American Really Screwed Up When It Sent the Wrong Airplane to Hawai’i

American

File this one under “how the hell did that happen?” On August 31, American sent an A321 from LA to Honolulu that wasn’t allowed to fly that far from land. While I don’t think any passengers were really in any danger, it’s concerning that nobody caught this when there were so many people who could have. American has made some changes to ensure it doesn’t happen again, but that doesn’t lessen the severity of this issue.

The flight from Los Angeles to Honolulu is a long and lonely one. In fact, there is absolutely nothing for 5 hours straight, and that means there’s nowhere to divert if something goes wrong. Engine reliability has become so good over the years that airlines have been able to fly even twin-engine aircraft on long stretches like this with just a few conditions. They have to be ETOPS-certified (which used to mean Extended Twin Engine Operations but now applies to all aircraft), they have to carry special gear, and they have to have a ton of fuel (enough to lose an engine at the exact midpoint and make it all the way back to an airport). This is noted on the nose gear of every American aircraft that has ETOPS. (This photo below is a 777 because I couldn’t find one of the A321 since it’s so new.)

American ETOPS Notice

While the distance from LA to Honolulu isn’t much different than the distance from LA to New York, all the extra requirements mean that smaller airplanes haven’t been able to reliably make the the Honolulu flight work. All that extra fuel weighs a lot, and Airbus narrowbodies in particular haven’t been able to make the trip. But with engine improvements over the years, it’s now a possibility, albeit with weight restrictions in some markets. Virgin America announced it would fly A320s to Hawai’i and then American followed that with an announcement of its own using A321s. American started this in mid-August and it was just two weeks later that the wrong airplane was used.

See, American has 3 different versions of the A321 in its fleet (4 if you include the US Airways ones). It has the A321T which is the fancy airplane with a bunch of First and Business class seats. This is used almost entirely to fly New York JFK to both LA and San Francisco. Then there’s the A321S which is in a more normal domestic configuration. Lastly there’s the new A321H fleet which is ETOPS-qualified to fly to Hawai’i. There’s virtually no way to mistake an A321T for anything else since the onboard product is so different. What happened here was an A321S flew to Hawai’i instead of an A321H.

From the passenger perspective, these two airplanes are identical. They have the same interiors, the same number of seats, etc. So a traveler would never know the difference. It should also be noted that while the A321S isn’t ETOPS-certified, it is an overwater airplane. That means it has most of the extra gear you need for flying over water, including rafts and life vests. (This airplane is overwater-equipped because of Florida. It can fly routes from Florida to the West over the Gulf of Mexico and to the Northeast on the Atlantic routings.)

What is the physical difference between the A321H and the A321S? The A321H has an extra medical oxygen tank and extra fire suppression canisters in the hold down below. That doesn’t sound like that big of a deal, and in the end it wasn’t. They discovered this happened when the flight was slightly more than halfway to Hawai’i. So it continued on without incident and the return was canceled. (I asked if they put the returning passengers on a Delta flight….) American then immediately self-reported the problem to the FAA.

So why is this a big deal? There are rules, and this is a big one. The fact that American let an airplane fly to Hawai’i that wasn’t allowed to go there is bad, really bad, because it shows gaps in the airline’s systems. Just think of everyone that could have caught this.

  • Maintenance personnel could have noticed the problem.
  • Dispatchers could have seen that it was the wrong airplane being sent.
  • Rampers could have noticed the giant “ETOPS” wasn’t written on the nose gear door.
  • Pilots could have known this wasn’t the right airplane.

I was going to throw flight attendants on to the list, but a spokesperson from American confirmed that while the flight attendants do check the medical oxygen supplies, they don’t count the bottles. I guess it would have been pretty tough for them to catch this, but it’s incredible that everyone else missed it.

According to American, they’ve already updated the software in dispatch so that it will automatically catch if the airplane being flown isn’t the right one. They’ve also stepped up communication to employees to hammer in that this can’t happen again. There are no other fixes planned at this point, but as they continue to investigate, they’ll see if there are other things they can do.

For me, this particular incident wasn’t that scary. It’s the fact that nobody caught it in the regular process of preparing to fly that I really don’t like.

[Image via Chris Sloan/Airways News]

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48 comments on “American Really Screwed Up When It Sent the Wrong Airplane to Hawai’i

  1. So the minimum equipment list was different (“an extra medical oxygen tank and extra fire suppression canisters in the hold”) and perhaps the manual had differences? They shouldn’t have done this, it shouldn’t have happened, yeah I get it.

