|

Series of Operational Errors by Pilot Led to 2009 Airplane Crash in Montana

The National Transportation Safety Board determined today that the cause of the March 2009 deadly crash of a Pilatus airplane was a series of operational errors made by the pilot. The pilot failed to ensure that a fuel system icing inhibitor (FSII), commonly referenced by the brand name “Prist”, was added to the fuel prior to the accident flight.

The pilot also failed to take appropriate remedial actions, including diverting to a suitable airport, after the airplane warning systems indicated a low fuel pressure state that ultimately resulted in a significant lateral fuel imbalance. And, the pilot lost control while maneuvering the left-wing heavy airplane near the approach end of the runway.

“The pilot’s pattern of poor decision making set in motion a series of events that culminated in the deadly crash,” said NTSB Chairman Deborah A. P. Hersman. “Humans will make mistakes, but that is why following procedures, using checklists and always ensuring that a safety margin exists are so essential – aviation is not forgiving when it comes to errors.”

On March 22, 2009, at about 2:32 pm (MDT), a Pilatus PC-12/45, N128CM, crashed about 2,100 feet west of runway 33 at Bert Mooney Airport (BTM) in Butte, Montana. The flight departed Oroville Municipal Airport in Oroville, California, en route to Gallatin Field in Bozeman, Montana but the pilot diverted to Butte for unknown reasons. The pilot and the 13 passengers were fatally injured and the aircraft was substantially damaged by impact forces and a post-crash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.

During the investigation, the NTSB determined that the pilot did not add a fuel system icing inhibitor when the airplane was fueled on the day of the accident. The Pilatus flight manual states that a fuel system icing inhibitor must be used for all flight operations in ambient temperatures below 0 degrees Celsius to prevent ice formation in the fuel system. The NTSB concluded that the airplane experienced icing in the fuel system which resulted in a left-wing-heavy fuel imbalance. The increasing fuel level in the left tank and the depletion of the fuel from the right tank should have been apparent to the pilot because that information was presented on the fuel quantity indicator. This should have prompted the pilot to divert the airplane to an airport earlier in the flight as specified by the airplane manufacturer.

The NTSB issued recommendations to the Federal Aviation Administration and the European Aviation Safety Agency, to require fuel filler placards and guidance on fuel system icing prevention.

To include the featured image in your Twitter Card, please tap or click their icon a second time.

Similar Posts

  • | | | | | | |

    Automation at Fault?


    Here’s the question: do pilots rely too much on automation? This question has been on my mind since hearing the parallels between the UPS Cargo jet crash and the Asiana passenger jet crash. This is on my mind not only as one who works toward aviation safety but also as a very frequent flyer. You can only imagine how my work carries me into international situations. I don’t fly as frequently as a pilot, but sometimes I fly internationally several times a month. I am on these planes frequently. I rely on them.

    So I find it disturbing that the NTSB’s hearing Thursday revealed parallels between the crash of UPS Flight 1354 and Asiana Filght 214. While I don’t know the answers, I can only hope the investigation shines light on ways to deal with this problem. What is the solution? Less reliance on Automation? Better training for pilots?

    On the other side of the coin, some parties will want even more automation, but I am reluctant to go in that direction. The idea of even more reliance on automation is anathema to me because the engineers and advocates of reliance on even more automation will not be on those even-more automated planes. While the technology and/or training will be on the chopping block, their actual necks won’t be.

    What I don’t find disturbing is the professionalism of the hearings. The webcast is well worth watching.

    The hearing webcast is recorded here: http://ntsb.capitolconnection.org/022014/ntsb_archive_flv.htm

    Note the NTSB cautions participants in the hearing not to engage the media and to stick to the facts.

    Or the recorded captions (unformatted) are here.
    https://airflightdisaster.com/wp-content/uploads/2014/02/ntsb022014.htm.pdf

    bio docket: https://airflightdisaster.com/wp-content/uploads/2014/02/biodocket.pdf

    To include the featured image in your Twitter Card, please tap or click their icon a second time.

