Paying Passengers Deserve Safety on All Flights

By Member Michael Graham

In 2015, the Federal Aviation Administration (FAA) required commercial airlines to develop a comprehensive safety management system (SMS) to improve safety for the flying public. An SMS is an organization-wide system that ensures operators are properly identifying, assessing, and mitigating the conditions that exist for an accident to occur.

The FAA, however, has not required the same for revenue passenger-carrying operations under Title 14 Code of Federal Regulations Parts 91 and 135, leaving passengers on these flights at unnecessary risk. Similar to passengers of commercial airlines, those passengers who pay for a charter flight, skydiving experience, or hot air balloon ride exercise no control and bear no responsibility over the airworthiness or operation of which they are being flown. Therefore, paying passengers of Part 91 and Part 135 flights deserve a similar level of safety as those who fly on a commercial airline. That is why Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations is on the NTSB’s 2021–2022 Most Wanted List of Transportation Safety Improvements.

The Problem

Togiak, AK – Separated section of empennage with vertical and horizontal stabilizers and rudder attached.

Since the airlines were required to develop an SMS in 2015, the NTSB continues to investigate Part 91 and Part 135 accidents that could have been prevented by an effective SMS—all involving paying passengers—including the following:

  • On October 2, 2016, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane operated under Part 135, collided with steep, mountainous terrain northwest of Togiak Airport in Alaska, killing both commercial pilots and their passenger. The operator did not have an SMS, and we found that after experiencing two previous controlled flight into terrain (CFIT) accidents in the preceding three years the company had missed opportunities to adequately assess this CFIT-related risks and implement more effective strategies for preventing such accidents.
  • On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to runway 1 at Teterboro Airport in New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died. The operator lacked both an SMS and a flight data monitoring program, and the company did not identify or mitigate hazards that contributed to this accident, including the pairing of pilots who had exhibited difficulties in training, the informal practice of some captains who allowed unapproved copilots to serve as pilot flying, and other patterns of flight crew procedural noncompliance.
  • On March 11, 2018, an Airbus Helicopters AS350 B2 lost engine power during an aerial photography flight and ditched on the East River in New York City. The pilot sustained minor injuries and his five passengers drowned. Again, the operator lacked an SMS and, although the operator’s employees were aware of the potential hazards that led to the accident, the operator did not have a robust safety program that could adequately prioritize and address hazards that played a role in this accident, including the potential for entanglement of a passenger harness/tether system with floor-mounted engine controls, the inability of passengers to evacuate without assistance, and the possibility the emergency flotation system might only partially inflate due to difficulties with the float activation mechanism.
  • On June 21, 2019, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield, Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. In this accident, the operator failed to address numerous safety issues that a formal SMS would likely have identified as significant risks and prevented the accident. These included allowing passengers to be transported in a poorly maintained airplane, not implementing any standard operating procedures (SOPs) or written guidance for the company’s parachute operations, providing no structured initial or recurrent training for company pilots, using flawed methods in calculating the weight and balance of its flights, and allowing its pilot to routinely violate numerous Federal Aviation Regulations. In April 2021, the NTSB issued Safety Recommendation A-21-13, which asked the FAA to require SMS for the revenue passenger-carrying operations discussed in the Part 91 aviation investigation report; these operations included parachute jump flights.

These accidents seemingly had little in common, yet, in each case, an effective SMS might have helped the operator identify hazards or better mitigate those that were already known.

An Effective SMS

Any operator can print out the four pillars of an SMS, put up a poster, and add an anonymous comment box to the breakroom. However, implementing an effective SMS that changes safety behavior in an organization is not a box-checking exercise. An effective SMS is a management system that brings safety conscious behaviors to the forefront of an organization, which aids in identifying and mitigating risks inherent in flight operations and other activities. Every day, every task.

An effective SMS must fully address the following four pillars:

  • Safety policy
    • Sets objectives, assigns responsibilities, and develops standards
    • Clearly defines roles and responsibilities
    • Engages accountable executive
  • Safety risk management
    • Systematic processes for identifying hazards and mitigating risks
  • Safety assurance
    • Monitors, measures, audits, and assesses the performance of SMS
  • Safety promotion
    • Ensures a positive and just safety culture
    • Circulates and incorporates safety lessons
    • Advocates, communicates, and trains the principles of SMS

By establishing an effective SMS and creating a safety culture that fosters the free flow of safety-related information and organizational learning about the nature of operational risks, operators will reduce the likelihood of an accident and improve the safety of their flight operations.

What Can Be Done

Oversight is necessary to ensure operators adhere to the principles and processes of an effective SMS to provide sufficient safety to paying passengers. The NTSB has investigated numerous accidents involving operators whose deficient SMS failed to identify and mitigate the conditions that contributed to the accident. Therefore, the NTSB calls on the FAA to require SMS for all revenue passenger-carrying Part 91 and Part 135 operations and provide ongoing oversight.

To operators, the NTSB’s investigations repeatedly demonstrate that an effective SMS could have identified the hazards and mitigated the risks that led to the accidents. Do not wait for an accident to occur or a FAA mandate to invest in the safety of your passengers, pilots, and other personnel, voluntarily implement an effective SMS today.

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