    But it does make me wonder what the point of the expensive certification process, on an aircraft-by-aircraft basis, is at all.

    It’s a technical violation that sounds scary but isn’t. And if they were allowed to certify the aircraft type rather than the individual plane, no doubt they’d willingly add the extra oxygen tank etc to all of the equipment rather than managing a subfleet in the first place.

      1. Are you sure they don’t carry ACTs? The whole US 321 fleet has them, and they generally use every bit of those tanks on transcon trips. I don’t see how AA can be doing it sans ACTs to HI, but I could be wrong…

        1. PVD – Sorry, I thought you were asking if they had additional tanks over the regular fleet. The answer to that is no. I have no idea if they have extra fuel tanks on the whole fleet or not, but they might. Point is, the A321H and A321S are the same.

  2. Taking your points:

    Did maintenance personnel know the plane was going to Hawaii? Or did they just do the maintenance and say “next”, not knowing where it was going to go.

    Despatchers should have known, but were they told? The planes are relatively new, so maybe it didn’t filter down.

    Pilots should have known. I mean knowing what you are flying is a pretty basic thing, one would have thought. Were they told? Or was it just assumed they would find out? If so, communications is pretty poor.

    Rampers could have noticed, but it’s not really something that might strike them unless they were looking out for it. Are they supposed to be looking out for it. Presumably it is on the wheel housing so that someone is supposed to notice it.

    Or was this just a case of “not my job, try someone who cares”? If it was this, it would be most worrying indeed.

  3. My understanding is that maintenance and inspection procedures are different for ETOPS aircraft. This seems like a more significant distinction than just extra O2 bottles and fire-suppression equipment, but you didn’t mention it at all. Am I wrong about this?

  4. Not entirely factual that “smaller aircraft have not made it to HNL reliably.” Please remember that Aloha routinely and effectively used the 737-700 ETOPS from several mainland gateways to HNL, including the challenging SNA………..Another fact check from yesterday’s column where you stated that WN has no interlude “distressed” passenger agreements with any other carrier. That is also false: they have an agreement with JetBlue……….Just keeping it real, Mr. Cranky.

    1. I meant “interline,” not “interlude”! Darn spell checker! But you might have time for an interlude during the delay in re accommodation!

  5. ETOPS requirements cover a number of things. It isn’t just about more fuel, fire suppression etc.
    You do need to carry enough fuel for a ‘worst case’ diversion. How much more depends upon the airplane.
    I know that the DL flight plan for 777’s flying LAX-SYD are planned to arrive in SYD with about 25,000 pounds more fuel aboard than a QANTAS 747-400 would. It is to cover a worst case diversion, which means considerably more fuel. With a single engine you are generally forced to a significantly lower altitude and lower cruise speed due to the loss of engine power and the drag from the ‘dead’ engine. That does pretty ugly things to the fuel burn.

    The minimum equipment list is also different. You can dispatch a domestic aircraft with an Inop APU.
    Not only must the APU be operative for ETOPS, it usually must be able to start and run throughout the flight envelope (most APU’s are not designed to start or run above about 20,000 feet). There is in fact a relatively long list of things that would be aggravations on a domestic flight,, but a no-go for ETOPS.

    As for extra tanks, unclear. On most large aircraft you can fill the tanks, or you can fill the cabin, but you
    cannot do both at the same time. For example on some BA 777’s (like the one recent one in Las Vegas) filling the tanks would actually exceed the MGTOW of the aircraft before the first passenger boarded! (BA’s GE90-85B powered 777-200ER’s have an unusually low MGTOW). You usually try to avoid AUX tanks however. They add weight to the aircraft whether you use them or not, and they add maintenance requirements, while occupying a lot of space below the floor (which limits baggage and freight carriage) even if you don’t need the fuel carriage.

    Usually for long range operations, you fill the tanks, and take the hit on payload. Some or much of that payload hit may be freight however.

  6. The fact that the author is such a pretentious tool that he spelled Hawaii in that contrived manner is what’s really concerning here.

    Idiot.

    1. Actually, Hawai’i is the correct way to spell the name of our 50th state. Get a clue moron. BTW, are you calling Cranky an Idiot, or is that how you spell your name?

