Bob Crandall retired in 1998 as chairman, president, and CEO of AMR, parent organization to American Airlines and while many people today might not remember his name, they’ll pretty quickly recognize what he created while he was at the helm.

Bob Crandall (L) with another industry giant, the late Herb Kelleher, co-founder of Southwest Airlines.

Crandall is the often combative, no-nonsense finance-marketing focused guy who, while at American created American Advantage, the industry’s first frequent flyer program. A strong opponent to deregulation before it took hold in 1978, Bob Crandall is also the brain behind modern-day yield-management that pointed to the path other airlines followed to squeeze every last penny out of an unused airline seat, right up to the moment the tug pushes the airplane back from the gate. He was also created SABRE, the first robust airline industry reservation system.

Crandall became the scourge of unionized airline pilots though in 1983 when he created the notorious B-scale pay system as a tool to fight the flurry of then evolving emerging low-cost airlines. He managed to convince pilots the airline could never afford shiny new aircraft if they didn’t figure out how to cut their labor costs. The move essentially put airline pilots everywhere on a war-time footing with their own management teams and facilitated the 1985 pilot strike at United.

Bob Crandall Today

Because Crandall always been a notorious industry pundit, Bloomberg.com on Tuesday probed him about airline bailouts, as well as Boeing’s push for cash for the aerospace industry in the wake of the economic downturn created by the Coronavirus. Boeing CEO David Calhoun said his company would only accept bailout money on the company’s terms and would not allow the government to take an equity stake in the aerospace giant. With the 737 Max debacle still fresh in people’s minds, some interpreted Calhoun’s mention of a bailout itself as nothing short of heresy. In fact, Boeing board member Nikki Haley resigned last week because she did not believe in offering cash to one industry giant while ignoring others.

Keeping Crandall’s comments in context, the International Air Transport Association (IATA) on Tuesday said, “Owing to the severity of travel restrictions and the expected global recession, IATA now estimates that industry passenger revenues could plummet $252 billion or 44% below 2019’s figure.”

Despite 20 years away from the airline industry, Crandall’s thoughts on Bloomberg shocked some and surprised others. Early on, he said he didn’t believe the airline industry needed a bailout, but that “it does need support” calling the airlines one of America’s most basic forms of transportation. “You can’t simply let these companies go away,” he said. “But these companies need to understand there needs to be some kind of controls put in place. It probably needs to be regulated like some form of utility.”

Crandall pointed out that, “In the last six years, the industry has spent more than its total free cash flow buying back stock and took on a mountain of new debt. So now we’re saying to the public, we used a lot of our free cash flow to buy back stock, which in a business like the airlines, I would say you should never do. And now we need some support. The airline needs to realize it can’t use its other resources in other ways.” Crandall warned that support might be needed for quite a while since it’s going to take time for people to willingly gather in groups again.

Remembering that Crandall is the dean of yield management, he was also clear about the fact that the airlines can no longer, “continue jamming seats onto an airplane and making the public unhappy. And they can’t spend their free money buying back stock.”

Does he think Boeing needs saving? “We don’t want to lose our leadership position in aviation, therefore we need to help Boeing … whatever it needs to sustain Boeing.” He was less certain about whether the Seattle plane maker might be headed for Chapter 11. “But when we put public support into a company, the public has the right to expect that once you [Boeing] recover, part of the rewards of recovery come to us. These companies need to be ready to give up being completely unrestricted.”

Will people travel less once the virus is under better control? “All the research we’ve ever done says consumers want to travel more. Five years from now, I think travel will be as robust as it is now.” But Crandall admitted the road to that recovery could be pretty rocky, especially in the near term. “Right now, I think we might be underestimating the near term effect of the virus.”

Does that mean returning to a time when the government set routes and pricing? While Bob Crandall thinks nationalization is probably overkill, he believes the government may need to make a substantial investment in the airline industry. He said, “We all need to decide what conditions we want to impose on the airlines until they pay us back.” He was adamant that during this recovery period, “an airline can’t just walk away from a city if that means they lose all airline service.”

With Congress having just passed its initial bailout legislation, we won’t need to wait much longer to see what happens next.

Rob Mark

When things go chronically wrong in aviation, a safety stand down is an efficient and effective treatment because you stop all operations and dissect what you’ve been doing and how you’ve been doing it to ferret out—and fix—the root causes of what’s been going wrong.

