Category Archives: Aviation Safety

Safe Travels This Holiday Season

At the NTSB, we determine the cause of transportation crashes and accidents, and issue safety recommendations that, if implemented, could save lives and minimize injuries. Unfortunately, we see far too many tragedies that could have been easily prevented. As we head into the holiday season, Vice Chairman Bruce Landsberg and Member Jennifer Homendy share some travel safety tips to keep you and your loved ones safe on our roads, on our rails, on our waterways and in the air.

 

 

 

 

 

 

Roundtable Discussion Yields Key Insights, Critical Actions Needed for Improving Safety of Part 135 Flight Operations in Alaska

By Chairman Robert Sumwalt

On September 6, in Anchorage, Alaska, I facilitated a first-of-a-kind roundtable of industry operators, government officials, educators, and aviation associations. Troubled by investigations into too many crashes involving Part 135 flight operations (which include air medical service, air taxi, air tours, charter, and on-demand flights) in Alaska, we called together some of the brightest experts across industry, academia, and government to help answer one question: How can we improve the safety of flight operations involving these aircraft?

We had some ideas on how to answer that question already; the issue is on our Most Wanted List of transportation safety improvements. For example, we know that safety management systems (SMS), flight data monitoring (FDM), and controlled-flight-into-terrain (CFIT) training can help ensure that operators manage their planes and pilots in the safest possible way, reducing the chances of a crash. But we wanted to hear ideas from others—specifically those flying in Alaska, where Part 135 crashes are so prevalent—and urge operators and regulators to make some of the changes we believe will help.

Between January 2008 and June 2019, we investigated 204 fatal accidents in Alaska

fatal part 135 alaska accidents
Fatal Part 135 Alaska Accidents – Accident data from January 1, 2008 to August 12, 2019

involving fixed-wing aircraft and helicopters, scheduled and nonscheduled, in Part 135 operations. These accidents killed 80 people. At the roundtable, Dana Schulze, the NTSB’s Director of Aviation Safety, briefed us on the leading causes of Part 135 accidents in Alaska, reporting that nearly 80 percent of fatal accidents in Alaska are due to CFIT, loss of control in flight, midair collisions, and unintended instrument meteorological conditions.

Alaska has several challenges compared to the “lower 48,” such as unique terrain conditions, difficult weather, and congested airspace. That’s why we thought it important to talk specifically to those navigating this terrain. However, the deadly consequences of a crash are the same, regardless of where it occurs, and aviators across the country should be concerned with the issues we discussed at the roundtable.

I kicked off the roundtable of 29 experts, many of whom were operators, with a reminder that there is a business case for safety. I challenged the panel to come up with concrete solutions that we could collectively address. From the start, we agreed on one thing: the September 6 roundtable wouldn’t just be a conversation; it would be a call to action.

Chairman addresses panel about risk management
NTSB Chairman Robert Sumwalt talks with panelists about risk management during the September 6 roundtable on Alaska Part 135 Flight Operations

Our panelists discussed four key areas: training, risk management, technology, and infrastructure. We were pleased to see that many of their ideas related to these topics aligned with recommendations the NTSB has already issued, which are noted below. However, we welcome a discussion about any and all other potential improvement areas. Areas which the panelists agreed that they will evaluate further and perhaps pursue individually and collectively included:

Training

  • Cue-based (simulator) training has an impact on pilot decision-making and should be encouraged and required. Pilots taking CFIT training on a simulator performed significantly better on subsequent real-world flights than those who didn’t. (Note: the NTSB supports and has made recommendations to improve CFIT training for pilots).
  • To improve safety, operators must consider five safety principles: knowledgeable pilots, training, proficiency, reliable equipment, and culture.
  • The five things every operation must do are (1) realize it needs to change, (2) have a project champion, (3) create clearly defined standard operating procedures, (4) offer quality assurance systems, and (5) mentor/train employees.
  • We must do a better job of training the trainers.