      Aloha.

      1. I wouldn’t say “Hawai’i” is correct. It’s somewhat more popular in Hawaii, but most authorities on English grammar and usage think “Hawaii” is proper. Generally, when we are writing in English, we don’t use diacritical marks. For example, in English we don’t write “México,” even though that’s the proper Spanish spelling. I don’t really see why “Hawaii” should be any different. Of course if you’re writing in the Hawaiian language, definitely use the okina!

    2. The facts of Hawaii vs Hawai’i don’t support this level of name-calling. It’s ambiguous.

      If you look up stuff at the US Board on Geographic Names, you will see that the state is named Hawaii, but most geographic features use Hawai’i. Putting in the punctuation mark is an effort–about 25 years old–to make the place name more accurately reflect the native pronunciation. Somewhat akin to Bombay/Mumbai, I guess.

      A review of the issue is here: http://www.geographictravels.com/2009/09/hawaii-versus-hawaii.html.

      Neither spelling is so obviously wrong as to demand this sort of name calling.

      Myself, I’ll stick to the Sandwich Islands.

    3. Hawai’i is the better way to spell it, as it reflects its pronunciation. If that bothers you so much…you have lots of issues.

      1. Well, “Hawai’i” reflects its pronunciation in Hawaiian, but not the “anglicized” (for lack of a better term) pronunciation used on the US mainland, or pretty much anywhere else in the English-speaking world for that matter.

        It might come across as a little too “politically correct” for some people’s tastes, but I have to agree with you, it shouldn’t be that big of a deal one way or the other.

    4. The author used the correct spelling of Hawai’i, more importantly why does this bother you so much? If this is the greatest problem with the article, which in fact is your issue more than the authors, you really need to consider why you are spending time reading this blog and not seeking therapy.

  7. As an AMT for Delta I am required to do a Pre Departure Check for any aircraft leaving the United States on an ETOPS flight. The aircraft weight and balance paperwork will not be released until the check is completed in our computer system. I can only imagine the flight wasn’t initially marked as an ETOPS flight and maintenance thought because the computer didn’t require a PDC, it wasn’t an ETOPS and…. it wasn’t leaving the US…..purely conjecture, but I can see how it might have come together that way.

      1. They might classify it as “international” for some purposes, much as, at least for first class lounge access, Continental used to classify EWR-Puerto Rico as an international flight. (Or the way most grocery stores classify eggs as “dairy” products even though a lactating mammal isn’t directly involved in their production.)

  8. ETOPS does have different maintenance and dispatch requirements, not sure if AA services all a321’s the same regardless of type. For example, you can’t perform MX on 2 similar systems at once. It is possible AA follows all of this and just didn’t certify all aircraft (and adjusts MEL accordingly).

    Realistically, no one was in danger, and the likelihood of something like the extra fire suppressant really mattering is extremely small.

    But as Cranky said, it is a very surprising gap in multiple processes involving people and computer systems. For pilots not to recognize this is a somewhat concerning event. In aviation, that is when accidents happen – multiple failures missed in multiple systems, not recognized by multiple people.

  9. If I were Boeing, I’d get going on the 757 MOM project. With the new 320 neo coming out, this could happen more often. (Shudder to think of flying in an A320 series to Hawai’i)

  10. “””””…….they’ve already updated the software in dispatch so that it will automatically catch if the airplane being flown isn’t the right one”””””

    You would think that would have been in place since day one.

    I blame the pilots for not checking to make sure the aircraft wasn’t the right type to fly that far over water. Will AA be secretly placing signs inside the cockpit/galleys so crews can see ETOPS and make that part of preflight check lists, to look and read?

  11. The ability to operate an aircraft in ETOPS requires a lot of behind the scenes actions as well as modifications to ensure physical aircraft reliability and functionality. Advisory Circular 120-42B and FAR 121.161 govern the requirements for ETOPS.

  12. Like jason asked… Does anyone know if the 321S has aux fuel tanks? I didn’t think they were an option on any A321s except the recently announced Neo Long Range version, but could be wrong. I’m wondering because even the newer A321-200s with the up-rated IAE V2500s come in on fumes after a transcon flight… so if no aux fuel tanks, then the weight restriction must be pretty significant.

