Flight Safety Detectives

A fatal midair collision involving a Cessna 172 illustrates several aviation safety concerns related to pilot training in and around airports with commercial operations. The incident involved a student and instructor on board performing touch-and-go landings and a Dash 8 departing on a passenger flight.

While the event happened in Kenya, the circumstances that led to this accident could happen in any location where airliners and small training aircraft operate out of the same airport. In this case, the midair collision occurred only about 500 feet above the ground and 1500 feet below a broken cloud layer in an area with over 10 km of visibility.

The Cessna 172 was performing touch-and-go landings on from one of the airport's runways. Shortly after the Dash 8 departed from an intersecting runway, the stabilizer of the airliner collided with the Cessna. The Cessna crashed, killing both on board. Todd Curtis and John Goglia analyze the preliminary report, which came out three months after the accident. 

They examine the transcript of ATC communications around the time of the accident. Anyone who operates aircraft in similar circumstances could learn something useful from studying this event.

Immediately after the collision, the transcript of the ATC communications stated that during 97 seconds, there was "unrelated transmission from other traffic." Any transmissions to or from aircraft near the collision could provide useful clues into what was known or not known by ATC and aircraft crews in the vicinity. 

Related document is available at the Flight Safety Detectives website.

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Boeing should use a third-party organization that would act on behalf of the FAA to monitor the design and production of its aircraft. That’s the proposal of special guest and Kilroy Aviation CEO Mike Borfitz published in a June 28, 2024 editorial in Aviation Daily.

This kind of oversight had been provided in the past by Boeing employees who acted as the eyes and ears of the FAA. The process is based on FAA regulations created in 2005 that allowed manufacturers to create Organization Designation Authorizations (ODAs), groups of employees who were paid by the manufacturer and who worked for the FAA. 

The effectiveness of this organizational setup for Boeing was questioned in the wake of the 737 MAX crashes in 2018 and 2019. Borfitz's proposal would address the weaknesses of the previous setup by having a third-party organization outside of Boeing's control act as Boeing's ODA. This would make it more likely that concerning issues would be brought to the attention of the FAA.

This episode includes a wide-ranging discussion of how aircraft are certified to FAA standards. Todd Curtis and Borfitz, both of whom worked for Boeing when the company merged with McDonnell Douglas, relate that the merger led high-level Boeing managers to focus more on shareholder value.

Borfitz expresses his belief that the current Department of Justice sanctions against Boeing that require an independent monitor to oversee compliance and safety for three years would be ineffective because it allows Boeing to return to its previous management policies in three years.

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Hypoxia is a significant danger in aviation and an insidious killer of passengers and pilots. Special guest Miles O'Brien hosts a discussion with aviation experts Todd Curtis, Greg Feith, and John Goglia that covers how hypoxia impacts all forms of aviation. They discuss personal experiences with hypoxia and share insights from several hypoxia-related accidents.

Hypoxia is a condition where the human body is deprived of oxygen which can reduce mental function. Hypoxia can be particularly hazardous for pilots because someone experiencing hypoxia may not be aware of its symptoms or its effects on their performance.

One high-profile incident in 1999 took the life to golfer Payne Stewart. He was a passenger in a Learjet 35 that took off from Orlando Executive Airport and became non-responsive to air traffic control. Fighter jets intercepted the plane and determined the crew was unconscious. After 1500 miles the jet ran out of fuel and crashed over South Dakota. 

Greg, Todd, Miles, and John have all experienced hypoxia in controlled altitude chambers. They share their experiences, which include feelings of euphoria, reduced mental capacity, reduced physical performance, and even a case of high-altitude bends. 

Key to understanding hypoxia is the concept of time of useful consciousness, which is the amount of time a person can spend at altitude without feeling the effects of hypoxia. That period of time gets smaller as altitude increases. Age, stress, and other factors may shorten those times.

Related documents are at the Flight Safety Detectives website.

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Planes that experience turbulence in flight are getting a lot of headline attention lately. During one widely covered incident of turbulence in May 2024 a passenger aboard a Singapore Airlines flight was killed.

Serious turbulence leading to injuries is not uncommon. Todd Curtis and John Goglia discuss several notable in-flight turbulence events, including the death of 1950s era test pilot Scott Crossfield.

Specific and useful information about turbulence conditions is often not readily available. However, pilots can avoid turbulence, either by adjusting the planned flight to miss major areas of turbulence or by deciding not to take off if the risks are high.

Airline passengers also have a role in dealing with turbulence dangers. Seatbelts and keeping items stowed in flight minimize the risks in bumpy conditions.

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As Boeing continues to be the subject of investigations and congressional hearings the concept of criminalization has come to the forefront. This could have a devastating impact on aviation safety in the U.S. Special guest and aviation attorney Mark Dombroff focuses on efforts to criminalize the investigation of aviation accidents and incidents. 