As we socially distance ourselves to temper the spread of Covid 19, conducting an individual safety stand down would be a productive use of our time isolation. We should start with an honest assessment of our cultural, social, and political practices, focusing on their contributions to the medical, social, and economic challenges we now all share. And if they exacerbate the problem rather than remedy it, we should consider changing them.

A safety stand down assessment is straightforward. What is most important to you? Start with Maslow’s Hierarchy of Needs. The foundation is the basic needs of food, water, warm, dry shelter, and security. With the pandemic putting many around the world out of work, these essentials are daily questions many are looking to government to answer.

Look at the solutions our elected officials are putting forward. Who do they benefit, and to what degree? What would benefit individuals more, corporate tax cuts, or a robust program of paid leave that would help employers see their employees through the pandemic’s shutdowns?

Some might say another tax cut would enable employers to do that. Perhaps. In our safety stand down assessment, we should look at how well that worked for employees with the trillion-dollar tax cut of several years ago.

Being aviation companies, one might expect the airlines to have used aeronautical decision-making, used their government-given tax bounty to make life better for their customers and employees, and prepared for a rainy day by paying down their debt and putting come cash aside for emergencies. Instead, they increased ticket-tax exempt fees, shrank seats, and used most of it to buy back stock that enriched their shareholders and the executive. And now that the rainy day will be around for an unseen period, they are lining up for a bailout. If they get one, we should implore our elected officials to include some conditions that benefit customers and rank and file employees.

Preventing problems from reoccurring is the ultimate goal of a safety stand down. Like the outbreaks of bird flu, N1H1, and Ebola that preceded it, Covid 19 offers another learning experience of preventive procedures. During our safety stand down assessment, we should support those who promise to heed that lesson and support it with focused preparation and funding.

And we should be open to related revelations. For example, parents who become home schoolteachers might realize, when they present their children with a structure, academic goal, that maybe they were wrong to blame teachers, and that maybe they have underpaid and under-supported for way too long. Consider this: Depending on how long it takes us to corral the corona virus, many people may not have jobs to go back to, and home schooling may become the new normal.

Given this perspective, as a society, we can only hope that any beneficial change resulting from a safety stand down assessment has an eternal self-like, not one of a New Year’s resolution. – Scott Spangler, Editor

Unless you’ve been a disconnected intraterrestial for the past week or so, you’ve probably seen the memes noting the triple one-week whammy of the change to daylight savings time (for those of you living in states subjected to it), a full moon, and a Friday the 13th. They all seem to be implications of bad times: the time change disturbance to our circadian rhythm, the full lunar reflection that seems to nurture humans to make bad decisions, and the stereotypical ill-fortune fate of triskaidekaphobics. It is all nonsense, of course, especially when you look on these events from a pilot’s point of view.

Zulu Time

The world could put an end to the circadian consequences of time changes and the confusion of calculating time zones when communicating live with someone who lives elsewhere. If English is the universal language of aviation, why not employ aviation’s time zone, set the world’s timepieces to 24-hour Universal Coordinated Time, and then leave it alone. If the world can’t agree that it is, truly, coordinated universal time, changes its designation back to Greenwich Mean Time or, my favorite for its cool word conciseness, Zulu time.

Before time zones, people set their clocks locally, starting at noon, when the sun reached its zenith over their community. Setting a schedule to these village clocks, each set to a different time as Helios made his daily trek from east to west, was more than a bit complicated, so the powers that be created time zones so people would not miss their trains. But compared to the airlines, hardly anyone travels by train any more, and because airliners can cross more than half of the world’s time zones in a single flight, setting their arrivals and departure times to Zulu seems to be working so far.

So why not the rest of the world? And it would give us some new songs to write, Instead of 9 to 5, the arbitrary span of an American workday, in today’s Central Daylight Time it would be 1300 to 0100. It doesn’t seem to have any clear poetic patters, but isn’t our uninterrupted circadian rhythms worth it? And pilots would receive an added benefit of no longer having to look at the local time and try to remember how many hours to add or subtract to fill out the flight plan form with Zulu time.

Full Moon Madness

Those in public and medical service will attest to the rise in decisions not thought through when the moon is full. The reason is simple, people can see better while acting under the delusion that their actions are less noticeable at night. That’s why the full moon has been known, since the evolution of load-lifting aircraft, as the bomber’s moon. And it is why the span of the full moon is the best time of the month to maintain a pilot’s night proficiency requirements.