      1. Most likely, I don’t see how they could do it without them. What I can say with certainty is that all of the LUS 321s have 2 additional center tanks (ACTs), so it would follow logically that the LAA birds (T, S, and H) are equipped in-kind as well. The LR version adds an option to carry a third ACT.

  13. Hindsight is always 20/20. Let’s hope this was only a wake-up call, and this kind of thing doesn’t happen again.

  14. CF,

    I’m giving the rampers a pass on this one. I’m not even sure those guys even know what ETOPS necessarily means, or what has to have it. Second, most of the time, they’re aren’t thinking all that much about the destination of the aircraft anyway.

      1. Nope. It’s “There’s a bag, here’s a plane, throw. Next”. I’ve watched plenty of rampers loading planes, but never seen one look at tags. It’s just a throw onto the belt, and that’s it.

        1. By and far most rampers do verify what they’re loading and where they’re sending the aircraft to. If you don’t, the consequences can be pretty far-reaching, especially if you end up sending something like HAZMAT on the wrong flight. But even sending the wrong bags can come back on you hard, and most realize that reading the tag is preferable to a trip to the supe’s office to fill out an irreg report and face a possible suspension.

          Plus, it’s nearly impossible now not to with the advent of scanners at most airlines. Even if you don’t read the big, bold 3-letter code that ‘s right above the barcode you’re scanning, the device will almost certainly let you know if you’ve messed up.

    1. As a ramper, part of my responsibilities included verifying tail numbers and, if I was dispatching an ETOPS flight, the presence of the “ETOPS” decal on the nose gear door. At one point that also meant checking life vest seals on every single seat. Knowing what ETOPS means is just part of the job at stations that op those flights.

  15. Actually, this is not surprising at all. During the pre-JCBA negotiations between American management and the APA, American’s negotiators pushed hard to eliminate the international and domestic divisions for their pilot group (thus carrying fewer pilots on the payroll). This was not a remarkably unreasonable stance, given that American was the last major carrier to have such divisions. The US Airways pilots on the APA’s Board of Directors warned the American pilots that if such a concession were granted, they would need to insist on a concomitant rigorous training program in international procedures (and ETOPS) for the domestic division pilots. Obviously the warnings went unheeded.

    Ultimately, the responsibility for ensuring the aircraft in question was ETOPS-certified lies with the pilot-in-command. He or she obviously had completed an OE, or would not have been dispatched for the flight, but its effectiveness is in question. The log book would have shown whether an ETOPS check had been done by maintenance (each leg of a flight requires a new ETOPS check), and the absence of one should have been detected by the pilots.

  16. Ouch.  Good piece.  As an aside, from Sawyer Aviation, LLC:

    ” The longest over water route in the world is the stretch between the U.S. mainland and Hawaii. Even between Hawaii and Tokyo there are alternate airports available, such as Midway Island (hence the name “Midway”). Going across the North Atlantic, alternates include Iceland and Greenland. Even more southerly routes would make the Azores a possible alternate.”

    http://sawyeraviation.com/what-is-the-longest-over-water-route-of-flight-with-no-alternatives/

    1. I agree. U.S. to HNL being the longest overwater flight without airport alternatives is unlikely. SCL-AKL on LA, SCL-SYD on QF, EZE-SYD on AR, and the soon to start operating EZE-AKL on NZ are all very long overwater flights (12-16 hours) requiring 330 ETOPS as there are absolutely no alternative airports as they fly over Antarctica.

  17. I find it very hard to believe that US mainland to Hawaii is the longest overwater route in the world.
    I suggest you take a good hard look at Johannesburg-Sydney. LAX-HNL requires 180 minute ETOPS. SYD-JNB requires 240 minute ETOPS to fly the great circle. While SYD-JNB can be flown as 180 ETOPS, it adds about 1000 miles to trip. Santiago chile (SCL) Auckland (AKL) is even worse, the great circle route
    requires 330 minute ETOPS. While it can be flown as 180 ETOPs, it also adds upwards of 1000 miles to trip to do so.

    1. Understand what you are saying.  Have also heard from pilots that west coast U.S. to Honolulu is the longest.  The main thing is there is no alternate airport on the route.  Do the routes you quote below have an alternate along the way?

  18. WOW! What a screwup. Thank goodness that there was no incident. The repercussions could have been tremendous. I had not idea about ETOPS until I read this article. This was educational to me. I find that the crew could not and did not notice this. I hope that American will fix this and never let it happen again.

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