Last week, the NTSB sent a team of investigators to Atlanta to investigate a Delta Air Lines Boeing 757 that experienced an engine fire shortly after take-off. The captain, who noticed the problem just as the airplane climbed past 3,000 feet, made a successful single-engine landing and the 170 passengers evacuated via the airplane’s emergency slides.
Most people associate the NTSB with catastrophic plane crashes—ones where numerous people are killed and the aircraft is destroyed. Photos of our investigators at accident scenes that are referred to as “smoking holes” are becoming rare when it comes to commercial operations Fortunately, the event in Atlanta last week was far from a tragic scenario. In fact, when the evacuation was completed, there were only three minor injuries.
So, why did NTSB send a team to Atlanta? Commercial carriers must report to the NTSB any uncontained failures or fires like this one. Our investigators want to find out what happened with that engine so that in the future, they won’t have to investigate the same kind of failure resulting in a smoking hole. Right now, we have no idea what we will find. The engine fire may have been the consequence of a design flaw, a manufacturing glitch, or a maintenance discrepancy that could occur again. And, another occurrence may not end as well.
Our investigators routinely investigate these kinds of events. Right now, we are investigating why an Airbus 320 experienced an electrical failure in the cockpit right after take-off from New Orleans in April. We are also looking at a Boeing 757 that ran off the runway in Jackson Hole last December. Neither of these events resulted in fatalities or catastrophic aircraft damage, but they still have a very important safety story to tell. These investigations are the best ones we do, because they keep us from being called to another smoking hole.
Last Friday, I gave a presentation at the Pilatus Owners and Pilots Association (POPA), the organization, or “type club,” for people who fly Pilatus airplanes. Pilatus is a leading manufacturer of single-engine turboprop aircraft, notably the PC-12.
My talk focused on weather, in particular icing. NTSB investigators see proof again and again that flying in icing conditions can be deadly. Different aircraft are equipped with different ways to combat inflight icing, but there is one defense that applies to all pilots of all aircraft, whether GA or commercial: training. Pilots should be able to detect changes in performance of their aircraft as icing develops. Pilots should hand-fly the airplane frequently to have a continuous understanding of what the icing is doing to the airplane and to avoid having the autopilot mask controllability degredation. They should know how to monitor and maintain appropriate icing speeds. They should train for stalls and approach to stalls with and without ice protections systems and be aware that the airplane with ice on the wings and tail can stall at angles that are as little as half those of a clean airplane. This can be a very nasty surprise to find oneself in a fully developed stall. Preparation and training are key to safe flight, particularly in icing conditions.
Which brings me to my second point. Membership and participation in type clubs can be extremely valuable for pilots in maintaining their knowledge and skills in flying. Many type clubs host discussion forums, publish magazines, and keep libraries of technical information. Many clubs are great about keeping members informed about service issues and can be a resource for all kinds of information about restoring, maintaining, and operating specific types of aircraft.
No matter what type of aircraft you own, operate, or maintain, chances are there is a type club for you. Check it out. I belong to a type club for pilots of Bonanza airplanes. Maybe I’ll see you at an upcoming meeting. Here’s a link to a talk I gave last year at the American Bonanza Society:
Earl F. Weener, Ph.D., took the oath of office as a Member of the National Transportation Safety Board on June 30, 2010. Dr. Weener is a licensed pilot and flight instructor who has dedicated his entire career to the field of aviation safety.
This week the Board met to consider the June 9, 2009, crash involving a New Mexico State Police (NMSP) helicopter conducting a search and rescue mission outside Santa Fe. The pilot and the lost hiker who was rescued both died and the spotter was injured in the accident. The investigation determined the pilot made inappropriate decisions in an increasingly risky situation. Just as importantly, the investigation uncovered an organizational culture that failed to prioritize safety over accomplishing the mission and permitted unnecessary risk.
That accident was two years ago. Since then the NMSP and its personnel have persevered through a difficult and trying time, responding positively to the lessons learned from this tragedy, and making many changes to improve their procedures and culture.
Here are some of the improvements NMSP has already made:
Incorporating the Airborne Law Enforcement Association standards
Implementing a Safety Management System approach to operations
Equipping their new helicopter with improved radios and flight tracking equipment
Instituting a Tactical Flight Officer program
Increasing pilot staffing
Equipping their aircrew with survival vests and personal locator beacons
And the list goes on. I commend the leadership and staff of the NMSP for their responsiveness and commitment to embrace these necessary changes. I hope that the lessons learned from this accident are recognized by others that conduct similar operations. At the NTSB, we recognize the important work of search and rescue teams across the nation — our goal is to make sure that everyone gets back safely, especially the men and women charged with conducting these important missions.
When I tell people about my work, I’m frequently asked about airline safety. Many recall major NTSB investigations, such as the TWA Flight 800 crash off Long Island, the American Airlines Flight 587 crash in New York City, or more recently, the Continental Flight 3407 accident outside Buffalo. Such tragedies — with their large loss of life — leave lasting impressions. Yet, most of the hundreds of aviation-related deaths each year occur in general aviation (GA) accidents.
GA is the term for flying that is neither airlines nor military. It includes a wide variety of aircraft, such as single-engine planes, floatplanes, helicopters, and business jets and turboprops. These usually smaller aircraft are often used for leisure trips, business trips, sightseeing, agricultural applications, emergency medical purposes, flight training, search and rescue, traffic reporting and many other uses. The pilots range from professionals earning a living flying to individuals with simply a passion for flying.
We are hearing a lot this week about the loss of separation between an Air National Guard Boeing 737, with First Lady Michelle Obama on board, and a military cargo plane near Andrews AFB. Fortunately, the error was caught, and corrections were made to prevent the 737 from encountering wake vortices from the cargo plane. Last January, a significant loss of separation occurred between a Boeing 777 bound for Brazil and two military C-17s just outside New York. At their closest, the aircraft were only separated by one mile.
“Loss of separation” occurs when the space — vertically or horizontally — between two airborne aircraft falls below the minimum allowable. Modern commercial and military aircraft are equipped with collision avoidance alerts from their Traffic Alert and Collision Avoidance System, or “TCAS.” These alarms sound inside the cockpit to warn flight crews about a possible collision in the air. The vast majority of these conflicts are resolved quickly, and passengers are never even aware of the event. Once in a while, the conflict is more serious and an aircraft must take sudden evasive action.
Domestic airline operators have racked up a remarkable safety record in the past two years. Large commercial transport aircraft experienced not a single fatal accident during this period – a welcome trend for commercial operations. I wish I could say the same for general aviation (GA). Sadly, in the recent ten day period from March 25th through April 3rd, ten fatal accidents occured involving GA light airplanes, ranging from a Cessna 150 to a Beechcraft Baron. That’s a rate of an accident per day, and just reflects the fatal accidents. Generally, there are five to six times as many accidents that do not involve fatalities but result in substantial damage or injuries, or both.
A soon-to-be-released NTSB statistical study of aircraft accidents from 2007 through 2009 will show the accident rate for Part 91 flying as essentially flat from 2000 through 2009. There were approximately 6 accidents per 100,000 flight hours, with about 1 in 6 of those accidents involving fatalities. This statistic includes both corporate and on-demand air taxi operations, which have accident rates approaching those of the commercial airlines. These operators, like the commercial operators, are to be congratulated on their safety record. However, as I pointed out, this is not the case for all Part 91 operations.