Pilot Superstitions

Most of the pilots I’ve met and known are not superstitious, unless it comes to missing a step in their preflight preparation and planning, or getting distracted while working through a checklist. Decades ago, one of them warned me about flying an airplane that still had paint on its rudder pedals, but if he explained why, I don’t remember it. Can anyone help me out?

Seeking illumination on the internet, Hartzell Propeller blogged on four superstitions, but half of them, carrying talismans or lucky charms, seem stereotypical of all superstitious individuals. The other two were preflight rituals and weather-related superstitions. They didn’t get into specifics, other than one pilot’s preflight habit of dancing on the wing with an umbrella. I’d be willing to bet the other idiosyncratic behavior is related to something important they missed in preflight or operation.

But maybe I’m missing something here. If you have a pilot superstition, or know of one—and can explain what’s behind it—please let me know, and I’ll share them here. –Scott Spangler, Editor

Embry Riddle Aeronautical University researchers are asking INSTRUMENT-rated PRIVATE pilots and AIRLINE pilots to complete a 2-5 minute questionnaire (https://www.surveymonkey.com/r/GK3ZD3B) as to the amount/type of NON-revenue flying in light aircraft undertaken by them. Such information, combined with light aircraft accident data, could lead to improved general aviation safety for either, or both, groups of pilots.

Wandering through Netflix’s streaming options hoping to trip over something that would hold my attention, in the Hidden Gems category I saw Mission Control: The Unsung Heroes of Apollo. Having visited the recently restored facility (See 87 Steps to the Moon: Journey to Mission Control Enriches Memories of Apollo 11), I pressed play. And I didn’t move or divert my eyes from the screen for the next 101 minutes.

What held me rapt was the unexpected story of mission control told by the men (and as several of the active duty female flight directors interviewed, “they were all men then”) who conceived the idea of mission control and worked long hours (with noted sacrifices to their families) to make it a critical component of not only the Apollo adventure, but all of America’s aerospace efforts that preceded it and grew from it.

It begins with Christopher Kraft, who explains Mission Controls genesis from the flight data collection effort on the X-1 project. It steps lightly through the Mercury and Gemini programs, which represent Mission Controls infancy and and adolescence, before one of Apollo’s flight directors, Gene Kranz, delves into its adulthood.

Many of the interviews are held in Mission Control itself, and through them the subjects share who sat where and their responsibilities. Meeting the men, in the white shirts with their skinny ties and ever-present cigarettes who sat unknown at their Mission Control consoles, was captivating.  And before they spoke about their working lives, the film delved into where they came from and what ultimately led them to Mission Control.

There was Stephen Bales, who grew up in an Iowa farming community, earned a degree in aerospace engineering from Iowa State, and was the guidance officer during the lunar landing of Apollo 11. Among many others was Glynn Lunney, another Apollo flight director, and his contribution to the Apollo 13 effort subtlety emphasized the supportive teamwork of everyone who worked the shifts that covered every space flight around the clock.

The film delves deeper into the missions of Apollo 8, 11, and 13, with interview contributions from astronauts including Charlie Duke and Gene Cernan. But Jim Lovell had the best line when he talked about the delayed acquisition of signal (AOS, and the subjects do an excellent job of unobtrusively giving life to a seemingly endless stream of acronyms) on Apollo 13’s reentry. He might have been joking, but he said the crew decided to stay quiet for a bit. “It’ll make a great movie!” he concluded, laughing. Indeed! –Scott Spangler, Editor

With the end of World War II lining up for its 75th anniversary celebration at EAA AirVenture Oshkosh, one might think there was little new information about the pilots who fought it. I was one of them, until I read the review of Race of Aces: WWII’s Elite Airmen and the Epic Battle to Become Master of the Sky, by John R. Bruning. (It should be no spoiler that I’ve already asked the library to add the 522-page tome published by Hachette Books to the its stacks.)

The reviewer, Elizabeth Wein, is no stranger to aviation’s preeminent conflict. She wrote A Thousand Sisters: The Historic Airwomen of the Soviet Union in World War II, which is a finalist for 2020 award for excellence in young adult nonfiction writing. Yet the names of the racing aces, Dick Bong, Tommy McGuire, Neel Kearby, Gerald Johnson, and Tom Lynch were new to her. Already well read on the exploits of these Fifth Air Force pilots, on whom the book focuses, I was ready to dismiss the new book as regurgitated history.

