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Lessons Learned from Business Aviation Accidents

“This accident was not unusual.”

Each of the following industry safety experts expressed this sentiment while providing their insights and takeaways from the NTSB reports in three high-profile fatal accidents involving business aircraft. This reinforces the continued need for business aviation professionals to heed lessons from such accidents in order to avoid repeating the same mistakes.

May 15, 2017 – Learjet 35A near New Jersey’s Teterboro Airport (TEB) – Two Fatalities

NTSB Probable Cause: “The pilot-in-command’s (PIC) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude. Contributing to the accident was the PIC’s decision to allow an unapproved second-in-command to act as pilot flying, the PIC’s inadequate and incomplete preflight planning, and the flight crew’s lack of an approach briefing.

“Also contributing to the accident [was the operator’s] lack of safety programs that would have enabled the company to identify and correct patterns of poor performance…”

FAA Safety Team Member Jeff Wofford, chair of the NBAA Safety Committee and the NBAA Professionalism Working Group and aviation director and chief pilot at Commscope, noted “multiple opportunities” where this accident could have been prevented, with the primary issues revolving around improper decision-making, not only by the flight crew, but also the operator.

“The company paired a captain with known performance issues with a first officer (FO) with known deficiencies,” said Wofford. “The second error was made by the captain, when he breached company policy by allowing the FO to fly the airplane when he was rated by the company as only allowed to fly with a company instructor pilot.”

Cockpit recordings indicated the captain was angered by air traffic control routing for the short repositioning flight from Philadelphia.

“The anger issue was certainly part of the reason that he was distracted and did not fly the procedure as depicted,” Wofford said.

“The final issue was allowing the FO to continue to fly in challenging conditions when the FO had made several comments about his reservations to continue.”

Operators bear ultimate responsibility to ensure pilots are trained and competent in their positions and aircraft, Wofford emphasized. Developing a flight operations manual and effective standard operating practices (“and following them!”) and frequent proficiency checks can be key to ensuring experienced pilots set the right example for new hires.

“Known deficiencies in any crew member need to be addressed,” he continued. “Entry-level pilots must be trained to a certain performance standard and then paired with a more experienced pilot to gain the additional experience that qualifies them to operate as an effective crew member. This fell very short of the mark with this crew.

“And last, but certainly not least,” Wofford concluded, “be professional! Build an effective safety culture and a good, just culture! Do things the right way. With a good safety and just culture, and a constant, companywide emphasis on professional behavior, this type of accident would not happen.”

June 30, 2019 – Textron Aviation Beechcraft King Air 350 at Texas’ Addison Airport (ADS) – 10 Fatalities

NTSB Probable Cause: “The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff…. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.”

“When we look at an egregious accident like this, it is easy to believe that it is an outlier, with few lessons that could apply to ‘our’ flying,” said Randy Brooks, vice president of training and business development for Aviation Performance Solutions (APS). “’Flight discipline,’ as defined by Dr. Tony Kern, is something that can be supported and nurtured, but ultimately is incumbent upon each individual aviator.”

Brooks cited “ample examples” indicating such discipline wasn’t practiced in the minutes leading up to the accident. “There was not a call for checklists that would typically be used before takeoff,” he noted, “and there was no indicated discussion of what they would do in the case of a loss of engine thrust on takeoff or any other emergency procedure.

“There was also a known risk that engine power levers could move without pilot intent if the friction lock was not appropriately adjusted,” Brooks continued, “yet this was one of several items on the pre-takeoff checklist that were not audibly performed.”

Lack of discipline extended to the flight deck environment between the 71-year-old pilot in command (PIC) and the non-type rated 28-year-old right seater. “The second-in-command was not allowed by the PIC to operate the flight controls when passengers were on board,” Brooks noted. “That made it unlikely that the SIC would feel empowered to intervene if needed during an emergency.”

While Brooks admitted that “recovery from this type of developed cross-control stall encounter at the altitude at which it was encountered is highly unlikely,” he also noted the lack of any requirement for angle-of-attack or sideslip data in many non-Part 121 aircraft simulators, including the King Air 350. Such data could have provided invaluable information to the pilots.

“Demonstration of these characteristics – and how to prevent them – are fundamental to comprehensive upset prevention and recovery training at safe altitudes in an aircraft with an appropriate margin of safety,” he added.

Jan. 26, 2020 – Sikorsky S-76B Near Calabasas, CA – Nine Fatalities

NTSB Probable Cause: “The pilot’s decision to continue flight under visual flight rules into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control.” Contributing factors included “the pilot’s likely self-induced pressure” to continue the flight and the operator’s “inadequate review and oversight of its safety management processes.”

Multiple persons interviewed by NTSB noted that the accident pilot prided himself on providing reliable and timely service for his high-profile passenger, NBA basketball star Kobe Bryant.

“The more important the passenger, or the more dire the patient’s condition on an ambulance flight, the more self-imposed pressure will exist for the crew,” noted Michael Ott, FRAeS, a member of the NBAA Safety Committee and director, program operations at Phoenix Air Group.

Company management must provide an environment in which flight crews can say “no” when conditions are unfavorable, he added. The FAA addressed the matter of self-induced pressure on aeronautical decision-making in Advisory Circular 60-22, which was issued more than 30 years ago.

“No manager would ever have wanted the pilot to do what he did in this accident,” Ott continued. He further noted the company’s training should have also required instrument training, given frequent fog in the Los Angeles Basin, even though its certificate was only for VFR operations.

“The pilot could still have overcome the unintended entry into instrument conditions and climbed safely into visual conditions,” added Ott. “Most importantly, if the company had a safety culture that encouraged employees to stop any activity that appeared to create an unsafe working environment, the pilot might have felt less pressure to complete the flight.”

Culture is a key consideration, Ott emphasized, as employees will emulate behaviors rewarded by management.

“If management promotes, praises and gives the best assignments to the people who ‘always accomplish the mission,’ then employees will strive to meet that standard,” he said. “If, however, management provides greater rewards to employees who make great safety decisions, employees will strive to meet that standard, as well.”

A safety management system provides important guidance in building such a culture.

“An effective SMS would have caught one or more of these issues,” Ott concluded, “by increasing the steps that management would take to protect its crews from the pressures associated with such a flight.”

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