Proactive Aviation Safety, Belatedly

Too many organizations get serious about aviation safety after the funerals for employees killed in chartered carrier crashes. Illinois State University (ISU) may be the latest to substitute genuine oversight for hope in the reliability of the charter operator.

The aftermath of the crashed flight

The aftermath of the crashed flight

On 7 April, 2015, a Cessna 414A twin-engine airplane, operated by Make It Happen Aviation, crashed approximately two miles from its destination, Central Illinois Regional Airport in Bloomington, Illinois. The single pilot and all six passengers were killed. Among the victims were the deputy athletics director and the associate head coach of the ISU Redbirds basketball team. Team boosters comprised the other passengers. They were returning from the final four college NCAA basketball tournament in Indianapolis.

The crash occurred shortly after midnight in foggy weather, with light rain and visibility for half a mile. The flight was descending to land, then the ground radar plotted an increase in altitude, suggesting a missed approach or, worse, the pilot’s loss of spatial orientation. In any event, no radio transmissions were received from the airplane about a climbing circle for a second landing attempt. The airplane dropped off radar coverage; three hours later, at approximately 4 a.m., the wreckage and the bodies were discovered by police and firefighters who were called to search the area.

The airport tower had closed at 10 p.m., but it is not unusual — although not necessarily safer — for airplanes to land at airports without trained air traffic controllers in the tower.

A short, one-hour, flight ended in disaster

A short, one-hour, flight ended in disaster

Coincidentally, on the same day as the crash, the National Transportation Safety Board (NTSB) issued a safety alert titled “Understanding Flight Experience.” The NTSB argued that “Pilots may have many hours of experience” and “Even if operating a specific type of aircraft is allowed by regulations, it does not mean the practice is safe.” The alert cited four general aviation accidents in which experienced pilots nonetheless crashed their aircraft.

The crash in Bloomington is part of the larger pattern of wrecked airplanes and lives cut short.

ISU issued a statement: “Words cannot fully express the grief that is felt in the wake of such a tragedy. We move between shock and profound sadness.”

After a period of grief, ISU may wish to examine Oklahoma State University’s (OSU) grim experience in January 2001. A Jet Express Services aircraft, a Beechcraft Super King Air 200 with twin power plants, was returning from Colorado to Stillwater Regional Airport in Oklahoma. It was one of three airplanes chartered to fly the school’s basketball team home after a game with the University of Colorado at Boulder.

The airplane crashed shortly after reaching cruising altitude. The sole pilot and the nine passengers were killed.

Similar to the crash in Illinois, the event was at night, with a lone pilot flying past his usual bed time in wintry overcast weather. In this case, the pilot was preoccupied with an electrical failure and probably did not sense the airplane’s right descending turn.

The airplane did not have, and was not required to be equipped with, a standby attitude indicator powered from a separate source.

As a source close to the investigation recalled, “The King Air was designed and certificated for single pilot operation and also to a lower certification standard — although the FAA [Federal Aviation Administration] would say ‘different’ — than air carriers. Therefore, it does not have some of the equipment found on an air carrier, such as standby instruments.”

“Of course, the issue is that passengers are unaware of the difference in the certification of a King Air versus, say, a B737 [airliner]. They assume it’s all the same,” the source added. That is, if they even think about FAA approval of an aircraft design.

The NTSB investigated the crash of the King Air, as it is now investigating the crash in Illinois of the Cessna light twin.

Many of the findings from the earlier investigation can no doubt be included verbatim in the 2015 crash:

– The pilot was properly certificated and qualified under Federal regulations.

– The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any pre-existing structural, engine, or system failures.

– The accident was not survivable for any of the airplane occupants because they were subjected to impact forces that exceeded the limits of human tolerance.

– Oklahoma State University did not provide any significant oversight for the accident flight.

Fifteen months after the accident, in April 2002, OSU published an eight-page policy regarding athletic team travel, which included athletes, coaches, mascots, managers, etc.

Extracts of this policy may be instructive:

“All air travel, except the use of commercial air carriers, shall be subject to the review of the institution’s aviation consultant.”

“The University will, through competitive proposals, retain an aviation consultant. Such individual or firm must have expertise in operations, safety and certification for the purpose of evaluating the certification and safety records, of charter air carriers, time-share and other aircraft and assure pilot certifications are in keeping with this policy….”

“The institutional aviation consultant shall have final approving authority for approving a firm/aircraft for purposes of this policy.”

“Two pilots will be required …”

“Charter aircraft used according to this policy must be maintained under the appropriate FAA operations specifications….”

“…weight and balance computations using average passenger weights are prohibited. A weight and balance form must be completed for each flight using actual weight figures for passengers…”

The policy goes on in this vein, being very specific. The table immediately below summarizes the impact of the policy:

 

The Difference an Accident Makes

OSU Athletic Team Travel Policies

Item

Before the Accident Crash occurred the night of 27 Jan. 2001

After the Accident Policies in effect after 22 April 2002

Number of pilots

Copilot optional, depending on weather and/or length of trip. Accident pilot often flew as a single pilot because
OSU athletic staff wanted to use all the seats.

Two pilots required; no exceptions.

Pilot qualifications

OSU pilots required or qualified hired part-time pilots, instrument rated, commercial pilot’s license, minimum of
2,500 hours as pilot-in-command, and 500 hours in multi-engine airplane.

Must be full time pilot with 1st class medical certificate, type rated in airplane to be used, minimum of 200 hours flying in past 90 days, and three instrument approaches and
three night landings in the past 90 days. Copilot must have multi-engine and instrument ratings, including 100 hours in type, 10 hours in past 90 days, and three instrument approaches and three night landings in past 90 days.

Flight conditions

Day or night in visual or IFR (instrument flight rules) conditions. Pilot judgment regarding whether conditions were safe for the trip.

All flights operated on IFR flight plan; aircraft may not depart into forecast hazardous weather conditions, including
severe icing, thunderstorms, severe turbulence or wind shear. Passengers cannot enter the cockpit or distract pilots when aircraft is below 10,000
feet.

Use of donated aircraft

Permitted. Accident aircraft was donated.

Donated aircraft permitted for coaches and staff but not flights carrying student athletes. Donated aircraft must be
powered by two or more turbine engines — which would rule out piston
engines.

Outside, independent advice

None

Aviation consultant retained to evaluate certification and safety records of charter air carriers, time-share and other aircraft, with final authority for approval.

Aircraft maintenance

No specific provisions

An FAA-certified repair station or the manufacturer must perform inspections and maintenance. Maintenance personnel
must be appropriately rated and must have trained within the previous five years
on the aircraft type they are maintaining.

Following the recent crash in Bloomington, chances are that Illinois State University opts for similarly strict policies regarding aviation. Hope is no substitute for prudent oversight.