Managing the Safety of Corporate Aviation

Air Safety Week, May 11, 2009

A member of the U.S. National Transportation Safety Board (NTSB) recently made the case for how Safety Management Systems (SMS) can help reduce the number of accidents involving corporate aircraft.

In a presentation to the 54th annual Corporate Aviation Safety Seminar (CASS), Safety Board Member Debbie Hersman said more needs to be done, especially as it relates to air charters.

Preliminary aviation accident statistics for 2008, reveals improvements in some industry sectors but increased accident rates in others. Fatalities among on-demand operations rose as did the accident rate for general aviation, but the number of accidents involving Part 121 and Part 135 carriers were not alarming.

While the overall aviation safety record in the United States is among the best in the world, the 2008 accident statistics reveal a mixed picture, and the Safety Board is particularly concerned with the spike in fatalities in on- demand air charter operations.

On-demand flight operations, which include aero medical, air taxi and air tour flights, logged over 3.6 million flight hours and had 56 accidents, killing 66 people, the highest number of fatalities since 2000. There were only 43 fatalities in 2007. But the accident rate per 100,000 flight hours (1.52) remained virtually unchanged from 2007 (1.54).

Those fatal accidents include the loss of emergency medical services rotorcraft. Nationwide for the year, four EMS crashes took 15 lives. In March, a chartered Pilatus PC-12 turboprop crashed in Butte, MT resulting in 14 deaths, including several children.

In comparison, the number of accidents involving large commercial carriers (Part 121) was 28 in both 2008 and 2007. In both scheduled and non- scheduled services, the airlines carried 753 million passengers on over 10.8 million flights without a passenger fatality.

In 2008, Part 135 regional air carriers that typically operate smaller turboprop aircraft made 581,000 flights, logging over 290,000 hours. These operators had seven accidents, none of which resulted in fatalities. This was an increase from three accidents in 2007.

In general aviation, there were 1,559 accidents, 275 of which involved fatalities, killing a total of 495, one fewer than the previous year. But the GA accident rate per 100,000 flight hours was 7.11, up from 6.92 in 2007. In the last 20 years, the highest accident rate was 9.08 in 1994; the lowest rate was 6.33 in 2006.

Hersman discussed how an SMS program might have saved the lives of five people on July 10, 2007.

The NTSB blamed the crash of a Cessna 310R in Sanford, FL on a series of poor decisions, both by corporate flight department management and by the pilots on the doomed flight.

The Safety Board said the accident that killed two pilots and three on the ground didn't have to happen.

On that morning the Cessna 310R, part of the fleet operated by NASCAR's corporate aviation division, crashed into a residential area, destroying two homes, while performing an emergency diversion to the Orlando Sanford International Airport in Florida after reporting an in-flight fire.

The Safety Board said that the accident was due to the NASCAR corporate aviation division's decision to allow the ill-fated aircraft to be released for flight with a known and unresolved electrical system problem. The NTSB also ruled that the pilots erred since they decided to fly that day with full knowledge of the maintenance discrepancy.

The day before the fatal crash, another NASCAR pilot flew the accident aircraft and reported a "burning smell" while in flight. The pilot turned off the weather radar and manually pulled the associated circuit breaker, after which the odor dissipated. He recorded this event in the aircraft's maintenance discrepancy binder and reported it to senior staff in the NASCAR corporate flight department.

Despite being aware of this unresolved issue involving the aircraft's electrical system, the flight department released the aircraft for flight, and the two pilots (one of whom was employed by NASCAR and was aware of the unresolved electrical problem) hopped in the aircraft for the flight between Daytona International Airport (DAB) and Lakeland Linder Airport (LAL).

The Safety Board said the NASCAR pilot was told about the electrical problem, and replied he "didn't care about the radar" as the short trip from Daytona Beach to Lakeland, FL was to be conducted under VFR conditions.

The NTSB said that at some point "it is likely that one of the pilots reset the circuit breaker that had been pulled on the previous flight, re- energizing related components in the electrical system, which likely led to the in-flight fire."

The Safety Board also determined that the NASCAR flight department had inadequate policies and procedures to prevent an aircraft with a known maintenance issue to be released for flight. The NTSB said that had a SMS been in place, which would have provided a formal system of risk management and internal oversight, the fatal accident might have been avoided.