Fortunately, I kept reading. To improve morale, after Eddie Rickenbacker visited the far Pacific outpost in 1942, Gen. George Kenny challenged his pilots to surpass Rickenbacker’s World War I tally of 26 kills. “Rickenbacker and Kenny each agreed to stand the winning pilot a case of Scotch, and the race was on.” This I did not know, had never heard, and I want to know more (hence the library request for the book).

Almost every warbird geek knows that Dick Bong was America’s leading ace with 40 victories, so he should have won the Scotch. And I’m sure Race of Aces will go into details about their telling dogfights. That’s not what I’m interested in because I’ve already read some version of what the book will share. My interest is learning more about the pilots beyond their combat experiences, and the review promises this.

Saying that Bruning, the book’s author, “is at his best when he delves into the pilots’ anguish and obsessions.” And “his telling is based on a dragon’s hoard of primary source material, including well over 1,000 interviews he conducted himself.” Since so few of these noted pilots survived the war, I’m curious to learn what new perspectives these sources have to share because they give shape to the human forms that fight in any conflict. – Scott Spangler, Editor

If wildlife encounters have made your flying life interesting during last year’s flying season, winter is the time to start thinking about doing something about it before the migrating critters return to your small nontowered aerodrome. Start by asking your airport manager and/or airport if the field has done a wildlife assessment and devised a wildlife management plan. If it has, get a copy and read it. What you learn may surprise you.

Airports certificated under Part 139 must conduct wildlife hazard assessments and develop wildlife management plans. This is no simple, quick, or easy endeavor. It requires time, a certified wildlife affiliated biologist who spends up to a year determining what critters may interact with flying machines each season. With this data, the biologist and airport personnel develop the airport’s Wildlife Hazard Management Plan, also required by Part 139.

The process sounds simple, but guess again. The assessment and resulting plan usually involve the US Department of Agriculture, Wildlife Services; the US Army Corps of Engineers (which oversees the nation’s water resources); The US Environmental Protection Agency (if anything from pesticides to landfills is involved); US Fish and Wildlife Service (which oversees migratory birds and federally listed wildlife and their well-being). And then there are all the state natural resources, wildlife, and environmental agencies. When dealing with airport wildlife, killing it is the last option, not the first, and it requires more than a few permits.

The FAA’s National Plan of Integrated Airport Systems lists nearly 3,300 airports that are eligible for Federal Airport Improvement Program. Of this number, fewer than 650 have towers whose controllers can warn pilots of wildlife activity. At nontowered airports (as well as privately owned, public use fields and private strips), pilots are on their own to see and avoid not only other airplanes but also the birds and other critters who have no understanding or appreciation of right of way.

The FAA recommends that operators of public-use airports “implement the standards and practices contained in the applicable Advisory Circulars.” If the airport has received AIP funding, they don’t have a choice in the matter, but they can also apply for funding to help pay for the wildlife assessment and management plan.

If your aerodrome is public-use but isn’t eligible for (or hasn’t been blessed with) AIP funding, start with AC 150/5200-32B, Reporting Wildlife Aircraft Strikes, and work with all of the pilots who fly there to report their strikes. This feeds the FAA’s National Wildlife Aircraft Strike Database and the FAA’s Feather Identification Program, which can give pilots a heads-up on the critters they may face when flying to your (or nearby) airport.

AC 150/5200-33, Hazardous Wildlife Attractants On or Near Airports may give you some ideas on ways you can mitigate wildlife that aren’t too involved, like making sure all of the dumpsters are closed up. And if your community is thinking about a new dump near the airport, read AC 150/5200-34, Construction or Establishment of Landfills Near Public Airports before you attend the public meetings on its creation.

If your wildlife effort somehow manages to raise the funds necessary for a wildlife assessment for your airport, AC 150/5200-36 and AC 150/5200-38 respectively address the qualifications the biologist must possess and the protocol for conducting the assessment. There is much more to read on the FAA’s Wildlife Regulations, Guidance, and Resources page. And if you are really curious, look at Wildlife Hazard Management at Airports.

