Chapter Twenty Five

 

“Ask him how long the final is going to be,” the voice of captain Don Jakyll was heard as the tape began.

“What’s the sequence for Consolidated 243?” First Officer Kley Hetherington’s voice could be heard next.

“I didn’t ask for the sequence. I don’t care how many planes are in front of me. I want to know how long the damn final is,” Don exclaimed.

 

“Let’s stop it here for a second,” Konnie suggested. “There seems to be a rather rapid acceleration in the level of agitation in Captain Jakyll’s voice.”

“Is the rate at which his level of agitation changes significant or somehow related to flight training inadequacies?” Wayne asked.

“At this point, not really,” Konnie replied. “I just wanted the group to note there is a change in the behavior of Captain Jakyll that might have an impact on his piloting skills.”

“Are you saying that pilots don’t fly as well when they get angry?” Wayne inquired.

“On the contrary. I’ve observed that you can piss off a pilot, then force him to complete several tedious tasks in an extremely short period of time, and at the same time scare the hell out of him, with little or no adverse affect on his ability to effectively and safely manipulate the controls of the aircraft.”

“But these distractions will have a significant impact on his decision-making ability,” Gail added.

“Thank you Gail.” Konnie reinforced Gail’s comment with a broad smile.

“Got it,” Wayne said.

 

“Consolidated 243, turn right 060, descend and maintain 6,000. Contact approach on 123.4. They’ll have the sequence for you.” The voice of an air traffic controller could now be heard on the tape.

“Right to sixty, down to six, and twenty-four point three for Consolidated 243,” came the reply from the first officer.

“Ah, negative Consolidated 243. That’s approach on one two three point four . . . two three point four,” the controller repeated.

“Sorry, one two three point four for Consolidated 243,” responded the first officer.

“Six thousand!” Don Jakyll’s emphatic voice was once again heard on the tape.

“Six thousand,” Kley responded.

“Charlotte approach, Consolidated 243 is with you descending to 6,000. How long will our final be today?” Kley transmitted to the new controller.

“Ah let’s see, your sequence is number eight for runway 23.”

“And how long will that final be?”

“Well, you can plan a ten mile final,” replied the controller.

 

“My man Gary Lee!” Dirk remarked in response to hearing the voice of his friend issue an ATC clearance.

“Excuse me?” Konnie stopped the tape again.

“Sorry,” Dirk apologized. “Couldn’t help myself. It’s just that every time I think of Gary Lee Puckett working as an air traffic controller—”

“You don’t mean ‘the Gary Lee Puckett’ from the ball team?” Wayne asked.

“One in the same.”

“Oh my God! You have got to be shitting me.” Wayne continued in a mild state of shock. “How in the world could they make an air traffic controller out of Gary Lee?”

“It took the combined efforts of the United States Marine Corps and the Federal Aviation Agency, but they got it done.”

“Unbelievable!” was all Wayne could reply.

“Wait till I tell him you made a lawyer out of yourself,” Dirk said. “You think he will believe that?”

“You can tell Gary Lee I’m a lawyer, but please don’t tell my mamma ’cause it would break her heart with disappointment. She thinks I’m—”

“A piano player in a whorehouse,” Dirk finished Wayne’s sentence.

“You gotta love the coach.”

“Excuse me,” Gail interrupted. “Is there something in your comments relevant to our agenda here today that you two would like to let the rest of us in on?”

“It’s like some sort of inbred clan,” Jordan explained. “There seems to be this ubiquitous group of individuals that played football for this coach renowned for his good ’ol boy tidbits of wisdom.”

“That’s all very amusing, but unless the activities of this group of individuals will help our review of this tape, I suggest we get back to the business at hand,” Konnie appealed to Dirk and Wayne.

“By all means, please continue,” Wayne apologized.

“Thank you.” Konnie started to push the button to continue the tape, but then stopped himself. “How did you know that the voice on the tape was that of your friend?”