As part of our training discussion, we talked about the recent closing of the Medallion Foundation, a flight safety advocacy organization in Alaska, and its impact on the industry. Medallion simulators will continue to be available to Alaska’s pilot community after the Federal Aviation Administration (FAA) determines where those simulators will be placed.

Risk Management

  • An SMS is important and worthwhile for improving safety, but it should be scalable
    Panelist Jens Hennig from GAMA with Corey Stephens FAA in background
    Panelists Jens Hennig, GAMA and Corey Stephens, FAA 

    depending on the size of the operator. Smaller operators may find it economically wise to outsource their safety assurance/FDM programs. (Note: As mentioned earlier in the blog, the NTSB has issued recommendations requiring SMS and FDM). One roundtable participant pointed out that there are 303 Part 135 operators in Alaska; of those, only eight are in the FAA’s SMS program.

  • Safety management requires the commitment of company leadership, but it’s just as important to involve pilots, mechanics, and management in the process so they recognize the value of an SMS, too.
  • An SMS should be a required prerequisite to participate in any federally funded programs, such as U.S. mail delivery and Medicare/Medicaid transport.
  • Useful data can be found in the FAA’s Aviation Safety Action Program. Carriers can benefit from the aggregated data collected in this information-sharing program.

Technology

  • Operators should equip their planes, either voluntarily or by requirement, with automatic dependent surveillance-broadcast (ADS-B) technology, and the FAA should consider helping smaller operators fund such an improvement. In Alaska, ADS-B is only required in the Class C airspace above Ted Stevens International Airport, and above 18,000 feet. We discussed the FAA requiring ADS-B in high-risk airspace, such as around the village of Bethel.
  • Pilots and air traffic controllers need more ground-based station coverage in strategic locations.
  • A terrain alert warning system (TAWS) should be an aid, not a navigational tool. There’s a tendency for some operators to inhibit their TAWS because of its low-altitude nuisance alerts; this is a hazard that needs to be mitigated. (Note: the NTSB has made recommendations in this area).
  • Technologies such as digital cockpit, 406 emergency locator transmitters, FDM equipment, and flight-following equipment look promising and should be considered.
  • When it comes to weather management, a meteorological automatic weather station isn’t authorized as a weather tool, but flight service will provide it as a supplement upon request. Satellite programs are showing promise for predicting icing and cloudy conditions.

Infrastructure

  • We need to enable more flights to operate under instrument flight rules and improve visual flight rules (VFR) operations (weather camera stations). Alaska should consider establishing a common traffic advisory frequency division across the state.
  • ADS-B can help in remote locations. Special VFRs and letters of agreement would also be helpful.
  • Federal money should be committed to improving infrastructure. For example, the FAA could establish a Capstone II program in Alaska, but very small carriers will need help with funding.
  • We need more pilot information reports to validate radar returns and polar satellites, and to fill in the gaps of weather station coverage.
  • Operators and pilots should better use air traffic control services.

We at the NTSB are committed to doing our part to improve Part 135 safety. Currently, the FAA does not apply the same requirements to Part 135 operators as it does to Part 121 commercial airlines. We believe that, regardless of the purpose of flight, one thing is for sure: all flights should be safe. But we don’t have to wait for the FAA to regulate; we know that operators can—and should—make the appropriate changes.

Perhaps the most significant takeaway and critical action suggested at the roundtable—upon which the entire group agreed—was related to the need for one group, organization, or entity to focus on flight operation safety issues in Alaska. I agree. FAA Administrator Stephen Dickson has also indicated that this concept of a “single focal point” in Alaska may be worthwhile. It looks like the time to act is now.

We greatly appreciate all the experts who came to this event and participated in our vigorous discussion. We are convinced that this roundtable will lead to life-saving improvements in Alaska that will then serve as models for the rest of the world.

This event would not have been successful without the dedicated NTSB staff who worked tirelessly to plan and execute it, and the great participation of the panelists.

Thanks for all for the contributions!

For more details on this event, including participants and agenda, or to learn more about Part 135 safety, watch the event recording and see our event web page.