  • NTSB SENDING TEAM TO INVESTIGATE EMERGENCY MEDICAL SERVICES HELICOPTER ACCIDENT IN TENNESSEE

    The National Transportation Safety Board is sending a team
    to investigate the crash of an emergency medical services
    (EMS) helicopter this morning in Brownsville, Tennessee,
    about 55 miles northeast of Memphis. Three crewmembers were
    killed in the accident; there was no patient onboard at the
    time of the crash.

    NTSB Air Safety Investigator Ralph Hicks has been designated
    as Investigator-in-Charge and is traveling to the scene from
    the Safety Board’s regional office in Atlanta. NTSB Chairman
    Deborah A.P. Hersman will serve as principal spokesman
    during the on-scene investigation.

    Improving the Safety of (EMS) flight operations has been on
    the NTSB’s Most Wanted List of Safety Improvements since
    2008:
    http://www.ntsb.gov/Recs/mostwanted/aviation_improvesafety_e
    ms_flights.html

    Peter Knudson will be the press officer on-scene. Mr.
    Knudson may be reached on his cell phone (202-557-1350) when
    he arrives in Tennessee this afternoon.

    To include the featured image in your Twitter Card, please tap or click their icon a second time.
  • | |

    FAA Press Release: Continental Airlines

    FAA Proposes $230,000 Civil Penalty against Continental Airlines

    FORT WORTH, Texas — The Federal Aviation Administration is proposing a civil penalty of $230,000 against Continental Airlines Inc., of Houston for allegedly operating a Boeing 767 on 22 revenue flights when it was not in compliance with Federal Aviation Regulations.

    The FAA alleges that on Aug. 12, 2008, Continental replaced the nose landing gear wheel and tire assembly on a B-767, but failed to install the required axle washer despite warnings in the maintenance manual and on the tire assembly itself. The warning said failing to install the washer could lead to failure of the wheel bearing.

    FAA inspectors discovered the violation during a records check and noted three identical earlier violations.

    Continental has 30 days from receipt of the civil penalty letter to respond to the agency.

    To include the featured image in your Twitter Card, please tap or click their icon a second time.
  • |

    NTSB Recommendations

    National Transportation Safety Board
    Washington, DC 20594
    February 23, 2012

    The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

    Modify the design and test requirements for the attachment points of passenger service units to account for the higher localized loading that results from the relative motion of the attachment structure. (A-12-1)

    Require that the installation design for overhead bins and passenger service units (PSU) manufactured by Boeing and installed in Boeing 737NG series airplanes be modified so that the PSUs remain attached to the bins or are captured in a safe manner during survivable accidents. (A-12-2)

    Review the designs of manufacturers other than Boeing for overhead bins and passenger service units (PSU) to identify designs with deficiencies similar to those identified in Boeing’s design, and require those manufacturers, as necessary, to eliminate the potential for PSUs to separate from their attachments during survivable accidents. (A-12-3)

    Develop test criteria and performance measures for negative-g strap assemblies to better evaluate their real-world loading capability during accident sequences. (A-12-4)

    Once test criteria and performance measures are established as recommended in Safety Recommendation A-12-4, amend 14 Code of Federal Regulations Part 25, as appropriate, to include the newly developed test criteria and performance measures for negative-g strap assemblies. (A-12-5)

    Require that negative-g strap attachment brackets manufactured by Ipeco be retrofitted with stronger brackets. (A-12-6)

    ************************************************************

    The National Transportation Safety Board recommends that the Federal Aviation Administration:

    Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)

    Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)

    Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)

    Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)

    Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)

    To include the featured image in your Twitter Card, please tap or click their icon a second time.
  • |

    Vision Airlines

    $49 FLORIDA FARE SALE ENDS MONDAY, JANUARY 31, 2011
    SUWANEE, Ga., Jan. 30, 2011 /PRNewswire/ — Vision Airlines, the nation’s newest big jet, low-cost carrier, will end its $49* introductory one-way Florida fare sale on Monday, January 31, 2011 at 11:59 PM Eastern Standard Time.