“I talked to him the day of the crash. He told me he was working Consolidated flight 243 when it arrived in Charlotte.”

“Any chance we could get him to participate in our group?” Wayne realized that from a litigator’s perspective, having an air traffic controller participate as a witness for his client could be of immeasurable value.

“I don’t know,” Dirk replied. “I’ll call him and find out.”

“His input from the ATC perspective could be invaluable.” Konnie envisioned the incredible opportunity to link the human factors aspects from both the flight deck and air traffic control theater of operations into a cogent human factor research project.

“I’ll call Gary Lee when we take a break.”

“Let’s continue the tape review,” Jordan directed.

“Before we start the tape, I’d like to point out that at this point in the approach, the descent profile appears normal,” Gail said.

Konnie agreed.

“The aircraft has descended to this altitude and turned to this direction.” Gail pointed her laser beam to the position on the chart that coincided with the comments on the CVR.

“So other than the revelation that Captain Jakyll is easily agitated, there’s really nothing earth shattering so far,” Konnie observed.

“Any questions?” Jordan asked. There was silence in the room. “Konnie, please continue.”

 

“Consolidated two forty three, reduce your speed to one eighty, then turn left to zero three zero.” Gary Lee was directing flight 243 into a descending left turn back toward the airport.

“Don, did you get that speed reduction?” Kley asked.

“Uh, no. I missed it. What did he say?”

“He wants us to slow to one-eighty.” Kley repeated the air traffic controller’s request to reduce their airspeed to one hundred and eighty knots. “You seemed a bit distracted there.”

 

“Stop the tape, Konnie,” Gail commanded.

“I’m one step ahead of you.” Konnie had already pushed the button.

“The first officer used a rather subtle yet significant term just then,” Gail said.

“Distracted,” Konnie added. “To a pilot effectively trained in human factor issues, the fact that his fellow pilot would use the word ‘distracted’ in conjunction with the failure of the other pilot to acknowledge an ATC clearance should have immediately elicited a response from Captain Jakyll that flight deck vigilance is being compromised and immediate actions should be taken to rectify the situation.”

“Could you translate that into English for the ‘aviator impaired’ among us?” Dirk requested.

“In other words, one of the pilots has stated that they’re not paying attention, and they need to start doing so,” Gail interjected.

“How the hell can you sit in fifty tons of airplane going ‘warp eight’ over downtown Charlotte, and not pay attention?” Dirk asked.

“The same way you can listen to one of the people you are interviewing talk for twenty minutes, and only hear two minutes of what they are saying,” Konnie said. “Over time, you naturally tune things out. Distractions will increase the amount of information you tune out.”

“Rather than belabor this issue, let’s restart the tape,” Gail suggested. “Just keep in mind that Kley has received effective human factor training and Captain Jakyll has not. This is perhaps the beginning of the series of events that will lead to the crash.”

“And how do you know Kley has and Jakyll has not received effective training?” Wayne asked.

“Because I trained Kley before he ever came to Consolidated Airlines,” Gail coolly responded. Up until now, none of the other members in the room except Jordan comprehended Gail’s true motivation for participating in this clandestine investigation that would most certainly result in her termination from the airline.

Wayne Bankhead perceived an even more telling benefit for his clients from her comments. “So you’re suggesting that based on what you have heard so far, in your professional opinion as a professor of aviation science at a nationally accredited university, you could testify in a court of law that there is a substantial difference in the level of training received by these two pilots?”

“I never said that,” Gail emphatically responded. “But . . . yes.”

“Getting a little warm glow in our nether regions, are we, counselor?” Dirk knew that Wayne had just discovered a litigator’s gold mine.

“Wanna touch my woody?” Wayne replied.

“Let’s not bore these folks with old football team rituals,” Dirk said.

“I suggest it might be a bit early to come to that conclusion,” Konnie said. “Let’s just let the tape run a while longer.”

 

“O.K.— flaps one,” Don responded to Kley.

“Uh, we might be just a bit fast for that. This has one of the snitch boxes in it,” Kley commented.

