Learn Lessons from Past Mishaps
Robert Breiling, head of the half-century-old Boca Raton, Florida, safety consulting firm that bears his name, just shakes his head when he reviews the causes of recent accidents and incidents. It’s the same story, different day. “Fifty percent of all business aircraft mishaps still occur during approach and landing.”
The proportion of landing accidents, relative to other phases of flight, actually has increased, Breiling notes. That’s primarily due to a plunge in the percentage of accidents between the final approach fix and runway threshold because of the availability of vertical guidance on more ILS, WAAS and FMS approach procedures.
What galls Breiling is the apparent lack of attention on the part of many pilots to the root causes. “Nothing is being done about it. There also has been a marked increase in single-pilot, owner-flown landing accidents in single-engine turboprops and light jets.”
Breiling’s point is that if people don’t study accident, incident and air safety history, drilling down into the root causes of these events, they’re then destined to repeat the same errors. He’s especially concerned by the single-pilot, owner-operator demographic as it has experienced a disproportionately large increase in accidents in recent years.
Owner-flown high-performance turboprops, such as TBM 700-series aircraft, are involved in a relatively large percentage of loss-of-control accidents, many involving stalls during landing and takeoff, resulting in a sudden, sharp wing drop and subsequent ground strike. Low ceilings and visibility were factors in a significant number of accidents. Use of prescription drugs, known to impair judgment and mental acuity, also was a factor in a significant number of single turboprop fatal accidents. Breiling says, however, that considerably fewer Pilatus PC-12 aircraft are involved in such mishaps, perhaps because a larger percentage of these single-engine turboprops are professionally crewed rather than owner-flown. Single-pilot twin turboprops also suffer a significant number of loss-of-control accidents, runway light misidentification causing off-pavement landings, CFIT mishaps and inadequate pre-flight of fuel quantity remaining. Breiling believes that many of the accidents involving N-registered airplanes are the result of the FAA’s not requiring aircraft type-specific pilot training and qualification in most light generation aviation turboprops. “The exception is the Mitsubishi MU-2. When the FAA created a Special Federal Aviation Regulation that required type-specific qualification and recurrency training, the accident rate dropped to near zero.”
Mishap patterns also emerge for turbofan aircraft. Learjet operators, for instance, appear to have more than their share of altitude busts, based upon looking at FAA Aviation Safety Report System data. Gulfstream IV-series pilots seem to be involved in a notable number of runway excursions. In general, business jets are involved in a disproportionate number of altitude deviations caused by pilot input error, FMS database anomalies or lack of proficiency with high-level automation.
Aviation Safety Reporting System
The FAA’s Aviation Safety Reporting System (ASRS) evolved because its safety team realized that, regardless of the development of new technologies, there would be no substantive improvement in accident, incident and violation rates without operators, pilots and air traffic controllers volunteering to provide critical information about inadvertent human errors and lapses in judgment. Historically, the FAA, along with other government agencies, had a tendency to group such honest mistakes with deliberate criminal wrongdoing. While the individual who made the error might have learned from the mistake, the aviation community, as a whole, couldn’t learn from the event because it was kept secret for fear of retribution.
By developing the ASRS, the FAA acquired a means of collecting, analyzing and acting on reports in a non-punitive manner so that others could learn from individual mistakes. Air traffic controllers, maintainers and ground service providers also can file ASRS reports, thereby contributing to the body of knowledge used to help pilots avoid unnecessary risks, to make improvements to the airspace system and to correct maintenance procedures on the ground.
There are a variety of prepared reports available at the ASRS website, including altitude deviations, air traffic controller reports, records of bird or animal strikes, icing encounter reports and crew fatigue records. Reports also are available on CFIT, GPS problems, RNAV navigation and CRM issues, along with fuel management problems, near-midair collisions and runway incursions, plus upsets, special-use airspace penetrations and wake turbulence encounters.
The GPS report, for instance, shows a pattern of GPS signal disruption near the Mateo (SMO) VOR near Mexico City’s Benito Juarez Airport and also in eastern New Mexico near the White Sands Missile Range. Those snippets warn pilots to be wary of depending solely on GPS for IFR navigation in those areas, to fall back on VOR/DME, DME/DME and/or IRS navigation with appropriate adjustments to navigation performance requirements.
As another example, the RNAV report reveals a continuing pattern of pilots not being fully aware of the capabilities and limitations of FMSes. Certain approach procedures may not be contained in FMS databases, step-down fix altitude crossing restrictions may be missing and vertical guidance may not function as required by the published procedure. Such shortcomings prompt pilots to double check each waypoint and crossing altitudes associated with approach and departure procedures, to study and understand vertical navigation functions and to monitor closely the performance of the automation system to assure that lateral and vertical navigation guidance is in accordance with published procedures.
