Let the Flyer Beware

 - July 1, 2021, 8:30 AM
A photo from the NTSB report on the AW139 that crashed in July 2019 in the Bahamas. (Photo: NTSB)

Recent accidents highlight a disturbing number of unqualified business aircraft operators. Billionaires and sports stars killed in private aircraft accidents get the headlines, but others are just as vulnerable. Rarely do the accident reports say the operator and flight crew did everything right. Rather, many reports offer statements that point to the organizational failures of a bad aircraft operator.

For example, the NTSB categorized the November 2015 crash of a Hawker 700 that killed nine people in Akron, Ohio, as “a disturbing accident after an unstable approach that raises serious questions about an operator’s procedures and culture.”

In the opening remarks of the public hearing into this accident, then NTSB chairman Christopher Hart said, “A traveler boards an on-demand charter flight with the assumption that these government and company protections are in effect. However, in the accident…we found a flight crew, a company, and FAA inspectors who fell short of their obligations in regard to safety.”

Hart went on to note that the company’s “casual attitude towards compliance and standards illustrates a disregard for operational safety, an attitude that likely led its pilots to believe that strict adherence to SOPs was not required.” He later added, “These companies must either improve their practices or close their doors. All companies have a responsibility to follow the regulations and actively manage safety in all facets of their operations.”

In aviation, there is a well-used playbook to carry out safe flight operations; the NTSB and industry leaders have long recognized the effectiveness of these modern safety systems and now encourage the adoption of safety management systems (SMS), flight data monitoring (FDM) programs, and other proactive safety programs.

NTSB “Most Wanted”

Both SMS and FDM are included as recommendations in the 2021/22 NTSB “Most Wanted” list of transportation safety improvements.

The NTSB called for the FAA to require and verify the effectiveness of SMS in all revenue-passenger-carrying aviation operations. This recommendation recognizes that an established SMS creates a culture aimed at making safety a top priority and reducing the risk of accidents.

To be effective an SMS must address safety policy, safety risk management, safety assurance, and safety promotion, according to the Safety Board. “SMS is not a book on the shelf. It is a management system that brings safety-conscious behavior to the forefront of an organization," noted NTSB member Michael Graham. "It starts at the highest levels and permeates throughout to all employees. Every day, every task.”

Since 2015, the FAA has required airlines operating under Part 121 to develop and implement an SMS to improve safety for the traveling public, yet it is not required for other revenue-passenger-carrying operations such as Part 135 charter flights.

According to the Air Charter Safety Foundation, of the 1,900 charter operators in the U.S., only 20 have been accepted into the FAA’s voluntary SMS program—approximately 1 percent of all Part 135 operators. Another 213 have applied, but once those operators are approved, they will still represent no more than about 10 percent of all charter companies.

Installation of flight data recorders (FDR) and establishing FDM programs also made the Most Wanted list. FDRs, also known as “black boxes,” are extremely helpful to investigators who are trying to piece together what happened during a crash. In the past, it was considered cost-prohibitive or technologically infeasible to install FDRs on many legacy airplanes and helicopters; these challenges have been overcome with the advent of lightweight recorders, which often will record flight parameters (data), video, or voice.

The NTSB believes that all charter and tour operators should not only install FDRs but also employ an FDM program. Accordingly, “these operators should also have programs in place that analyze the data derived from these devices. Recorders and flight data management programs would not only help investigators solve accidents, but they would also help aircraft operators prevent crashes in the first place by allowing crew actions to be evaluated regularly.” 

“Not learning from the past is a brutally expensive and dangerous way to run a flight operation,” said NTSB vice chairman Bruce Landsberg. “Through the analysis of past flights, flight data monitoring can catch errors before they have a chance to lead to accidents.” 

Charter Safety

Beyond the NTSB, other industry leaders such as Air Charter Safety Foundation (ACSF) president Bryan Burns are keenly interested in advancing air safety. He said his organization recommends "taking a holistic approach to safety, which includes a multi-layered approach.” According to Burns, the foundation of this approach to safe operations and controlling risk is an effective SMS that is routinely evaluated through an accredited aviation audit. These third-party audits can identify gaps or weaknesses within an organization’s safety enterprise.

As mentioned, an SMS is more than a “book on a shelf.” It is a living and breathing part of any safety system. The safety risk management and safety assurance elements of an SMS are fed with data. Data sources include employee hazard reports, supported through a just culture, and other safety programs such as FDM and the Aviation Safety Action Program (ASAP).

A just culture provides an atmosphere in which all staff are encouraged to provide—and feel comfortable providing—safety-related information. According to Burns, “ASAP is a system that encourages aviation staff to voluntarily report safety issues and events (without fear of reprisal), and then captures and aggregates data in to effectively report safety concerns.”