For more information on promoting wildlife strike awareness and mitigation, visit Bird Strike Committee USA, a volunteer organization that holds an annual conference (August 25-27, 2020 in Minneapolis).

Ultimately, pilots should be critter aware on every flight. Winter is no guarantee that all of them have moved to warmer climes or are taking a nap. In many places, snowy owls arrive with the cold white stuff that falls from the sky. They like airports because airport signs give them an excellent perch to search for prey on a vast expanse of level ground. – Scott Spangler, Editor

A recent New York Times story about the hidden drug epidemic rooted in the conflict between prescribed medications and over-the-counter (OTC) drugs and supplements focused on people in their 60s, but as I read, I could easily see that pilots taking prescribed medications could also be unknowing participants.

According to the article, people in their 60s take an average of 15 prescriptions a year. “And that’s in addition to the myriad of over-the-counter drugs, herbal remedies, vitamins and minerals they may take, any of which — alone or in combination — could cause more problems than they cure.”

Taking aspirin or another nonsteriodal anti-inflammatory drug (NSAID) such as ibuprofen, for example, could heighten the chances for bleeding for those taking a prescribed anticoagulant like Coumadin.

This combination of prescribed and OTC drugs—and their interactive side effects—is known as “polypharmacy.” It is the result, the article said, “of our fragmented health care system, rushed doctor visits, and direct promotion of drugs to patients who are ill equipped to make rational decisions about what to take, what not to take, and when.”

Contributing to it are the number of prescribing physicians, who may not know what the prescribed and OTC drugs the person is taking, and this is what made me think of pilots, especially if they fly for a living. Rare is the professional pilot I’ve known who will volunteer anything that might put a medical certificate in jeopardy.

Given the consequences to such pilots and those who fly with them, this is foolish and shortsighted. Everyone should compile a list of every prescribed and OTC drug and supplement they consume and use it as a checklist when any doctor asks what you’re taking. And if the doc doesn’t ask, be a proactive patient and present it before the appointment end, especially if there is another prescription in the offing.

Before any pilot swallows an OTC drug new to them, they should read the FAA Aviation Safety page, Pilots and Medication. Here’s the attention getter: “Impairment from medication, particularly over the counter (OTC) medication, has been cited in a number of accidents in general aviation. In a 2011 study from the FAA’s CAMI Toxicology Lab, drugs/medications were found in 570 pilots (42%) from 1,353 total fatal pilots tested. Most of the pilots with positive drug results, 511 (90%), were flying under CFR part 91.”

Then pilots should run the OTC checklist in What OTC Medications Can I Take and Still be Safe to Fly? An affirmative answer to questions such as “Am I having trouble clearing my ears at ground level?” and “If currently taking a medication only for symptom relief, would you be safe to fly without it?” yields this warning: “STOP. You might not be fit to fly!”

This page includes a table that lists go/no-go medications and the rational for the rating. The table also lists the medication or active ingredient that determines the medication’s go or no-go rating. The table lists the frequently used OTC medications: Antihistamines; Nasal Steroids; Nasal Decongestants; and Cough remedies.

After reading the active ingredients in the go/no-go table, you’re ready for the three-step evaluation of choosing an OTC medication. 1. Identify the active ingredients. “Verify that you have taken this medication in the past with no side effects. 2. Read the label. If it warns of possible drowsiness or to “be careful when driving,” it is not safe for flying. 3. Read the directions carefully. “If this is the first time you are taking a new medication, wait at least (5) dosage intervals and ensure that you suffer no adverse effects from it before flying while on the medication.”

A pilot’s aviation medical examiner is the ultimate resource when it comes to avoiding interactive drug problems. If there is a conflict between the prescription and OTC medications, an AME, said the Pilots and Medication page, in many cases can recommend treatment options “that may allow you to fly.” –Scott Spangler, Editor

Humility is the absence of vanity or excessive pride, a state or quality of being humble. Humble individuals are conscious of—and acknowledge—their defects or shortcomings. They are modest and not overly proud. Humility is an essential element in aviation safety, and it needs to be periodically recalibrated at least annually.

This self-assessment depends, on large part, on how the aviator’s year has gone. If it could have been better, most likely these less than happy events have already recalibrated a pilot’s humility. On the other hand, if a pilot has had a good year (or consciously forgotten the unfulfilled consequences of less than stellar decisions), then the aviator should take stock and recalibrate because no one flies without fault.