 

“Stop the tape again,” Jordan said. “Snitch box?”

“It’s a slang term the pilots use to describe the aircraft in our fleet that are equipped with a very precise monitoring technology called the digital flight data recorder,” Gail said. “The acronym for the system is DFDR. The data from this system provided the information displayed on our chart here.” Gail directed her laser pointer to the flight profile poster. “For example, we can correlate the conversation on the tape to this point on the profile, thereby determining that the aircraft is flying at two hundred and forty knots when Captain Jakyll asks for the flaps to be extended to the first setting for the approach, or ‘flaps one’ as he states on the tape. This speed is in excess of the limit for that flap setting, and Kley has just reminded the captain of that. This is significant in that it indicates the Jakyll is distracted from monitoring his airspeed.”

“Effective human factor training addresses distraction avoidance,” Konnie added. “It doesn’t presume to prevent it, but rather teaches crews to recognize when it is occurring and take steps to address the cause of the distraction. An effectively trained captain at this point would acknowledge the distraction and communicate to the other pilot his plan for preventing further distractions. Let’s listen to the tape. I doubt we will hear any distraction avoidance conversations.”

 

“Fine, when we get to two-thirty, put the flaps to one!” Don’s exasperated voice replied.

“Don, that turn was for us. He wants us to turn to zero-three-zero.” Kley continued to point out ATC clearances that Don was missing.

“Uh, oh yeah, right to thirty. I thought we were going to get a ten mile final,” Don’s voice sounded somewhat puzzled.

“No, that was LEFT to zero-three-zero,” Kley corrected Don. “This looks like he might be turning us back toward the airport.”

“By God, he better not,” Don responded. “We’re way too high, and besides I can’t even see the runway in this ground fog anymore.”

 

Konnie paused the tape. “In the short time it took for Flight 243 to descend from here,” he began his analysis as Gail pointed to a location on the chart, “to here,” he continued as Gail moved the laser beam a short distance down the descent profile, “Captain Jakyll has missed two ATC clearances, and misunderstood his first officer’s attempts to repeat those clearances. This increase in errors is significant. Kley is doing an excellent job of monitoring the captain’s activity, but there has been no acknowledgment by Jakyll that he is not totally focused on flying the aircraft. I want us to be aware that the situation has started to deteriorate significantly on the flight deck.”

 

“Consolidated 243 turn left to heading two-seven-zero, descend to two-thousand six-hundred, report the airport in sight. You’ve got traffic in the turn at two o’clock, a United 737, he’ll follow you.” Gary Lee could once again be heard on the CVR tape.

“Left to two-seven-zero and down to twenty-six hundred,” Kley repeated the clearance.

“I’ve lost the field in this scud.” Don complained of the ground-hugging fog layer.

“I’ve got the United guy at two o’clock,” Kley informed Don.

“Screw the United ship. I’ve lost the goddamned airport!”

“ What’s the distance for LECAR?” Don snapped.

“Six point five DME,” Kley nervously informed Don.

“Son-of-a-bitch! We’re only two miles from the approach fix! Gear down,” Don commanded, the heightened level of agitation clearly evident in his voice.

 

“Let’s stop here,” Gail said. “Note that our chart shows the aircraft is approximately four thousand feet above the ground when Captain Jakyll states he is only ‘two miles from the approach fix.’ A normal descent profile would result in an aircraft being twelve or thirteen miles from the runway. Flight 243 is only seven miles from the runway at this point. In other words, they are well above a normal descent profile. That explains the reasons for the Captain extending the landing gear and more flaps. He is attempting to decrease the airspeed and increase the descent rate in an effort to land the aircraft.”

“Why did the controller put him so close to the airport at that high an altitude?” Jordan inquired.

“From what we have heard so far, we can’t be sure. It is highly probable that the controller intends for the pilot to accomplish a visual approach. This type of approach permits the captain to maneuver the aircraft in any manner he sees fit to locate the runway and land. The key to accomplishing a visual approach is that the pilot must see the airport.”

