By John DeLisi, Director, Office of Aviation Safety
On November 10, 2015, a Hawker 700A operating as a Part 135 charter flight crashed on approach to Akron Fulton International Airport in Akron, Ohio. The crash killed 9 people. During our investigation, we learned that the first officer was flying the airplane, although it was company practice for the captain to fly charter flights. We also discovered that the crew did not complete the approach briefing or make the many callouts required during approach. Additionally, the flight crew did not configure the airplane properly, the approach was unstabilized, and the flight descended below the minimum descent altitude without the runway in sight.
How could this happen? Wasn’t the flight crew trained to follow standard operating procedures (SOPs)? (Yes, they were.) Didn’t they know when to lower the flaps? (Yes, they did.) Yet, weren’t they flying the airplane contrary to the way they were trained? (Yes, they were.)
The crew ignored, forgot, or improvised their company’s SOPs and the airplane’s flight manual information. Even more disconcerting was that, upon our review of the cockpit voice recorder (CVR), it appeared that this type of haphazard approach was fairly routine for them. How could that be?
The NTSB investigators discovered that no one at the company was monitoring—or had ever monitored—the way this crew flew the airplane. Because the airplane was not equipped with a flight data recorder, a quick access recorder, or any type of data monitoring device, the operator had no insight into what was happening inside the cockpit or how this crew was flying its airplane. The fact was that this crew was able to fly an airplane carrying passengers in an unsafe, noncompliant manner, which ultimately led to tragic consequences. If the operator had better insight into the behavior of its flight crew and had taken the appropriate actions, this accident may have been prevented.
That is a lesson learned the hard way—and we have seen similar such situations in several accidents the NTSB has investigated in recent years.
It’s time to be proactive about aviation safety and accident prevention! The NTSB believes flight data monitoring (FDM) programs for Part 135 operators—which includes charter flights, air tours, air ambulance flights, and cargo flights—is one answer to this problem.
An FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and can lead to mitigations that will prevent future accidents. Too many Part 135 operations occur in which the operator has no means to determine if the flight was being flown safely. An FDM program can help companies identify deficiencies early on and address patterns of nonstandard crew performance. Most importantly, with an FDM program, pilots will know that their performance is being monitored. As a result of the Akron investigation, the NTSB recommended that the Federal Aviation Administration (FAA) require all Part 135 operators to install flight data recording devices. But it’s not enough to just capture the data; we also recommend that operators establish an FDM program to use the data to correct unsafe practices. The FAA has yet to act.
But some Part 135 flight operators aren’t waiting for FAA mandates; they have already made the investment in such a proactive safety program—and with great success. One operator I read about started an FDM program recently and is having success using the data in a nonpunitive fashion to monitor approaches. With this critical data at its fingertips, the operator is attempting to identify instances of incorrect aircraft configuration or exceedances of stabilized approach parameters. Designated line pilots assess the data captured in the FDM program to determine if further follow up is needed.
Another Part 135 operator involved in an accident near Togiak, Alaska, investigated by the NTSB recently made the commitment to equip every airplane in its fleet with a flight data recorder. The operator told us the data will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.”
Kudos to both these operators for learning from past lessons and committing to a culture of safety.
Last year, a Learjet that was being repositioned following a charter flight crashed on approach to an airport in Teterboro, New Jersey. Both crewmembers died. While the final NTSB report on this accident has not yet been released, our analysis of the CVR revealed that the first officer, who was not permitted by the company to fly the airplane, was, in fact, flying the airplane. During this flight, the captain was attempting to coach the first officer. The first officer flew a circling approach; however, when the airplane was one mile from the runway, the circling maneuver had not yet begun. The first officer gave the controls to the captain, who proceeded to bank the airplane so steeply that the tower controller said the wings were “almost perpendicular to the ground” just prior to impact.
It comes as no surprise that the performance of this flight crew was not being monitored by any FDM program.
Isn’t it time to make passenger-flying operations safer? We see this type of program on major commercial Part 121 airlines, so why not on Part 135 aircraft? After all, flight data monitoring is the best way to ensure pilots are flying safely and passengers reach their destinations.
NTSB Safety Compass Blog 