    “However, Vision Airlines still offers the lowest one-way fares in the industry on its direct flights from 17 southern U.S. departure cities to six Florida destinations,” says company spokesman Bryan Glazer. “On average, Vision Airlines’ fares to Florida cost $89. Fares across the airline’s route system range from $69 – $199.”

    The first flights start taking-off on March 25, 2011.

    “Vision Airlines has now sold more than $1 million in tickets, since we opened our online store and call center 13 days ago,” says Chief Operating Officer David Meers.

    “On January 18, minutes after Vision Airlines unveiled its 23 city mega-expansion plan and announced its one week $49 seat sale, the company’s reservations center was flooded with phone calls and its website was overwhelmed by more than 50,000 hits; causing its servers to crash,” says Glazer. “Within 48 hours, Vision Airlines sold-out of the limited $49 fares.”
    Vision Airlines’ Sales and Marketing Director Clay Meek explains, “To deal with the technical problems, Vision Airlines increased its server capacity, brought more customer service agents on board and then added more $49 seats on every flight. To top-it-off, we extended our $49 introductory fare sale, which was slated to end on January 23, but will now end this Monday night.”

    Meers emphasizes, “At this juncture, Vision Airlines believes it is more important to satisfy first-time customers rather than turn them away because they missed-out on a fare sale. Our first goal is to get passengers on Vision Airlines’ jets so they can experience our fast, friendly and efficient service. After their first flight on Vision Airlines, we are confident that we will earn passenger’s repeat business.”

    Vision Airlines Cities

    • Asheville, NC – Atlanta, GA – Baton Rouge, LA – Birmingham, AL – Chattanooga, TN
    • Columbia, SC – Destin/Ft. Walton Beach, FL – Ft. Lauderdale, FL
    • Greenville/Spartanburg, SC – Gulfport/Biloxi, MS – Houston, TX – Huntsville, AL
    • Knoxville, TN – Little Rock, AR – Louisville, KY – Macon, GA – Miami, FL
    • Niagara Falls/Buffalo, NY/Toronto, Canada – Punta Gorda/Ft. Myers, FL
    • Sanford/Orlando, FL – Savannah, GA – Shreveport, LA
    • St. Petersburg/Clearwater/Tampa, FL
    To include the featured image in your Twitter Card, please tap or click their icon a second time.
  • |

    NTSB PROVIDES INVESTIGATIVE UPDATE AND PHOTO OPPORTUNITY OF LAB WORK RELATED TO BOEING 787 BATTERY FIRE IN BOSTON


    January 23, 2013
    WASHINGTON – Tomorrow, National Transportation Safety Board Chairman Deborah A.P. Hersman will provide an update on the NTSB’s investigation of the Jan. 7 fire aboard a Japan Airlines (JAL) Boeing 787 at Logan International Airport in Boston.

    Chairman Hersman will brief credentialed members of the news media on the progress of the investigation, after which she and senior staff will take questions. Those unable to attend in person can call in to a teleconference line.

    Reporters will then be invited to view the materials laboratory where the battery is being examined. Photography will be allowed but no “stand-ups” or taped reporting from the lab will be permitted.

    For planning purposes, RSVP is required for those planning to either attend in person or call in.

    Location: NTSB Boardroom and Conference Center, 429 L’Enfant Plaza East, SW, Washington, DC

    Date: Thursday, January 24, 2013

    Time: 2:30 p.m.

    Participants: Chairman Deborah A.P. Hersman; John DeLisi, Director of NTSB Office of Aviation Safety; and Dr.
    Joseph Kolly, Director, NTSB Office of Research and Engineering.

    The following factual information has been developed about the battery: It consists of eight cells of 3.7 volts each. All eight cells had varying degrees of thermal damage. Six of eight cells have been CT scanned and have been disassembled to expose their electrodes. All electrode windings in the battery are in the process of being photo-documented and are undergoing microscopic examination. In the coming days, the remaining two cells will undergo the same examination. Additional information will be provided tomorrow.

    To include the featured image in your Twitter Card, please tap or click their icon a second time.