s no automation engaged, complete manual flight, and that would be no flight director, auto thrust, autopilot. Level 4 is a fully automated aircraft. Delta did not train their pilots but suggested they declare an emergency if they lost their autopilot.
Dempsey emailed me that a Delta Boeing 737 on final in ATL in IMC, meaning they were in the clouds, and at 700 feet the pilots decide to go around but hit the auto throttle button instead of go-around button and the flight director stayed in approach mode. Neither pilot noticed that the pitch was 3 degrees and power was at 56% N1 power, those were not the pitch and power settings for a go around. They should have been approximately 12 degrees up and 90% power. Dempsey said that they didn’t even have the situational awareness to look beyond the flight director and recognize something was wrong. They got to 186 feet, with over 2,000 feet per minute descent, before going around, as the warning systems wailed in the background. Passengers on that flight came within seconds of dying.
Did these pilots attempt a go-around and push the wrong button? That might explain why they did not flare. I am not saying this is what happened, but the thought occurred to me rewriting this event. The NTSB will hopefully answer that question.
The Safety Presentation
Captain James Graham invited me to give a safety presentation as part of his ploy to have me removed, despite already having removed me for mental health concerns because I reported safety. I explained to Captain John Tovani, the director of training, at that presentation, that 90% of my concerns were training related. Yet Delta did nothing but pay a doctor $74,000 to diagnose me as bipolar. The short version of how this ended can be read in the Seattle Times article.
While Dickson was the FAA administrator, awaiting Delta’s appeal, the file regarding Delta’s violation of order for violating duty times regulations disappeared. I have the FOIA response that it existed, but the FAA sanitized Delta’s culpability. Dickson resigned within days of Delta losing their appeal.
Captain James Graham Credibility Assessment by ALJ Judge Morris:
“The Tribunal further questions the candor of Captain Graham’s testimony at various points and occasionally found his testimony to be incredible. In particular, the Tribunal gives little credit to his statements that Complainant’s safety report had no bearing on his decision to refer Complainant for a Section 15 evaluation.” (Decision and Order pg. 71).
“Tribunal accepts as proven—the many inconsistencies in his testimony between his deposition and his hearing testimony. Compl. Br. at 40-42. The sequence of events left the Tribunal with the impression that Captain Graham harbored little if any tolerance for criticism of the organization he ran, especially criticism from a line pilot like Complainant.” (Decision and Order pg. 71).
“The two key actors involved here are Captain Graham and Mr. Puckett. They were the parties moving the pieces in the chess game in which Complainant found herself an unwitting player.” (Decision and Order pg. 99)
Endeavor Air CEO, Captain James Graham
Endeavor Air CEO James Graham
Please answer the question.
How is it possible that Captain James Graham could possibly become Endeavor Air’s, Delta’s wholly owned subsidiary, CEO?
Pilot training under his leadership at Delta was substandard, and when a pilot tried to speak out, with an internal safety report, he violated federal regulations and retaliated. I never lost my first class medial, despite a bipolar diagnosis, but Dr. Altman forfeiting his medical license. Beating Delta in trial and appeal, Dickson retired early from the FAA. Yet how is Captain Graham allowed to be the CEO of Endeavor Air as a result of his actions?
No, I am not surprised that this Delta plane crashed in Toronto. I’m simply surprised that an accident has not happened sooner. The FAA is allowing Delta and Endeavor to do whatever they want to save money; training be damned. These pilots, while their error caused the crash, are every bit a victim to FAA approved substandard training. The CEO, Captain James Graham, and FAA are fully responsible.
In that nobody was held accountable at Delta for their retaliatory actions, despite their loss in federal court, including Graham, Dickson and the Delta CEO, Ed Bastian, I wrote a book to help encourage employees to safely report, and how to use the law to protect themselves, Delta's Debacle, Legal Lessons Learned and Shared to Save your Career and Improve Safety. Safety is contingent upon employees reporting safety concerns.
I'm uncertain what else I can do, but enough is enough. If substandard training worldwide is not improved, then we will see more of these accidents. This time we got lucky, but safety should not be based upon luck.
