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Lifesaving Takeaways From 3 Recent Business Aviation Accidents

Aviation safety experts offer critical lessons that can be learned from two fatal accidents and a collision between two airplanes.

Accidents remain an unfortunate reality in our industry, but they can also spur important discussions about business aviation operations.

As of March 2024, final probable cause reports had not been issued by NTSB on the following high-profile accidents involving business aircraft. However, even preliminary findings from investigations conducted by the NTSB can yield valuable lessons.

While it’s important to avoid drawing conclusions or veering toward speculation without knowing all the facts, “I think there is a cultural benefit to having these conversations,” said Randall Brooks, executive vice president for flight operations at Aviation Performance Solutions (APS).

“There can be some benefit having discussions that may even go beyond a particular instance, to considering things that will make them better and safer,” he added.

February 24, 2023

A Pilatus PC-12/45 air ambulance, N273SM, was substantially damaged when it was involved in an accident near Stagecoach, NV. The pilot and four passengers were fatally injured.

From the NTSB Preliminary Report: “The airplane … ascended to 18,900 ft msl before a left turn to a northeasterly heading was initiated. The airplane continued a northeasterly heading and had ascended to about 19,100 ft, before a descending right turn was observed at 2113:31. The data showed the airplane remained in a descending right turn until ADS-B contact was lost at 2114:01 at an altitude of about 11,100 ft msl.”

“The flight departed under instrument conditions, and the pilot was warned of some light to moderate turbulence and icing conditions enroute. All of those can lead to a loss of control inflight (LOC-I.)”

Warren Pittorie Co-Chair, Loss of Control-Inflight Working Group, NBAA Safety Committee

Warren Pittorie, co-chair of the Loss of Control-Inflight (LOC-I) Working Group of the NBAA Safety Committee, noted several factors relevant to this accident involving a nighttime medevac flight from Reno/Tahoe International Airport (RNO) over mountainous terrain to Salt Lake City, UT.

“The flight departed under instrument conditions,” Pittorie said, “and the pilot was warned of some light to moderate turbulence and icing conditions enroute. All of those can lead to a loss of control inflight (LOC-I.)”

“I’m always suspicious when there’s mountainous terrain nearby of what the winds were doing,” added NBAA Safety Committee member Scott Glaser, president and CEO of Aerospace Operations LLC. “Having done a significant amount of flying in mountainous areas, I know how quickly an aircraft attitude can be changed by weather in those conditions.”

Operating in nighttime IMC without a visible horizon can add stress for even experienced instrument pilots, Brooks noted. “Depending on which study you look at, between 90 and 94 percent of LOC-I accidents are in nighttime or IMC,” he said. “Life’s a bit different when you can’t look out the window.”

July 8, 2023

A Cessna Citation II, N819KR, was destroyed when it was involved in an accident while attempting to land at French Valley Airport (F70) near Murietta, CA.The two pilots and four passengers were fatally injured.

From the NTSB Prelim: “At 0335 [local], the automated weather observing system (AWOS) at F70 reported in part, clear sky and visibility of 10 statute miles (SM). At 0355, the reported weather was an overcast ceiling at 300 ft, and visibility of 3/4 SM. At 0411, reported weather showed the visibility had reduced to 1/2 SM and fog.”

After initially canceling IFR while approaching F70, the rapid decline in observed weather conditions due to coastal fog moving inland led the two-person flight crew to pick up another IFR clearance while approaching the non-towered airport.

“To switch from IFR to VFR, then back to IFR, you’re already setting yourself up for kind of an unstable approach,” Pittorie noted. “The flight crew went to minimums and didn’t have the airport in sight the first time, so they flew the published missed. Now, we can start to think about the pressure to complete the mission.”

“What we’ve found in training are pilots stating that throughout their career, in training or otherwise, they’ve never been asked to perform a low-level go-around in a turbine airplane. It’s an important tool to have in your toolbox.”

Scott Glaser NBAA Safety Committee Member, President/CEO of Aerospace Operations LLC

“What we’ve found in training, however,” Glaser continued, “are pilots stating that throughout their career, in training or otherwise, they’ve never been asked to perform a low-level go-around in a turbine airplane. It’s an important tool to have in your toolbox.”

Brooks also emphasized the importance of setting – and adhering to – personal minimums in such cases. “Did they have an alternate [airport]?” he said. “It doesn’t matter what the weather is reported; all that matters is what they saw when they got down to DA (decision altitude) and what they decided to do.

“For me, this invokes a discussion about professionalism,” Brooks added. “I don’t know exactly what was going on that in that cockpit, but professionalism requires us to establish personal minimums and adhere to those standards.”

October 24, 2023

A Raytheon Hawker 850XP, N269AA, was taking off on runway 22 at William P. Hobby Airport (HOU), Houston,TX, when its left wing collided with the vertical stabilizer of a Cessna Citation Mustang, N510HM, landing on runway 13R. No injuries reported.

From the NTSB Prelim: “The local controller had instructed the crew of N269AA to line up and wait (LUAW) on runway 22. The crew of N269AA said in a post-accident interview that they believed they heard that they were cleared for takeoff when they took off. The collision between the two airplanes occurred at the intersection of the two runways.”

“I have a laundry list of stuff that plays into this one. There’s a lot of little moving things that were all going on here.” ”

Randall Brooks Executive Vice President for Flight Operations at Aviation Performance Solutions

In addition to the added risks involved in concurrent operations to intersecting runways, the Hawker flight crew told investigators they were distracted by missing V-speeds displayed while taxiing to the runway. On the roll, the crew told the NTSB they had rudder bias and pitch trim alerts.

“That’s all taking their eyes from outside the aircraft and focusing their attention inside,” Brooks added. “Why did the Hawker continue this takeoff? That’s almost a separate issue from the collision.”

Pittorie, who has a doctorate in aeronautical sciences and human factors, highlighted the opportunity for flight departments to review their ground operations procedures. “Do you train for these types of failures on takeoff?” he asked. “If so, what’s the company policy? More than likely you should call for a rejected takeoff.

“Why do we often feel this need to rush?” Pittorie continued. “Why are you pushing past these alarms to take off in a potentially unsafe aircraft, and then – because you’re distracted – missing an incredibly important ATC instruction to stop on the runway?”

“Pilots need to know when to pump the brakes,” Glaser added. “This goes back to professionalism and recognizing when we’re task-saturated. Again, we’re goal oriented. We’re used to some level of multitasking on a regular basis, and we often get away with it. And then at some point, it bites us.”

While it may be easy to focus attention on one party involved in this accident, Brooks noted the importance that everyone remain vigilant when operating in the airport environment.

“Always look out for the other guy,” Brooks concluded. “We’ve had several close calls lately where a pilot saw another aircraft where it shouldn’t have been and called for an abort for the aircraft on the ground. Keep looking around, even on rollout.”

Review the work of NBAA’s Safety Committee at nbaa.org/safety.

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