“It’s obvious from the tape that he can’t see the airport,” Wayne interjected.

“Yes it is,” Gail agreed. “That’s why I wanted to pause the tape. There is clearly a lack of coordination between the controller and the pilots. Let’s continue the tape with that in mind.”

 

“Do you think we ought to ask for a vector back around for the approach?” Kley anxiously asked.

“I’ll let you know if I want a vector. Give me flaps five . . . NOW!” Don commanded

“Our speed is, uh . . .”

“Flaps five, damn it. Landing checklist,” Don barked.

“Start switches . . . Continuous.” Kley began to read the landing checklist. “Overhead Recall . . . Checked,” he announced to indicate that the Recall button on the forward instrument panel had been depressed to ensure that any warning lights on the panel over the pilot’s head out of their normal viewing area were not indicating a system malfunction. “Speedbrake . . .” Kley paused his recitation of the checklist.

“I’ve still got the boards out,” Don replied.

“Gear . . . Down, three green,” he continued, but there was no response.

“Down, three green?” Kley repeated the checklist challenge.

“Huh?” Don replied. “Yeah, three green,” he snapped.

“Localizer alive,” Kley announced.

“Damn, we flew right through it,” Don replied almost instantly. “I’ll get it back.”

“Runway’s in sight at twelve o’clock,” Kley announced in an excited tone.

“Got it . . . We’ll make this just fine,” Don continued. “I’ll get this beast on the ground if it kills me!”

“Consolidated 243, are you going to be able to get down from there?” Gary Lee’s voice was once again heard on the tape.

“Auto-brakes.” Kley continued the checklist.

“Those guys really piss me OFF,” Don’s voice interrupted Kley’s.

“Off,” Kyle replied to Don’s command.

 

“Let’s stop again,” Gail said. “That was not the correct response to the Auto-brake item on the checklist. There’s an obvious breakdown in communication here. Don used the word OFF as part of his statement describing his disgust with the air traffic control vectoring, but Kley heard the word OFF as a command from the captain to leave the auto brakes OFF.”

“Is it significant that the Auto-brakes are off ?” Jordan inquired.

“Absolutely,” Gail responded. “Our pilots are trained to let the Auto-braking system slow the airplane down after landing. They are required to be turned on unless they are not working.”

“So it appears that the airplane is about to land with no brakes,” Jordan surmised.

“Not exactly,” Gail said. “The brakes are available. It’s just that the captain will probably be anticipating a deceleration rate after touchdown that is much greater than usual. We’ll have to wait and see how he responds to this situation.”

“And what was that comment about the ‘boards being out’?” Wayne asked.

“Boards is a vernacular term for the speed brakes.” Gail replied. “They are square devices on the top of the wing that a pilot can extend to aid in deceleration in flight. They also are very important in reducing lift produced by the wing once the aircraft touches down. If the ‘boards are out’, they may not be properly armed for deployment after landing. Let’s see if they arm them”. Konnie pressed the button and continued the tape.

 

“Flaps twenty-five,” Don said. “Make it thirty.” Don ordered Kley to extend the flaps to the final landing position.

“Flaps . . . Thirty, green light, detent,” Kley responded with the last item on the landing checklist.

“Thirty, green light detent.” Don confirmed the position of the flaps was correctly set for landing.

“Landing checklist . . . complete,” Kley proclaimed. “I’ll call the tower,” he stated in order that they might get their clearance to land. “Charlotte tower, Consolidated 243 is with you for 23.”

“Consolidated 243, the winds are zero-five-zero at eight knots. You are cleared to land. Are you going to be able to get down from there?” The tower repeated the same concern that Gary Lee had expressed.

“Cleared to land.” Kley made no reference to the tower’s concern for their descent to the runway.

“One thousand feet,” Kley announced as the aircraft descended. “Five hundred feet, ref plus thirty, sinking fifteen hundred.”