ACSF's organizational-based ASAP is a bright spot when it comes to Part 91/135 voluntary safety programs. It was originally designed for Part 135 charter operators and has now expanded to include several Part 91 operators. According to Burns, “the program is structured so ACSF, not the FAA or operator, shoulders 90 percent of the administrative burden.” Since its inception over six years ago, it has grown to include more than 200 participants—and Part 91 operators now make up over half of the total.

The foundation supports its members by providing education through training and access to safety programs, such as its ASAP program. According to Burns, “When it comes to safety, there’s no finish line.” Establishing and maintaining across-the-board safety measures requires constant vigilance and improvement. As it happens, many of our members need a pathway to safety…a starting point and some guidance.”  

Burns also provided insight into the state of SMS in business aviation circles. He added, “It may surprise you to know that half of the ACSF’s Part 135 and 91 members who join the ACSF’s ASAP program do not already have a robust SMS. And, as such, those operators will likely be caught off guard—especially in the Part 135 industry—when an SMS becomes required by the FAA in 2022.”

ACSF has recently created an SMS Tool that is available free of charge to its members. “From my experience, a true, active SMS solution can take up to three to five years to mature. It takes that amount of time to change the process, attitudes, and culture," said Burns. "The old way of doing things in-house no longer applies. So, the time to get started is now. That is why we created the ACSF SMS Tool—to provide a simple, easy-to-use software platform for their use. Plus, they can receive solid guidance from our staff on how to get started building out their SMS. Best-practice organizations also participate in an accredited audit program.”

Different Outcomes

Culling through NTSB reports—especially the “recommendations” section—provides a great opportunity to not only learn but also improve safety across the industry. SMS, FDM, and even safety audits are frequently mentioned in these reports.

In February 2021, the NTSB released the final report on the Sikorsky S-76 crash that killed Kobe Bryant, his daughter Gianna, and six others. In this crash, the pilot continued flight into IMC, became disoriented, lost control of the helicopter, and crashed.

Contributing to the accident, according to the NTSB, “was the pilot’s likely self-induced pressure and plan-continuation bias, which adversely affected his decision making.” The NTSB also determined that the operator’s inadequate review and oversight of its safety management process contributed to the crash.

In the final report, the NTSB issued four safety recommendations to the FAA and operator. These recommendations addressed preflight weather and risk planning, spatial disorientation, inflight decision making, the benefits of a mandatory SMS, and the benefits of FDM.

The NTSB determined that the operators did not fully implement its SMS program. The Board also noted that charter operators were not required by the FAA to have an SMS. The operator did use some SMS tools—it had a “book on the shelf”—but it did not perform any safety assurance evaluations, such as those to ensure the effectiveness of a flight risk analysis form. The NTSB concluded that had the operator been required to have an SMS, the FAA would have helped in implementing the program and provided additional oversight to ensure that it met the objectives of the program and enhance its ability to manage risks.

It also determined that an FDM program, integrated within an SMS, has the “potential to provide important information regarding pilot performance during flights, which may be particularly beneficial for operators that conduct single-pilot operations and thus have little opportunity to directly observe their pilots in the operational environment.” But, again, the FAA required neither an FDR nor FDM program for Part 135 operators.

In another report, a crash involved a Leonardo AW139 in the Bahamas. This flight, operated under Part 91, occurred in July 2019 and killed Chris Cline, a coal billionaire, and six others, including his daughter and two pilots. The primary focus of the investigation was the lack of oversight from the operator and a troubled training history for both the pilot in command (PIC) and the second in command (SIC)—issues that might have been identified by an accredited third-party audit.

In this case, the Part 91 operation supported Cline and his family with three business jets, one floatplane, and the AW139. The final report noted that the helicopter had been operated independently of the fixed-wing aircraft and managed by the PIC of the accident flight. The SIC was a contract pilot. According to the fixed-wing chief pilot, he had few interactions with the helicopter operation.

An NTSB Human Factors Group report revealed troubling information about both pilots’ initial and recurrent training on the AW139. Instructor notes pointed to marginal training performance, a lack of understanding of key aircraft systems, and poor CRM skills.

The accident PIC was faulted for a “lack of skills and knowledge” during initial training in 2017 and recurrent training in 2018. During 2018 recurrent training, “progressive training/checking was halted and changed to traditional FAR 61.58 [basic proficiency check] training due to the applicant not reaching the required proficiency and failed more items than required.”

In addition, the accident SIC had major issues with training. Instructors noted problems with CRM, automation management, and situational awareness, and indicated that the pilot could be easily overwhelmed with ATC and weather. As with the PIC, the SIC’s 2018 recurrent training was reverted to FAR 61.58 due to failures.

Modern business aircraft are complex machines that require a high level of organizational structure and formal programs to support safe operations. A common theme in these NTSB reports is a lack of commitment from the operator to create the organizational structure to provide adequate oversight and management of flight operations, training, standards, and compliance. SMS and programs such as FDM provide greater safety but require additional resources and funds. Resource-limited companies are problematic, and as ACSF’s Burns said, “When operators go rogue, it is driven by cost.”