Do not blame the pilots for accepting runway 33, as pilots daily accommodate runway change requests safely. Do not blame the helicopter pilots because they were doing training and human error is inevitable. Do not even blame the lights of the city, the night, night goggles, or a controller for managing two runways. These are all known and ongoing facts of daily operations. Blame the FAA! Why? That agency had the responsibility and authority to mitigate the risk in this environment, and despite multiple warnings they did nothing.
Below is a copy of the ICAO risk mitigation chart. Everyone can see that these operations into DCA would be in the red zone mandating a fix. They've always been in the red zone because we should never have had military operations conducting training and flying below passenger aircraft.
The FAA did not mitigate risk in this high risk environment, despite every message saying they should, and thus this accident happened. The question was never "if" it would happen, it was always "when" it would happen. The FAA rolled the dice on the profitability of airline operations over passenger safety. The passengers, crew, and all their families lost.
Our safety system is supposed to identify and reduce risk so accidents don't happen. In the past, we had a system that fixed the problem after we killed people, so it wouldn't occur again. Today we have systems in place to mitigate risk, to avoid the crash before we kill people, but the FAA does not enforce any of them.
History taught us that poor crew communications impacted safety, thus in 1990 CRM began. AQP became a methodology for training with a CRM focus. The 5th generation of CRM brought us Threat and Error Management. These regulations and programs identified our industry was working towards a positive safety culture. Without a positive safety culture, we do not have a safe environment. Then in 2015 came Safety Management Systems (SMS). But wait! Did you know that the International Civil Aviation Organization (ICAO) introduced SMS to its annexes in 1980? It took the FAA 35 years to enact SMS in the United States. This federal regulation was not enacted until 2015, but airlines were not required to have one in place until 2018.
SMS is a federal regulation that mandates risk mitigation. Everyone in the organization is tasked to identify and report high-risk operations to those empowered to create change and reduce risk and avoid accidents. Unfortunately employees are retaliated against when they report safety concerns and their lives are subsequently destroyed. Even when the FAA knows of the violations, the employees still face adverse actions. While it's not the FAA's responsibility to defend pilots, it is their responsibility to protect the airspace! The FAA received ASAP reports and knew of the multiple near misses and yet they did nothing.
We know that that the Blackhawk helicopter hit the American Eagle Jet. We know that this was a checking event. We even know they were off altitude and course. The answers as to why the course and altitude irregularities, will (should) be disclosed after the accident investigation. I speculate that human error was involved. Human error is inevitable, and the reason we have implemented safety measures over the years, to help trap and capture those errors. While it appears the industry has been working to improve safety, unfortunately todays safety measures are nothing but smoke and mirrors.
CBS NEWS
Why is the FAA to Blame?
Because the FAA has an incestuous relationship with airline management. Many of those in FAA oversight also do not have a clue as to the new regulations or constraints of flying today. One FAA oversight inspector on Delta's certificate said, when I mentioned SMS and AQP, "I don't know what those are because I retired before they came into effect." That is scary. Regardless, the options as how to mitigate risk in this DCA environment were many, but they would have impacted the bottom line of airline operations. Therefore, status quo until death.
Until we prohibit the revolving door between airline management, the FAA, and the board of directors position, and find an FAA administrator who believes in life over money and doing the right thing, we will continue to play Russian Roulette with passengers lives.
Heartfelt Prayers to all
living with loss as a result of this crash.
My heartfelt prayers go out to the families of those lost in this accident. I will not allow your loved ones deaths to be in vain. I'm actually angry at what transpired because it could have been avoided if the FAA did its job. This is the very reason I spoke out in 2015, to fight for safety so accidents would not happen and I fought a legal battle for seven years to create change. (Petitt vs Delta, Seattle Times) Nobody was held accountable. No change was made. And the FAA looked the other way and even sanitized records of violations. There are a lot of good people working in the FAA, but they too are fearful for their jobs if they speak out. Something must be done. I took early retirement in 2023 so I could be a voice for safety, and I while we cannot bring your loved ones back, I will fight to make change happen.
I hope that every person will file a wrongful death lawsuit against the FAA. I have evidence of what I write here today and will provide as requested. We cannot bring your loved ones back, but we can create change together and ensure the pain you feel will never be experienced by anyone else.
