Flight Safety Detectives

The first fatal HondaJet accident just occurred. Greg Feith and John Goglia go over the known facts of the air crash in Mesa, Arizona on November 5. 

The jet ran off the runway and struck a car on a nearby road, killing the driver and four of the five people on board the jet. They draw similarities with a 2014 takeoff accident involving a Gulfstream jet near Boston. 

Poor preflight preparation may be the biggest contributor to this deadly event. Greg and John share the simple tests and steps that can be the difference between a successful and a fatal flight. 

Greg and John also discuss Greg's recent recognition from the National Aeronautic Association. Greg was named a 2023 Distinguished Statesmen of Aviation.

Greg and John finished the episode with a discussion of the show's newest advertiser, Piston Power, and how their various options for managing routine and non-routine repairs may benefit an aircraft owner.

They also welcome a new sponsor - PistonPower™. The company offers general aviation’s first and only Unscheduled and Power-by-the-Hour programs for piston aircraft. Designed by aviation pros who’ve designed and built similar programs for turbine engines, PistonPower™ brings stability to your maintenance budget and peace of mind to your business and personal flying.  

No Risk. No Surprises. Stabilize Your Maintenance Budget!

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A U.S. Army UH-1 Huey helicopter survived the perils of Vietnam but came to a disastrous end in West Virginia. The 1962 helicopter crashed after its engine failed, killing the pilot and five passengers.

The 2022 crash happened during an annual event that offers visitors an opportunity to fly either as passengers or as a second pilot. This helicopter was a warbird--a former military aircraft operating as a civil aircraft. It was operated under a special airworthiness certificate in the experimental category.

Although the pilot in command had flown this same helicopter at the annual event in the previous two years, he had logged only 21 hours of flying experience in that helicopter. One of the five passengers was a helicopter pilot who had paid to operate the helicopter during the flight. 

About 15 minutes into the flight, the engine failed. The helicopter struck power lines and a rock face before crashing and catching fire. The NTSB could not determine if the pilot in command or the helicopter-rated passenger attempted the emergency landing.

Despite the number of people killed in warbird crashes, it is unlikely the FAA will make major changes in how it oversees operators of these types of flights because of the relatively small number of operators. John and Todd share thoughts on what these operators can do to ensure safety.

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Flight Safety Detectives host John Goglia will be inducted into the National Aviation Hall of Fame, a rare accomplishment in aviation. John is the first person whose career was focused on aviation maintenance to be selected. John Goglia and Todd Curtis talk about the honor before diving into a recent drone accident in Boston that injured two people. 

The drone crash occurred in downtown Boston during the taping of the TNT show "Inside the NBA." The drone crashed into a pole and fell, injuring people in the crowd. The drone flight would likely have had a FAA exemption to allow a flight both near crowds of people and close to Boston's Logan Airport.

Todd and John also discuss John's recent visit to the NBAA (National Business Aviation Association) exhibition in Las Vegas. John saw many of the companies and technologies behind the vertical takeoff and landing aircraft associated with advanced air mobility (AAM) companies like Joby. The FAA has just released regulations related to the commercial use of such aircraft.

Todd and John talk about the potential for AAM operations in the U.S. They discuss several possible issues might slow adoption.

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A fatal Piper PA-28-300 plane crash was caused by a loose fuel line that should never have been installed on the aircraft. The NTSB investigation of the fatal May 2018 crash shows that a fuel line that was not approved for use on that aircraft led to an engine fire. 

Todd Curtis and John Goglia examine the details. Although the fuel line used was an approved aviation part, it was not approved for use in this aircraft. The NTSB could not determine who installed the part or when it was installed.

Approved parts used in unapproved ways is an ongoing issue in aviation. Some individuals in the general aviation community even promote the use of auto parts instead of more expensive approved aviation parts.

John, who worked on FAA committees on the issue of unapproved parts in the 1980s, has seen many unapproved part issues with several major airlines. The FAA began requiring more documentation for aircraft parts in the 1990s, but the problem persists.

The accident pilot was aware that the engine had issues. Before the flight, the pilot told a CFI that he would perform an engine runup and take off only if the runup was successful. 

This accident involved pilot decision-making under uncertainty concerning whether to take off with an engine problem. This kind of issue happens at all levels of aviation. The fatal crash of an Alaska Airlines MD83 in 2000 is just another example.

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Another flight training accident, another lacking NTSB report. Todd Curtis, Greg Feith, and John Goglia discuss the NTSB report of a fatal June 2021 flight training accident near Indianapolis that lacks useful details or analysis.

The accident aircraft was Diamond DA40 with an instructor and student on board. The instructor had received a CFI certification about nine weeks before the accident. Most of the instructor's 329 hours of flight experience were with the same make and model of aircraft.

The accident sequence began with a stall that turned into a spin. A certified CFI must demonstrate the ability to recover from a spin. The airplane flight manual included specific instructions for spin recovery.

The NTSB recreated the accident sequence using a data card from the airplane and it showed that proper spin recovery techniques were not used. What was much less clear was how the CFI reacted in the situation.

The NTSB did not investigate the training of the CFI, the procedures used by the flight training organization, or the experience other students had with the CFI. There are not enough facts or insights in the report to make it useful to the aviation community.

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Aviation around the world changed as a result of the fatal accident involving Air Canada Flight 797. The investigation led to massive changes to the materials inside the cabins of commercial aircraft.