Remembering Captain Al Haynes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

This past Sunday, August 25, 2019, Captain Al Haynes died a week shy of his 88th birthday. Captain Haynes was a remarkable pilot who, 30 years ago last month, brought United Airlines flight 232 to an emergency landing in Sioux City, Iowa, with no means of control except the ability to vary the thrust produced by the airplane’s two engines (the DC-10’s third engine had experienced an uncontained engine failure). Although 111 passengers ultimately perished in the accident, the actions of Captain Haynes and the other crewmembers saved the lives of 184 others on the flight.

The sequence of events started when the airplane’s central engine in the tail failed, sending heavy, high-speed shrapnel spraying through the rear of the airplane. The shrapnel cut all three of the airplane’s hydraulic lines and all hydraulic pressure was lost. This left no way for the pilots to control the airplane—at least, no way intentionally designed for that purpose. Hydraulic pressure was needed to move the airplane’s control surfaces and allow it to turn, climb or descend in response to pilot input, and to configure the airplane for landing by extending the flaps.

After the engine failure, the airplane started banking to the right and its nose dropped. The crew tried to stop the bank and bring the nose up, but the airplane did not respond. The only controls that worked were the throttles for the remaining two engines, one on each wing. By varying how much power each engine produced—that is, applying differential thrust—the pilots were able to stop the turn and bring the airplane level.

The plane pulled right, and slowly oscillated vertically in what is called a phugoid cycle, losing approximately 1,500 feet of altitude with each cycle. Among the passengers on the flight was Captain Dennis Fitch, a United pilot and training check airman, who came to the cockpit and offered Captain Haynes any help that he could provide. Captain Haynes welcomed Captain Fitch’s help.

Captain Fitch began to apply differential thrust, and that way, regained some control of the airplane. He was able to minimize the phugoid and gain some directional control, although the airplane could only turn to the right. The decision was made to make an emergency landing at the airport in Sioux City, Iowa.

The crew was able to use differential thrust alone to control the airplane’s direction of travel and descent, and line up the DC-10 with the runway. But, with no hydraulics, the flaps could not be extended. When the DC-10 was designed and approved, the total loss of hydraulic-powered flight controls was considered so unlikely that there was no need to develop and approve a procedure to deal with such a situation. Because flaps control both the minimum required airspeed and sink rate, however, the flight 232 crew could control neither.

Just prior to landing, the airplane was going 220 knots and descending at 1,850 feet per minute, well above the normal targets of 140 knots and a 300-feet-per-minute descent. As the plane touched down, the right wing tip hit the runway first, and the plane began to break up and catch fire, ultimately resulting in the fatalities of 111 people. For 184 others, Captain Haynes and his flight crew are credited with their improbable deliverance from an unlikely accident cause.

In our investigation of this accident, we pointed out that the interaction of the pilots, including the check airman, during the emergency showed the value of crew resource management (CRM – then known as cockpit resource management) training, which had been practiced at United Airlines for a decade. Ten years before the United flight 232 accident, we recommended that CRM training be required for all airline flight crews.

Flight simulator reenactments of the accident airplane’s flight profile carried out as part of our investigation revealed that it was virtually impossible to control all parameters simultaneously needed to land safely at a predetermined point. After observing the performance of a control group of DC-l0-qualified pilots in the simulator, we concluded that Captain Haynes’s damaged DC-10 airplane, although flyable, could not have been successfully landed on a runway after the loss of all hydraulic flight controls, and that, under the circumstances, United flight 232’s flightcrew reacted commendably and beyond reasonable expectations.

But the benefits of CRM training were clear. The flight crew, lead by Captain Haynes, used CRM to deal with a situation considered so unlikely that there were no procedures or training on how to respond. When talking about the accident later, Captain Haynes said, “If I hadn’t used CRM, if we had not let everybody put their input in, it’s a cinch we wouldn’t have made it.”

Although he always denied that he was a hero, Captain Haynes was the right man at the right time for an event considered to be so unlikely that it was virtually impossible. Thirty years after that accident, and mere days after Captain Haynes’s death, we at the NTSB remember how his CRM practice saved over half the people on United flight 232. Aviation is safer the world over thanks to Captain Haynes.

