NTSB Boss Urges Focus on Safety

 - November 30, 2007, 11:28 AM

While corporate aviation has an enviable safety record, one comparable to that of the airlines, some flight departments operate on a shoestring budget with inadequately experienced or trained crews or shoddy maintenance practices, according to NTSB chairman Mark Rosenker.

Speaking at this year’s Safety Standdown Seminar in Wichita, he touched on flight crew and mechanic training, preflight preparation, human fatigue and maintenance issues. Then he turned his attention to pilot professionalism and urged attendees not to confuse professionalism with getting paid to fly.

Having admonished business aviation, Rosenker then recounted three airline accidents in which flight crews failed to perform their duties to an acceptable level of professionalism. Although all three were FAR Part 121 regional operations, one was operating under Part 91 for a positioning flight.

“My colleagues on the Board and I are disturbed that all three of these accidents–and several others in business aviation during this same period–have involved a less than professional approach to airmanship,” he said. “Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts and precise compliance with SOPs and regulations, including sterile-cockpit compliance.”

In October 2004, a Bombardier CRJ operated by Pinnacle Airlines crashed on a Part 91 positioning flight. The NTSB determined the probable cause of the accident to be, in part, “the pilots’ unprofessional behavior, deviation from standard operating procedures and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover.”

The following week, a Jetstream turboprop, doing business as a scheduled Part 121 flight, crashed on approach into Kirksville, Mo. The CFIT accident claimed 13 lives. The probable-cause statement cited the pilots’ unprofessional behavior during the flight.

Three months ago, the Safety Board deliberated on the 2006 Comair regional jet accident in Lexington, Ky., in which the crew took off from the wrong runway, killing all but one of the 50 people aboard. The NTSB concluded that non-adherence to FARs, company procedures and checklist discipline set the stage for the accident.

“By the way, in spite of the cues that the Comair crew had when taxiing for takeoff, we recommended that all Part 91K, 121 and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for takeoff,” Rosenker told the group. “I mention this because even with all of the information provided to pilots via cockpit display, publications and air traffic controllers, the final line of defense is you, the pilot.”

Two years ago, a Cessna Citation 560, operated for Circuit City executives, crashed near Pueblo, Colo., while on an instrument approach. The two pilots and six passengers on board were killed. The flight was operating under Part 91. The NTSB determined that the probable cause was the flight crew’s failure to effectively monitor and maintain airspeed and comply with procedures for de-ice boot activation on the approach, which caused a stall from which they did not recover.

“From that accident, we recommended that the FAA require that operational training in the Cessna 560 emphasize the airplane flight manual requirements that pilots increase the airspeed and operate the de-ice boots during approaches when ice is present on the wings; and that the FAA require that all pilot-training programs be modified to contain modules that teach and emphasize monitoring skills and workload management,” said Rosenker. “These recommendations are indicative of the Safety Board’s concern that training deficiencies in corporate flight departments can lead to tragic circumstances.”

He added, “You can build, buy and fly the most advanced whiz-bang, go-fast airplanes, but if you’re not adequately trained on using the hardware, all those advancements mean little.”

Lapses in Business Aviation
Rosenker said that inadequate preflight preparation can lead to an unhappy ending “and our files are too full with these types of accident.” For example, in February 2005 a Challenger ran off the departure end of Runway 6 at Teterboro Airport at a groundspeed of about 110 knots, through an airport perimeter fence, across a six-lane highway and into a parking lot before coming to rest in a building. The two pilots were seriously injured. The cabin aide, eight passengers and one person in the building received minor injuries.

The accident flight was an on-demand Part 135 passenger charter flight. The Safety Board determined the probable cause to be the pilots’ failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended speed.

Two years later, a CitationJet departed controlled flight and hit the ground while attempting to land back at the Van Nuys Airport in California. The Part 91 positioning flight was en route to pick up paying passengers, and the two professional pilots on board were killed.

Witnesses reported that during the preflight the copilot loaded bags into the left front baggage compartment, but they did not see him latch or lock it. A few minutes later, the airplane was started up, taxied out and took off. Witnesses at the end of the runway said that the baggage door was open as the airplane was climbing about 200 feet above the ground, and they said it was “slow.”

One of the pilots radioed that they wanted to return to Van Nuys. The witnesses saw the airplane turn slightly left, descend, turn steeply to the right and hit the ground. Examination of the front left baggage door indicated that the key mechanism was in the unlocked position. “If some of you are cutting corners on your preflight preparation out of complacency, or to please your passengers, then you are playing with fire,” Rosenker warned.

As an example of what can happen if a pilot is fatigued, Rosenker cited an air-ambulance positioning flight that departed from Wichita on Feb. 17, 2004, en route to Dodge City, Kan. The airplane was a King Air and the pilot had been awake for 21 hours. Radar data indicated that the airplane entered a gradual, straight-line descent toward the Dodge City Regional Airport, but flew past the airport before descending into the ground.

The pilot made no communication with ATC during the descent. The pilot, flight nurse and flight paramedic were killed. The NTSB determined that the probable cause was the pilot’s failure to maintain clearance from terrain due to pilot’s lack of sleep.

The NTSB chairman noted that his agency’s “Most Wanted List” of safety issues addresses runway incursions, the need for cockpit resource management for Part 135 operators and fatigue involving pilots and mechanics. “How well maintenance is handled in corporate flight departments is as important as the quality of the pilots, and I am very pleased to see that this year’s Safety Standdown includes the issue of maintenance,” he added.

Rosenker concluded, “It seems that even though the airplanes that you all fly and maintain have gotten more advanced over the years, and even though the requirements for the certification of the hardware have gotten more stringent over the years, the biggest killer of corporate airplanes continues to be human failure, not unlike other forms of transportation.”