 

“Whoa, big fella,” Gail loudly announced. “Stop the tape! This is getting ugly! I saw it on the profile here, but I had to hear for myself what sorts of flight deck communications were taking place.”

“What’s up, Gail?” Wayne inquired.

“Those last flight parameters Kley called out are way out of limits for our approach procedures.”

“How so?”

“To begin with, we have very explicit procedures regarding flight parameters for all landings. These parameters set limits for airspeed, rate of descent, aircraft configuration, and engine speed or thrust settings that will in no uncertain terms be deviated from once the aircraft is below one thousand feet. The reason for this is simple. We want to ensure that every approach is conducted with the highest degree of probability that a safe landing will occur. Right now these guys are in a classic ‘high and hot’ approach situation. I can’t believe Kley hasn’t said something. Our procedures specifically call for—”

“What exactly can’t you believe, Gail?” Konnie interrupted her. “Think about what you’ve just heard. Kley has made several attempts to point out to the ‘captain of the ship’ that he is not complying with S.O.P’s for most of this approach. Furthermore—”

“Ess Oh whats?” Dirk inquired

“S.O.Ps,” Gail said. “It’s an acronym for Standard Operating Procedures. It means that which is expected and accepted as a normal mode of operations. Anything outside of these parameters requires a substantiated reason for that deviation.”

Jordan reviewed the situation. “So what we’ve got here is an airplane that is too high and too fast for landing, the normal braking system is turned off, the Speed Brake system that should deploy on touchdown to increase the effectiveness of the brakes is not armed for extension, and in spite of the fact that the first officer has tried his best to get the captain to recognize all of these facts, he is continuing the approach. It’s hard to believe that this could happen.”

“If you just look at it from the standpoint of pilot error and a crash, you’re absolutely right,” Konnie agreed. “But taken in the context of our discussions as this scenario has unfolded, are you beginning to comprehend how this crew got to where they are?”

“It still seems incredible,” Jordan said.

“Yes it is,” Konnie agreed. “That’s why I’m convinced that there is something else influencing the captain’s behavior, and I think that once we find out what that something is, we will be able to provide Mr. Bankhead with the information he needs to link the behavior of this company’s management to the crash.

“I hope you’re right,” Jordan said as Konnie restarted the tape.

 

“Well, we may be high, but at least we’re fast,” Kley commented on the tape.

 

“That’s what we call ‘hinting and hoping,’” Gail said as the CVR tape continued to roll. “In other words, he’s hinting there’s a problem with the descent profile, and hoping the Captain will respond to the hint.”

 

“One hundred,” a robotic voice broke in.

 

“That’s the automatic call out from the radio altimeter,” Gail explained. “It will make several more call outs before touchdown.”

 

“Don, this doesn’t look good.” Kley urged the captain to recognize the dangerous nature of the approach for landing.

“Fifty—forty—thirty—twenty—ten,” the robotic voice could be heard counting out the final few feet of the aircraft’s descent to the runway.

“Don, we’re to fast! Let’s just go around,” Kley pleaded with the captain to abandon the approach.

A thumping noise could be heard on the tape as the aircraft touched down.

“No spoilers!” Kley’s clearly anxious voice could be heard.

“Got ’em,” Don said, his tone much more relaxed than Kley’s. A whirling sound like that of an electric can opener could be heard as the spoilers extended.

“No autobrakes!” Kley’s voice approached a scream. “Get on the brakes, Don! Two thousand feet.”

“Max brakes,” Don responded, his voice remarkably calm.

“Shit! Here come the lights!” Kley screamed. “What are you doing?”

Various types of grinding noises interspersed with painful moans and grunts from Don could be heard on the tape as the aircraft slid sideways off the end of the runway.