Safe Skies for Africa Ends, but the Safety Journey Continues

By: Nicholas Worrell, Chief, Office of Safety Advocacy

August 2019 Safe Skies for Africa symposium, Lagos, Nigeria
NTSB staff and attendees at the Safe Skies for Africa symposium in Lagos, Nigeria

After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at the time. Administered by the US Department of Transportation and funded by the US State Department, the SSFA program has accomplished many of its original objectives since inception, including improving the safety and security of aviation on the African continent. Over a dozen symposia and workshops have been held over the life of the program, and we organized past SSFA symposia with the South Africa Civil Aviation Authority and Kenya’s Air Accident Investigation Department. This year’s event was hosted by the Air Investigation Bureau-Nigeria (AIB-N), who also sent a team of accident investigators and industry representative to participate.

Former NTSB Managing Director (and program pioneer) Dennis Jones spent nearly 20 years in the SSFA program, participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators. In his opinion, the Safe Skies program has done what it was created to do. At the outset of the program, few African airlines and hardly any US airlines were flying to Africa, even though it’s the world’s second-largest continent. Today, two US carriers provide direct service to Africa, and six African countries (Egypt, Ethiopia, South Africa, Morocco, Cape Verde, and Kenya) have direct routes to the United States.

Along with increased US commercial air service to Africa, air investigation quality has improved, resulting in a lower accident rate and greater safety in commercial aviation in Africa. Many African nations now have their own accident investigation agencies, and some are even developing multimodal agencies based on the NTSB model.

We were honored to again join other NTSB communications specialists and experts, as well as former NTSB Managing Director Dennis Jones, for the final symposium. The symposium focused on the following topics:

  • The NTSB’s background and history
  • Emerging aviation safety issues
  • The investigative process and human factors
  • Accident classification and substantial damage
  • Helicopter operations
  • The challenges of providing family assistance
  • Effective safety advocacy: creating positive change in transportation safety

Our team shared lessons learned from NTSB accident investigations, as well as strategies to help our international counterparts take steps in their own aviation safety journey. The AIB-N participants were focused and receptive to our presentations, and the event was bittersweet as we parted ways with old colleagues and brought the program to a close.

Although the SSFA program has resulted in many improvements over its 21 years, more remains to be done. Safe and reliable aviation connects people all over the world, in more ways than you may realize. Aircraft components, engines, and airframes come from manufacturers all over the world. The airplanes they comprise might be flown by airlines in any country. We are all stakeholders in aviation safety, regardless of what continent we inhabit.

We look forward to more programs like SSFA that will advance international collaboration on aviation safety issues. I’m confident that new safety ambassadors will follow in the footsteps of those who participated in the SSFA program, and I look forward to working with the pioneers who participate in these programs going forward.

For our blogs on the other NTSB SSFA symposia in South Africa and Kenya, please see links below:

https://safetycompass.wordpress.com/2018/08/09/ntsb-supports-safe-skies-for-africa-initiative/

https://safetycompass.wordpress.com/2018/10/01/another-step-toward-safer-skies-in-africa/

 

Why We Care When Things Go Right

By Lorenda Ward, Sr. Investigator-In-Charge, NTSB Office of Aviation Safety

As an investigator-in-charge (IIC) at the National Transportation Safety Board (NTSB), part of my job is to launch to aviation accident scenes. When my team and I arrive at the scene of an accident, we come prepared to uncover the sequence of events that led to the accident—whether it was weather, human factors, or a problem with the plane’s structure, systems, or engines. It’s the NTSB’s responsibility to find out what occurred and provide recommendations to prevent future accidents.

When we investigate an accident, we don’t only look for the things that went wrong, but we also look for those that went right. Sometimes these “rights” ensure the accident didn’t become an even greater tragedy, and sharing them can help crewmembers and operators in the future ensure the safest flight possible. A good example of this is a recent accident we investigated in Michigan.