The effort to use criminal prosecutions to address aviation safety issues in the U.S. would dramatically impact the process of getting to the facts, including making witnesses more reluctant to come forward with details. Criminalizing will make the safety investigation process more difficult and less effective.

While some in the legal community favor criminalization, it is not the approach used in most of the world. Aviation accident investigation focuses on understanding what happened and how to prevent similar events in the future. A criminal investigation would shift the goals to assigning blame and handing out punishment. 

Several notable past investigations came up during the discussion, including a fatal 2006 midair collision in Brazil involving a 737 and a corporate jet. The corporate jet pilots were detained in Brazil for several months and threatened with prosecution for almost 18 years. When TWA Flight 800 crashed, there was tension over whether the FBI or the NTSB would conduct the investigation. 

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Missing equipment and inexperience led to a plane crash that killed 3. Precipitation, turbulence, and icing were factors in the crash of a Piper PA-30 Comanche in Oklahoma. The pilot did not have an instrument certification and was not able to handle the conditions.

The pilot had a private pilot and multiengine rating but did not have instrument training. Todd Curtis, Miles O’Brien, and John Goglia discuss what may have driven the pilot to fly into deteriorating weather. “Getting there” seems to have been the focus rather than planning and preparation.

The pilot was cruising at about 8,500 feet and climbed to as high as 16,500 feet. While the aircraft could provide supplemental oxygen, the equipment to use that system was not on board.

The pilot likely climbed to escape a storm. He flew to an altitude where supplemental oxygen was required. The plane crashed and all 3 people on board were killed.

Related Documents are available at the Flight Safety Detectives website.

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The fatal crash of Hughes 369 helicopter being used to trim trees has a backstory that gives insight into what went wrong. This workhorse of a helicopter apparently had damage from previous incidents.

The NTSB investigation found cracks in an engine mount that were likely present before the crash. John Goglia and Todd Curtis look beyond the fatal accident and share three previous investigations involving this helicopter. Two involved a crash with serious structural damage or a hard landing. These events may have stressed the engine mounts. 

The fatal crash happened when the helicopter was in use for an operation that used a large 10-bladed saw to trim trees close to power lines. The helicopter went into a spin and low altitude and crashed, killing the pilot. 

This episode highlights the importance of knowing an aircraft's history. Studying previous events involving a particular aircraft could reveal issues that should be inspected more closely or more frequently. The required 100-hour and 300-hour inspections were completed for the helicopter at the center of this discussion. However, additional inspections would have been smart given the previous accident history of the helicopter.

Related documents are found at the Flight Safety Detectives website.

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Training flight gone wrong! An examination of a February 2024 accident that involved an unstable approach, a tail strike, and a near collision with an airplane hanger.

Both the instructor and student involved in the Cessna 172 accident survived. Their account of the event provides insights into how a routine training flight turned into a near disaster. The instructor's decision-making created a dangerous situation.

Shortly before landing, ATC redirected the aircraft to a much shorter runway, and the instructor allowed the student to bring in the aircraft too high and too fast. The instructor then allowed the student to land instead executing a missed approach.

After the student put the aircraft on the runway and braked hard enough to lock the brakes, the instructor took control of the aircraft, continued to apply brakes and pulled back on the control column hard enough to cause a tail strike.

The instructor turned onto a taxiway near the end of the runway and took off again, barely missing a nearby hanger. Fortunately, the instructor was able to land the damaged aircraft.

The Australian authorities reference FAA criteria for a stabilized approach in the accident report. The detectives share anecdotes that reinforce the importance of judging whether an approach is stable and being consistent with landing procedures.

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The crew of a United Airlines 727 tried to turn back shortly after takeoff from Los Angeles, but did not make it back to the airport. The plane crashed into the Pacific Ocean.

Greg Feith, Todd Curtis, and John Goglia discuss the crash of the 727-22QC in 1969. Electrical failures and electrical system design contributed to the plane crash. The accident happened on a night with limited visibility due to the weather.

The aircraft had three electrical generators, but only two were working. Shortly after takeoff, the crew shut down one engine due to a fire warning. That move shut down one of the two working generators.

John discusses the complexities of 727 electrical systems and other aircraft of the era. The NTSB found that total power loss occurred after all the electrical loads were placed on the one remaining generator.

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Oil and oxygen don’t mix on airplanes. A crew doing maintenance on the Air Force One oxygen system ignored safety procedures resulting in $4 million dollars of damage the plane.

The damage was caused by maintenance activity on the oxygen system of a U.S. Air Force VC-25A, a 747 aircraft that regularly flies the President of the United States. This event occurred in 2016.

John Goglia and Todd Curtis share evidence that crew did not follow the VC-25A's aircraft maintenance manual procedures for cleaning the tools, parts, and components before performing leak checks on the oxygen system. 

This is perhaps the highest profile incident of an aircraft damaged due to improper oxygen system maintenance procedures. John notes that failure to follow procedures is the FAA's top cause for maintenance problems in commercial aviation.

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