Few turbine business aircraft are involved in inadvertent special-use airspace incursions, according to ASRS reports. However, one Gulfstream V crew, departing Reagan Washington National Airport northbound, reported violating the P-56 prohibited airspace in Washington, D.C., surrounding the White House due to the lack of ATC issued departure procedures or knowledge of required avoidance procedures as contained in the Airport/Facility Directory Special Notices and as charted on the LAZIR FIVE RNAV departure procedure. A Hawker crew reported inadvertently violating a Presidential TFR around Martha’s Vineyard and landing at the airport without prior permission after departing a non-gateway airport.
ASRS is the accident safety equivalent of a canary in a coal mine. It provides early warning indications of safety risks that, if not checked, can develop into major or fatal accidents.
NTSB Aviation Accident/Incident Database
The NTSB provides one of the most-comprehensive online aircraft accident and incident databases of any reporting agency. It supports search queries including dates, places, aircraft and engine types, scheduled and non-scheduled certificated air carrier, and name of air carrier. These filters enabled business aircraft operators to identify risks associated with the aircraft they operate, the types of operations and procedures they typically fly, and the airports they frequent.
Search for accidents and incidents involving Gulfstream IV series aircraft, for example, and you’ll find several post-landing runway excursion mishaps. These events have occurred in the U.S., Canada, France and Africa, among other regions. The most-common themes in these mishaps are the apparent failure to stabilize the aircraft during landing approach, the apparent failure to execute a go-around or missed approach when it was not safe to land and the apparent willingness of the flight crew to attempt to land the aircraft in unsafe conditions.
The NTSB database also indicates a significant number of maintenance-related issues that caused or contributed to GIV-series accidents or incidents, plus a few instances of flight crews failing to conduct thorough preflight inspections. Case in point: One mishap occurred when a crew, before departing on a mission, forgot to reconnect the nosewheel gear linkage after the aircraft was towed.
Search for mishaps around certain airports and many trends become apparent. Teterboro, for example, experiences plenty of challenging weather conditions, gusting crosswinds and contaminated runway conditions. GIV-series aircraft, among other types of turbofan business aircraft, have been involved in several runway excursions when pilots attempted to land there. Few of these mishaps resulted in fatalities, but several caused major aircraft damage.
NTSB data alerts operators to a significant uptick in accidents in older Learjets, high-performance light jets that now can be purchased for well under $1 million but still require top-notch pilot proficiency skills. On Nov. 9, 2014, for example, a Learjet 35A descended more than 1,200 ft. below the 1,349-ft. glideslope intercept altitude at the outer marker on a second ILS approach to Runway 06 at Freeport’s Grand Bahama International Airport, as the crew attempted to land the aircraft visually in hard rain and obscured visibility conditions. The aircraft struck a crane in a shipyard at 115 ft. AGL, shearing off part of the right wing and fuel tank and causing the aircraft to crash into a garbage mound at a recycling plant next to the shipyard, about 1.9 mi. short of the runway. Both pilots and seven passengers were killed.
In November 2013, the crew of a 1979 Learjet 35, repositioning to Cozumel, Mexico, after a medevac flight from Costa Rica, departed Fort Lauderdale International Airport’s Runway 10L. At 2,200 ft. and 200 KIAS, the crew declared an emergency after the aircraft suffered an engine failure. ATC instructed the crew to fly northbound and climb to 4,000 ft. The crew said it was unable to comply and they attempted to return to the airport in VFR conditions. But the aircraft lost altitude and airspeed, crashing into the Atlantic Ocean at close to 150 KIAS according to ATC radar data. Both crewmembers perished as did a physician and flight nurse.
In December 2012, a 1969 Learjet 25, en route at night from Monterrey to Mexico City – Toluca, lost control at 28,700 ft., climbing to FL 370. It then plunged almost 23,000 ft., crashing into 6,766-ft. elevation mountainous terrain at an 89-deg. angle on Rancho El Tejocote due to undetermined causes. However, the aircraft did have a previous damage history and a record of vibration as airspeed increased to 265 KIAS or Mach 0.74. On at least one occasion, the crew thought the vibration was caused by the stall-warning stick shaker, but when they turned off the system, the vibration continued. Mexican accident investigators suspect that both the vibration and loss of control might have been caused by a horizontal stabilizer control malfunction, but at no time did the crew declare an emergency to air traffic controllers nor did they switch the transponder to squawk 7700.
In August 2008, a Learjet 23 crew attempted a short 25-nm night flight from Puebla, Mexico (MMPB) north to Tlaxcala (MMTA). But Tlaxcala had no runway or approach lights and thus was limited to daylight VFR operations. The crew misjudged their position and suffered a CFIT crash short of the runway in a nearby lake that claimed their lives.
In November 2007, a crew of a Brazilian-registered 1981 Learjet 35A departed São Paulo Campo de Marte Airport for a short hop eastward to Rio’s Santos Dumont Airport. On takeoff, the tower noted that the aircraft pitched up at a steep attitude and then rapidly rolled 90 deg. to the right. The aircraft continued its right turn, descending toward a residential area before rolling left and crashing into houses about 1 mi. from Campo de Marte. In addition to the two crew fatalities, six people on the ground were killed on the ground.