On March 8, 2017, an Ameristar Charters Boeing MD-83 ran off the end of the runway during a high-speed rejected takeoff at Ypsilanti Airport in Michigan. The plane was scheduled to carry 6 crewmembers and 110 passengers to Washington, DC—among them, the University of Michigan men’s basketball team, cheerleaders, band, coaches, and some parents. Fortunately, no one was killed, though some passengers sustained minor injuries.

March 8, 2017, Ypsilanti, Michigan, runway overrun during rejected takeoff
Rear view of accident scene

I led the small team that was launched to the accident site. On scene, we found that the right geared tab of the elevator flight control system had become jammed. Our investigation showed that this occurred during a strong windstorm that struck the area while the aircraft was parked at Ypsilanti Airport prior to the flight.

Seconds after the captain tried to “pitch,” or rotate, the airplane’s nose up, he quickly realized that the airplane was not going to get airborne. At that time, the airplane was traveling at a speed of 158 mph and was about 5,000 feet down the 7,500-foot runway. Because the elevator was jammed in the airplane nose-down position, no matter how far back the captain pulled the yoke, the nose refused to pitch up. The captain quickly called to abort the takeoff, but the plane was traveling too fast to be stopped on the remaining runway. It departed the end of the runway at about 115 mph, traveled 950 feet across a runway safety area, struck an airport fence, and came to rest after crossing a paved road.

Our investigation determined that the flight crew had completed all preflight checks appropriately, including a flight control test, and found no anomalies before initiating the takeoff. Furthermore, we determined that there was no way the pilot checks could have detected the flight control jam.

It’s important to note that, not only did the captain appropriately reject the takeoff once he felt the airplane was not able to fly, but the check airman did not try to countermand the rejected takeoff. And after the plane came to a rest, the cabin crew also followed procedures to coordinate a careful, safe passenger evacuation.

Also essential to the safe outcome was the fact that the passengers followed the crew’s instructions, so everyone got off quickly without any serious injuries. Unfortunately, too many times, we see passengers delay an evacuation by ignoring crew instructions to, say, retrieve their luggage.

Although the accident airplane crashed through a perimeter fence and crossed a road before coming to a stop, an extended runway safety area that was added to Ypsilanti airport between 2006 and 2009 allowed the airplane plenty of room and time to come to rest safely. This expansion was part of a national program started by the Federal Aviation Administration in 1999 in response to an NTSB recommendation to add runway safety areas to many commercial airports.

Our investigative team learned that three critical factors—things done “right”— helped prevent this accident from becoming a tragedy, in which numerous lives could have been lost:

1) The captain’s quick response

2) The crew’s adherence to procedures, which resulted in a quick and efficient evacuation

3) The addition of a compliant runway safety area

After 20-plus years of investigating accidents, it’s refreshing to me to see an accident in which more things went right than wrong, and where people lived to tell the tale because of good decision making. These cases don’t normally get a lot of attention, but it’s important for us to understand and report out all our findings—even the good—because we see lessons there, too.

I encourage everyone to read the full Ypsilanti report. A link to the accident docket and related news releases are also available at https://www.ntsb.gov/investigations/pages/2017-ypsilanti-mi.aspx.

When an Aircraft Goes Missing

By Mike Hodges, Air Safety Investigator, NTSB Office of Aviation Safety

On August 9, 2008, a privately-owned Cessna 182E airplane was reported overdue near Juneau, Alaska. The NTSB immediately started monitoring search efforts being conducted by the US Coast Guard, the Alaska State Troopers, the Civil Air Patrol, and a host of good Samaritans. The search area was expansive and included remote inland fjords, coastal waterways, and steep mountainous terrain. In an effort to start gathering information that was potentially relevant to the accident, we interviewed other pilots flying in the area, as well as Federal Aviation Administration (FAA) Flight Service Station personnel to better understand weather conditions at the time the airplane disappeared. After an extensive but unsuccessful search, search-and-rescue activities were suspended on August 20, 2008.