On June 2, 1983, the DC9-32 on a routine flight from Dallas to Toronto had an inflight smoke event that led to an emergency landing in Cincinnati. As the passengers and crew began evacuating the aircraft, a flash fire in the cabin created heat and toxic smoke that killed 23 of the 46 occupants.

The NTSB investigation revealed that the fire caused the release of dangerous levels of toxic chemicals and gases from the materials used inside the cabin. This finding led to a systematic transition to new fire-blocking materials. John Goglia shares his role in replacing materials on aircraft he maintained.

This accident also led to the requirement for smoke detectors in lavatories. It also led to the use of air-driven flush motors in lavatories, rather than electrical flush motors.

Related documents are available at the Flight Safety Detectives website.

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Two recent Cirrus accidents killed a total of seven people. Greg Feith, John Goglia and Todd Curtis have some advice for Cirrus pilots to avoid similar tragedies. They caution newer technology supports, but is not a replacement for, good planning and pilot decision-making.

One accident at Kill Devil Hills airport in North Carolina, killed four adults and one child. Another, in Provo, Utah airport killed both occupants.

The Kill Devil Hills aircraft apparently had the maximum possible number of occupants. Todd shares his experiences flying with a heavily loaded aircraft and how weight impacts safe flight practices. 

Kill Devil Hills Airport has a relatively short runway. Planning and maintaining a stabilized approach, making adjustments for trees and towers, and factoring in weather conditions all need consideration when planning to take off and land there.

Accident investigators are urged to look into the specific training the pilot had for this Cirrus model.

In the Utah flight, the aircraft may have entered an accelerated stall and crashed during a second approach shortly after turning from the downwind leg to the base leg.

Like the first accident, ADS-B data indicated that the accident aircraft did not recently land at the accident airport. The pilot’s lack of familiarity and planning may be key factors in the crash.

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Fight instructor-related accidents and check ride failures at all levels of certificates and ratings are on the rise. Why? Insights are hard to come by. 

The report on a February 24, 2024 fatal training flight in South Africa that killed the student pilot and the instructor does nothing to help that issue. The Flight Safety Detectives’ analysis of the document finds a lack of any insightful analysis of the factors that led to the fatal crash. 

There are no useful insights or lessons that could benefit aviation safety. Any accident investigation has to provide some kind of aviation safety benefit, and this investigation did not meet that standard.

The flight involved a pre-solo student. The training manual may have included things not normally taught to a pre-solo student. Based on eyewitness testimony, the aircraft had a low and fast approach, followed by a wingover maneuver. The report does not answer the basic question of whether it was the student or instructor at the controls.

Greg Feith points out key factual evidence not analyzed or explained in the report. Todd Curtis calls for more details about the flight instructor and the flight school. John Goglia surmises that the report was written by someone without an aviation operations background. 

Greg, who sits on the National Association of Flight Instructors (NAFI) board of directors, encourages the audience to attend the upcoming NAFI national safety summit, https://nafisummit.org/. The summit will address concerns over the quality of flight training.

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A second-in-command pilot left the cockpit and either jumped or fell out of an open rear cargo door of a CASA 212 aircraft flying over North Carolina. Digging into the details reveals he was self-medicating for anxiety and he may have been overcome by agitation during flight.

In this 2022 event, the main landing gear was damaged when the plane that was supporting sky diving tried to land. The crew diverted to a larger airport for a second landing attempt. During that diversion, the second in command was visibly upset. He left the cockpit and either intentionally or accidentally left the aircraft, falling to his death.

During the investigation, the NTSB found that this pilot was known to be a perfectionist who was hard on himself regarding his performance as a pilot. 

The toxicological tests indicated that the pilot who died has mitragynine in his system, which is associated with the drug Kratom. The Food and Drug Administration has not approved Kratom for any use, and the Drug Enforcement Agency has identified Kratom as a drug of concern. Internal FAA policy considers its use disqualifying for pilots. 

The probable cause for this event does not say anything about the role of Kratom or mental health issues. Addressing mental health in aviation is part of a larger societal problem that should be addressed. Aviation professionals don't have the incentive to get treatment for mental health issues because coming forward could end their career.

Related documents are available at the Flight Safety Detectives website.

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The preliminary accident report on the August 9, 2024 crash of a Voepass ATR72 near Sao Paolo, Brazil has just been issued. John Goglia, Todd Curtis and Greg Feith apply their expertise to examine the findings and critical aviation safety issues.

The report has detailed facts, including a summary of the flight, but several key pieces of information are missing. One big issue – no detailed transcript of what was said in the cockpit during the flight.

The report focuses on the aircraft's deicing and anti-icing systems, including its apparent malfunctions. This system was first activated after the crew received an alert from the aircraft's ice detection system, and was turned off less than a minute later. 

The crew did not react appropriately after turning off the deicing system warning. Rather than leaving the altitude where the icing was occurring or disengaging the autopilot, the crew did neither.

Based on the portions of the crew's conversation during the flight in the report, John concludes that the crew was not paying enough attention to flying the airplane. They did not address warnings from the aircraft.

There is a potential conflict of interest that may impede getting all the details of this accident. The Brazilian Air Force runs CENIPA, the aviation accident investigative authority, and the Brazilian air traffic control organization. Greg and John share their firsthand experiences with investigators dealing with outside influences using the example of the 1994 Roselawn, Indiana ATR72 accident.

Key takeaway here: pilots, especially professional pilots, need to educate themselves about how icing affects their aircraft.

Related documents are available at the Flight Safety Detectives website.

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