Business Aviation Accidents Offer Lifesaving Lessons Learned

Nov. 9, 2022 – Piper PA-46-500 Meridian, Near Bignell, NE, 2 Fatalities

NTSB probable cause: “The pilot’s flight into low instrument flight rules conditions and turbulence, which resulted in spatial disorientation, loss of control, and an impact with terrain. Contributing to the accident was the pilot’s lack of total instrument experience.”

Investigators found the pilot had purchased the high-performance turboprop single about three weeks prior to the accident and received approximately 15 hours of transition training. That included one hour in IMC as part of the pilot’s reported total of 5.2 hours in actual instrument flight time.

Kimberly P. Coryat, safety chair for the Piper M-Class Owners and Pilots Association (PMOPA), said the pilot may have falsely believed his recently acquired airplane would be able to compensate for his lack of experience.

“This is one of those accidents that strikes me as falling under the heading of ‘illusory superiority,’” Coryat said. “The pilot was in an airplane that was marginally unsuitable for his experience level, and in weather that was definitely unsuitable for his skill level. The 25,000-hour ATP who was behind him on approach noted that the conditions of flight were extremely challenging.”

The NTSB also determined the pilot had received a weather briefing 2.5 hours prior to departure, with no evidence of receiving further updates. “The pilot reviewed the TAF [terminal area forecast] in his briefing, expecting MVFR conditions to prevail at his expected time of arrival,” the board’s final report said.

However, data gathered along the flight route indicated low IFR conditions on the approach to the destination airport with low visibility, localized areas of freezing precipitation, low-level turbulence and wind shear. Coryat noted those conditions are ripe for possible spatial disorientation, particularly during a go-around in a high-performance airplane.

“The left-turning forces and rapid pitch-up of the nose, plus perhaps an incorrect response to these forces, and a human’s vestibular system can start providing conflicting information, resulting in spatial disorientation that can easily tumble,” Coryat said.

“The pilot had so little total flight time, so little Meridian time and so little instrument time that it saddens me to think he felt competent to deal with that weather,” she added. “This serves as a stark reminder of the need to promote developing personal minimums… and banging the drum of adherence to them.”

Dec. 15, 2022 – Beechcraft King Air C90A, Near Kaupo, HI, 3 Fatalities

NTSB probable cause: The operator’s “inadequate pilot training and performance tracking, which failed to identify and correct the pilot’s consistent lack of skill, and which resulted in the pilot’s inability to maintain his position inflight using secondary instruments …. [C]ontributing to the accident was the lack of a visible horizon during dark night overwater conditions….”

The pilot’s reactions to losing the primary electric attitude director indicator (EADI) and autopilot highlights the impact of human factors – including panic, distraction and pressure to retrieve a medical patient – on the decision-making process. However, a series of “unsatisfactory” training ratings in the pilot’s record likely point to a larger issue.

“This appears to be a classic Swiss cheese model scenario,” said Norman Gionet, CAM, a member of the Human Factors Working Group of the NBAA Safety Committee. “Everything lined up: weak training, equipment failure at night and he was alone” on the flight deck.

The NTSB noted the pilot had failed three of six scheduled checkrides with the operator on his first attempts. Each time, the pilot retested and was marked “satisfactory.” That followed six Notices of Disapproval in the pilot’s FAA record in both fixed-wing and rotorcraft, citing “consistent deficiencies in the use of navigational systems, instruments and multiengine aircraft maneuvering.”

A review of an onboard camera system showed the pilot on the accident flight using his cell phone to listen to music after departure, and later interacting with the two medical personnel onboard, both violations of the operator’s standard operating procedures. It also revealed the King Air’s multifunction flight display was out of service for the accident flight, as well as four prior flights.

The failed EADI and autopilot also meant the aircraft would have been unable to legally transport the patient. “They were flying a compromised aircraft with a compromised pilot,” Gionet said. “That really leads back to [the operator’s] culture. Add just one more problem to the mix, or three or four, and it’s just a matter of time before it goes wrong.

“The FAA requires training on what I think of as the ‘big’ things,” said Gionet. “Engine failures, V1 cuts, unusual attitudes, etc. All those are incredibly important, of course, but we also need to think about the more subtle failures, and that includes recognizing our own limits. We have the responsibility to call ourselves out when we may be unsuited for a particular flight, for any reason.”

March 3, 2023 – Bombardier Challenger 300, Over Windsor Locks, CT, 1 Fatality

NTSB probable cause: “The flight crew’s failure to remove the right side pitot probe cover before flight, their decision to depart with a no-go advisory message following an aborted takeoff, and their selection of the incorrect non-normal checklist inflight, which resulted in an in-flight upset that exceeded the maneuvering load factor limitations of the airplane and resulted in fatal injuries to a passenger whose seatbelt was not fastened.”

Norman “DQ” Dequier, director of flight operations for Aviation Performance Solutions, noted this accident would not have occurred had the flight crew followed their company’s standard operating procedures following the initial aborted takeoff.

“The NTSB noted that SOP was to ground the airplane and report the issue,” Dequier said. “Even if they’d shut down the aircraft and then powered it back up, it would have resolved the fault that created the issue that was not allowing the trim system to function properly.”

The error chain continued to build, however, with the NTSB citing as contributing factors, “the pilot-in-command’s (PIC) decision to continue the climb and use the autopilot while troubleshooting the non-normal situation, and the PIC’s pilot-induced oscillations following the autopilot disconnecting from the out-of-trim condition.”

While this accident is another example of a series of related factors lining up toward an unfortunate outcome, Dequier homed in on the crew’s response to the sudden loss of control inflight as the most significant issue.

“People may have a tendency to say the upset wouldn’t have ever happened had the crew not made these other mistakes,” Dequier said. “The truth is there are many potential causes that can put the airplane into an unexpected attitude, where the crew must then know how to react properly. In this case, their reactions created a loss of control.

“We have so many mitigations, all intended to reduce the probability of accidents,” said Dequier. “Despite all our SOPs, technology, regulations and efforts, upsets will still catch pilots unaware unless they are trained properly in how to respond to such situations – and how not to make them worse.”*

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