FAA Accident and Incident Data System (AIDS)
This is one of the most difficult databases to exploit because the FAA’s AIDS search engine isn’t user friendly and selection information is limited to report numbers, dates, operators and aircraft types. The FAA says this is an accident and incident database, but the records contain only incidents that didn’t result in major aircraft damage. Most reports are generated both by operators’ maintenance or defect reports and by FAA Form 8020-23 aircraft accident or incident reports.
Searches are limited to one aircraft manufacturer or model at one time. It’s not possible to search for the type of event, such as accident or incident, or the severity of accident damage. Clicking on a link brings up a brief history of the event. But when returning to the search results page the hyperlink doesn’t change color, so it’s easy to lose your place on the results page matrix.
In addition, there are numerous errors in the listings. For example, Dassault Aviation obviously does not manufacture Husky Aircraft. But, the Aviat-A-1B is listed as one of Dassault’s models. As another example, Falcon 10 aircraft are powered by TFE731 turbofans, not GE CF700 engines, the powerplants fitted to legacy Falcon 20 aircraft. Jets don’t create prop wash. Hurricanes don’t accompany snowstorms. Falcon 900 aircraft are not Falcon 50 aircraft, even though the larger jet is grandfathered on the original Falcon 50 type certificate.
Nonetheless, much can be learned from visiting this site. Of the more than 300 Falcon Jets incidents on file, for instance, there only are seven involving Falcon 50 series aircraft. There was only one record of an engine failure, an event that occurred when the center engine failed as the aircraft climbed through 9,000 ft. Lesser events include ruffling the control surface feathers of a Cessna CE421 Golden Eagle with jet blast when leaving the ramp of an FBO, a minor ground wingtip to wingtip collision and hail damage while an aircraft was en route from Broomfield, Colorado, to Oklahoma City.
Falcon 10 aircraft suffered a significant number of TFE731 engine failures, according to AIDS records. Most were handled without incident by proficient flight crews. Falcon 900 series aircraft also suffered a substantial number of TFE731 engine malfunctions, but none resulted in an aircraft accident.
Having excellent short-field capability, Dassault Falcon Jets can use general aviation airports with shorter runways than can some other large-cabin business aircraft. As a result, they may operate on narrow runways and taxiways and in close proximity to light aircraft, fences, unlighted obstacles and wildlife. Runway excursions are rare, according to AIDS records, but there have been several instances of bird or deer strikes, minor ground collisions and even a few general aviation aircraft that have been damaged by jet blast.
Big Picture and Context
It takes substantial time and effort to mine all available databases. To learn the lessons of history applicable to your flight operations, you need to retrieve and review accident and incident reports by aircraft type, by airport and by weather condition, among other variables. Sift through the reports and you’ll find where there are significant risks of engine and systems malfunctions, runway excursions, wildlife strikes and ground collisions.
Probe deeply into accident details and you’ll discover that pilots make fatal errors in judgment due to external pressures. Otherwise preventable accidents occurred when pilots “were dying to complete the flight” because of their perceptions of passenger expectations for mission success. Forensic investigation into the fatal accidents involving a GIV departing Bedford, Massachusetts, in May 2014, a GIV landing mishap at Le Castellet, France, in July 2012 and a GIV runway crash at Bukavu-Kavumu in the Democratic Republic of the Congo, among others, all appear to involve flight crews’ yielding to external pressures.
Studying accident and incident histories can help flight departments develop risk assessment and reduction toolkits. For instance, if you’re planning a flight into an airport that has a history of large-cabin aircraft runway excursions in wet and windy conditions, if you’re on a time-sensitive mission with key passengers aboard and if available runway length is an issue for the type of aircraft you operate, then you might want to carefully assess the risks associated with using that landing facility. The average age of the business aircraft fleet, particularly in the light and midsize segments, is getting older. Accident and incident reports clearly indicate that older aircraft are involved in more mishaps than newer aircraft. Pilot training, judgment and proficiency are factors, as are substandard maintenance practices. Pilots of older aircraft tend to miss more discrepancies on preflight inspection that result in mishaps, according to accident records.
In addition, Breiling notes that veteran captains with 10,000 to 15,000 logged hours, or more, may be susceptible to complacency regarding such risk factors, based upon his examination of accident reports. Having flown accident free for their entire careers, they may not appreciate that they’ve been extraordinarily lucky during their careers not to have suffered a mishap. A proactive approach to safety requires operators to be aware of specific aircraft type, airport, weather condition and external pressure risk factors. But the only sure way to avoid risks associated with past accidents and incidents is to study mishap history. The databases are available online at no cost to website visitors. Invest the time to learn from others’ past errors and misfortunes and you’ll substantially increase your immunity from suffering the same problems.
Courtesy: Business & Commercial Aviation, Feb 2, 2015: Study Accident and Incident History Data to Avoid Risk by Fred George