There is no better place to reassess one’s aeronautical humility than Callback, published by NASA’s Aviation Safety Reporting System. It receives, processes, and analyzes thousands of incident reports that pilots submit annually. It publishes the more interesting incidents in each issue and publishes the ASRS Year End Roundup in December, which is perfect for a pilot’s annual humility evaluation and recalibration.

In tune with the season, the Callback roundup is a “lighthearted medley” complied from the 108,000 reports ASRS received this year. Although I’d wager that the pilots making the reports were not so lighthearted when the situations they described were unfolding.

Imagine, you’re a private pilot winging your way out of the Washington, DC, Special Flight Rules Area when your 50-pound dog jumps from the back to the front seat. In the process it hit the panel and cleared the flight plan out of the Garmin 430, pulled the cigarette lighter power cord for the GDL 39, knocked the tablet to the passenger side floor, and “ripped the microphone port of my headset out at the connector.”

The pilot didn’t realize that his dog had disconnected his mic when ATC’s calls made clear that they could not hear him. It took him a while to untangle the cord from his dog and its leash while trying to fly the plane and not bust the Class B or the Flight Restricted Zone.

If, at any time while reading this report, or any other, you thought that “I’d never do that!” or “That would never happen to me!”, then you need to recalibrate your humility. In one form or another, it can happen to all of us. All it takes is a moment of inattention or assumption.

Just ask the ASRS Roundup pilot whose twin Bonanza was topped off with Jet A. In a hurry to secure the airplane in weather, he requested “top off main tanks only” without specifying what to top them off with. He likely assumed that the new line service guy would read the 100LL placards, and if that failed, the Jet A duckbill nozzle would prevent him from putting the wrong go juice in the airplane.

But that didn’t happen. The Jet A truck didn’t have a duckbill nozzle, and the gas guy was new to aviation. Fortunately, the pilot caught the error when he saw the big JET A label on the truck, but he didn’t see it until his tanks were topped off. Pilots who think this could not happen to them either watch every drop that goes into the tanks, or they trust their lives to the line crew. In either case, a humility adjustment might be in order.

Ultimately, it is to every pilot’s benefit to read each issue of the ASRS Callback. This not only keeps pilots humble, it builds a mental library of less than safe circumstances that might grab their attention and arrest their progress on the error chain. –Scott Spangler, Editor

During the interviews for a story on avionics interfaces, one source made a passing reference to interface failure of the Boeing 737 Max MCAS (Maneuver Characteristics Augmentation System). The significance of this observation did not resonate until I started reading FAA Advisory Circular 25.1302-1, Installed Systems and Equipment for Use by the Flightcrew, dated May 3, 2013.

The guidance in the 62-page AC “is intended to minimize the occurrence of design-related errors by the flightcrew and to enable the flightcrew to detect and manage errors that do occur.” I added the italics because the 737 Max interface certainly did not enable the crews of the two doomed 737’s to detect and deal with the MCAS errors. (And why the FAA conjoins flight and crew is beyond me, so I’ll separate them in the following sections of the AC.)

The AC addresses the design and approval on installed flight deck equipment and makes “recommendations for the design and evaluation of controls, displays, system behavior, and system integration, as well as design guidance for error management.” The complexity of the system design “from the flight crew’s perspective is an important factor that may also affect the means of compliance” with the certification requirements.

Part 25 requires manufacturers to design installed equipment whose behavior is “operationally relevant to the flight crew tasks…predictable and unambiguous.”

Operational relevance is the combined effect of the system’s operational logic, control function and placement, displayed information, and the crew’s perception and awareness of the system’s operation.

Complex controls that are inconsistent with each other or other systems are a source of errors. The family of controls includes buttons, switches, knobs, keyboards, keypads, cursor control devices, and touch screens.

After reading the guidance on “system behavior,” one wonders what obtuse rationalization laid the foundation for this aspect of MCAS certification.

Chapter 5 of the AC says a predictable and unambiguous system “enables qualified flight crews to know what the system is doing, and why. This means a flight crew should have enough information about what the system will do under foreseeable circumstances as a result of their action or a changing situation that they can operate the system safely.”

Clearly, this guidance did not lead to the desired safe outcome on two occasions. – Scott Spangler, Editor