For all aviation accidents such as this one, when initial search-and-rescue activities are suspended and no wreckage is found, the NTSB issues a preliminary report, available to the public in an aviation accident database that can be accessed through our website. If the wreckage is not located within 180 days from the initial date of disappearance, we complete a final report with a probable cause statement of “undetermined.” The final report includes all pertinent information that was initially gathered at the time the aircraft was reported missing. If the wreckage is eventually located after the initial 180 days, we reopen and complete the investigation.

On October 25, 2017, I was the on-call air safety investigator for the NTSB Alaska Regional Office. Alaska State Troopers notified me that a deer hunter had discovered airplane wreckage on Admiralty Island, about 15 miles south of Juneau, Alaska. We eventually determined that it was the missing Cessna 182E. So, 9 years after the airplane went missing, we reopened the case.

In Juneau, I met with an aviation safety inspector from the FAA, an Alaska State Trooper, and members of Juneau Mountain Rescue. As with most remote aircraft accidents in Alaska, traveling to the scene requires an airplane or helicopter because there are no roads. The NTSB chartered a commercial, float-equipped Cessna 206 airplane, and we flew to Young Lake on Admiralty Island in the Tongass National Forest—the largest intact temperate rainforest in the world.

Flying to Young Lake near the accident site
Flying to Young Lake near the accident site

As an air safety investigator working in Alaska, I often face unique challenges, whether it’s a hike to a remote area to reach an accident site or a wildlife encounter. In this case, after arriving at the northern end of Young Lake, we hiked nearly 2 miles to the accident site, each of us carrying either firearms or bear spray because of the large population of brown bears on the island. We also carried satellite phones because there’s no cell phone reception in the area. The wreckage was in densely‑forested, steep mountainous terrain a little over a mile northwest of the north end of Young Lake, at an elevation of about 1,075 ft. mean sea level. The average tree height at the accident site was about 100 ft.

Landing on Young Lake
Landing on Young Lake

When we arrived at the site, the FAA aviation safety inspector and I documented and examined the wreckage. The cockpit and fuselage were destroyed by a postimpact fire. The wreckage of the missing airplane was confirmed via the serial number located on the airframe data plate. Time and nature had taken their toll—the heavily corroded wreckage was covered with dirt, fungus, leaves, and branches. The Alaska State Trooper recovered the remains of the two occupants.

View of the wreckage
View of the wreckage

Once the investigative and recovery activities were completed, we hiked back to Young Lake, contacted the commercial aviation operator for pickup, and returned to Juneau. Because the location was so remote, the wreckage was not recovered.

NTSB Air Safety Investigator Mike Hodges
Mike Hodges using a satellite phone at Young Lake to provide an update to NTSB leadership

On-scene activity is just one part of our investigative process. In each investigation, we look at the roles of the human, the machine, and the environment. By learning about the factors that cause an accident, we can make recommendations to prevent similar accidents in the future. In this investigation, I reviewed the airplane’s maintenance records, considered the pilot’s aviation training and medical records, and examined meteorological and topographical data for the accident area. As a result of the investigation, the NTSB determined that the probable cause of the accident was the pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. The pilot’s self‑induced pressure to complete the flight also contributed to the crash. The final accident report can be viewed here.

If you ever happen to come across aircraft wreckage—or what you think is aircraft wreckage—no matter how old it appears to be, please notify local law enforcement and the NTSB Response Operations Center in Washington, DC. If you’re able, please provide latitude and longitude coordinates of the wreckage location, along with photographs of what you found. The NTSB can then continue investigating what happened, which can help prevent future accidents from occurring. Also, importantly, family and friends of those who died in the accident may be interested in the new information. If you ever have the chance to visit the NTSB Training Center in Ashburn, Virginia, you will see an etched window on the front of the building that states the building is dedicated to the victims of transportation accidents and their families. The display also summarizes the NTSB’s crucial work of improving transportation safety for our great nation: “from tragedy we draw knowledge to improve the safety of us all.”

NTSB Training Center display

When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

MWL06s_Part135

Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.