Oklahoma Basketball Team Crash Spurs Overhaul of Oversight

Air Safety Week, June 23, 2003

Should one of these components fail, a.c. power could be lost even though both inverters were working. It is noteworthy that modern aircraft electrical systems can be significantly lacking in redundancy while meeting all certification standards. Note also that a copilot is not required if the aircraft is equipped with a serviceable three-axis autopilot. However, when the a.c. power fails: the autopilot fails, the only usable (d.c. powered) attitude indicator is on the right hand side where there need not be a copilot, and the circuit breakers are on the right side at knee level, which could induce an unusual attitude as the pilot in the left seat leans across to examine them, and probably with a passenger obscuring the way.

None of these components was recovered from the accident site; there is no relevant failure history on them, and investigators could not make a definitive determination as to what caused the a.c. system to fail. The electrical failure was cited as a contributing cause in the crash, the primary cause of which was that of the pilot's failure to assess the cues he did have of a.c. power loss and to utilize the remaining functional instruments (and the copilot) to retain control of the aircraft.

The cultural context

Having pinned the probable cause on the pilot, the safety board nonetheless dwelt at some length on the organizational and cultural context in which this flight took place. The board found "numerous deficiencies, unsafe practices, and deviations from regulations occurred during the flight."

"The management required for a safe operation appears to have been absent, which was a 'significant' factor in this accident," the report noted. For example, OSU's flight department had no records on the pilots or the airplane. Because it was a donated flight, the trip was not coordinated with the manager of the flight department.

The policy changes put in place since the accident speak for themselves. It is another case of previously slack rigging being tightened after running aground, not beforehand. Thomas H. Huxley's remark in 1877 about knowledge as the basis for safety applies: "If a little knowledge is a dangerous thing, where is the man who has so much as to be out of danger?" A requirement to respond to that question might put safety programs and management decision-making in a new perspective.

Twinning is a term that was coined some years ago for the philosophy of close juxtaposition of critical flight instruments which are essentially there to back each other up (and so require subconscious ongoing cross-check - i.e. the failure of one to replicate the other's movement becoming cause for instant alarm). Examples are altimeter and standby altimeter, main attitude display and its backup/standby attitude instrument. An HSI (horizontal situation indicator - compass) will not immediately kill you if it fails. However a faulty attitude indication will. Why? A good example is the Air India B747 that crashed in 1978 over the inky-black water west of Bombay. Once the pilot flying got past a certain attitude in pitch and roll, the heavy aircraft was quite unrecoverable at that altitude. A classic example is the Korean Air Lines (KAL) B747F freighter that crashed Dec. 22, 1999, on initial climb out of Stansted, UK. There was an apparent failure of the attitude director indicator, a "comparator" buzzer sounded three times as the captain expressed concerns over his distance measuring equipment (DME) indication.