 

“I think we’ve heard enough Konnie,” Gail said in a voice quivering with emotion. “Let’s stop here.” Tears welled up in her eyes. She looked upwards to the ceiling in an attempt to keep the moisture forming at the base of her eyelids from spilling over and running down her checks. Her attempts to conceal her emotions as she listened to the excruciating pain Kley and Don were subjected to as Flight 243 cascaded across the rutted terrain adjacent to the end of runway 23 were to no avail. There was silence in the room as all eyes turned to her and observed her lower lip and chin slightly quivering. A single tear dripped slowly from her right eye, brushed against the base of her nose, and slowly flowed around the corner of her mouth. She placed her hand on her jaw in an attempt to covertly wipe the tear from her face before it was noticed by the others in the room.

“Well,” Konnie said after a short period of silence, “What do we have here?”

“We don’t have squat!” Wayne said emphatically. “With all due respect to your efforts to assemble this group, present a coordinated audio and visual re-enactment of the final minutes of the flight, and interject your professional play-by-play analysis of this disaster...” Wayne instinctively paused his diatribe for the effect he so often used during his closing arguments as a litigator. “...if you introduced this presentation into evidence in a trial against a client of mine, I couldn’t wait to rip it to shreds in cross examination.”

“That’s exactly what I hoped you would say,” Konnie replied.

“Then what’s the purpose of this gathering?”

“Up to this point in time, every crash litigation involving these types of circumstances, has found the pilot to be at fault. Pilot error is almost universally accepted as the cause.”

“Well, that’s damn sure what I would go after here,” Wayne agreed.

“We have some additional evidence we would like to show you now that we hope will change your mind. Gail has provided us—” Konnie was interrupted by a knock at the door to the conference room.

“Excuse me.” A man in the black vested attire of a waiter opened the door. “Your break beverages are set up outside in the hall.” He pointed in the direction of a table laden with various soft drinks, ice, fruit, and bottled water.

“Did someone order beverages?” Konnie inquired.

“They’re compliments of the management,” the waiter answered.

“Great,” Dirk said. “I could use a break. Any cold beer on that table?”

“I’m afraid not. But I’ll be glad to take your order to the lobby bar,” the waiter offered.

“On second thought, I’ll just stick with a soda. Gotta Dr. Pepper out there?”

“That we do.”

The room emptied, and the waiter approached the conference room table. He began picking up empty coffee cups, water bottles, and other debris that had accumulated during the meeting. As he worked, he occasionally glanced back at the door to ensure that everyone had moved down the hall to the refreshment table which he had intentionally set up over twenty feet from the entrance to the room.

Satisfied that there was no one lingering by the door, he purposely knocked a paper cup onto the floor, bent over to pick it up, and then crawled under the table. He quickly attached a small wireless microphone securely to the underneath side of the table. He crawled back out from under the table, and surveyed the room to ensure no one had observed him.

He collected more debris and walked toward a trash can in the corner of the room that was partially concealed by a fichus tree made entirely of plastic. He dumped the trash into the receptacle, glanced once again toward the door, pulled back one of the branches, and attached a tiny video camera to the trunk of the tree.

Confident of the integrity of the camera, he then walked around the table and stopped in front of the chart displaying the descent profile of Flight 243. He took a small digital camera from his vest pocket, snapped several pictures of the chart, and then calmly walked out of the room.

As he walked down the hall, he observed that the closest person to the conference room entrance was the tall gentleman who requested the “cold beer” but settled for a Dr. Pepper. He was talking on his cell phone as the waiter walked past.

The waiter continued down the hall, exited the building, walked across the parking lot, and entered the side door of a white windowless panel van. He sat down on a small stool adjacent to a bench attached to the wall of the van, and pulled back the blanket revealing a video monitor and digital sound recording equipment. He remotely adjusted the zoom on the lens of the camera attached to the fichus tree trunk in the conference room so that it zeroed in on the chart he had taken the still shots of just moments before.

Satisfied with the focus clarity of the close-up view of the chart, he then retracted the zoom lens to widen out to a shot of the entire conference room table. Confident in the capabilities of his equipment to capture the content of the discussions taking place in the room, he retrieved an apple from his coat pocket, and calmly began to eat it as he waited for the group to return to the conference room.