Aviation Law Monitor : Aviation Lawyer & Attorney : Michael Danko Law Firm : California Airplane & Helicopter Crashes : Aviation Law Monitor

The NTSB released its preliminary report on the Pine Mountain Lake crash.  As usual, the preliminary report contains no conclusions concerning the cause of the crash. For that, we'll have to wait up to 4 years.  The preliminary report does, however, hint that the NTSB's investigation will focus on whether the pilot pressed on into weather beyond what the regulations allowed.

The full text of the report is here.  Some excerpts:

Instrument night meteorological conditions prevailed at the accident site, and no flight plan had been filed.

Instrument weather conditions are those that require a pilot to fly by reference to his instruments rather than by looking out the window. To fly in instrument conditions, a pilot must be instrument-rated, his plane must be properly equipped, and he must have a clearance from air traffic control.  He is not necessarily required to file a flight plan.  For example, instead of filing a flight plan, the pilot may have departed San Carlos in good weather and then obtained a "pop-up" clearance from air traffic control before entering instrument conditions at Pine Mountain Lake.  Nothing unusual or unsafe about that. 

A pilot, who stated that he flies to the airport most weekends, reported attempting to land a Cessna 510 while on an instrument flight plan, about 1 hour prior to the accident. He reported that throughout the instrument approach he was unable to identify the runway environment. He performed a missed approach, and diverted to Modesto where he landed uneventfully. He stated that he has flown into the airport utilizing the instrument approach regularly over the last few years, and this was the first time he had to divert to an alternate airport.

As discussed in this post, crash, a pilot on an instrument approach to runway 27 must "go missed" if he descends in the clouds to the minimum allowable altitude  -- in this case 770 feet above the ground --  and still can't see the runway.  Instead of going missed as required, some pilots will descend "just a little further" believing that, in just a few more seconds, they will break out of the clouds and the runway will appear before them.  Descending below the minimum altitude set forth in the instrument approach procedure is a violation of FAA regulations and a leading cause of instrument approach-related accidents. The NTSB seems to suggest that the pilot of the accident aircraft, N4175A, must have ventured below minimums to get beneath the clouds because the Cessna jet had to go missed.  However, the fact that the Cessna was forced to execute a missed approach at the airport one hour before the accident means little. Weather can change in an hour. 

The remaining two propeller blades were attached at the hub. All of the blades exhibited leading edge gouges, and varying degrees of tip twist. 

Gouges and blade twist is an indication that, the time of impact, the engine was developing power. Engine trouble can likely be ruled out.

A third witness, located 1/2 mile northeast of the approach end of runway 27, heard a low flying airplane, which he presumed was flying directly over his house, with engines running "full bore."

What was the pilot doing 1/2 mile northeast from the runway? (See image below.) As discussed in this post, the pilot should have been lined up for a straight-in approach.  And during the approach procedure, the pilot should have been throttled back for descent.  A pilot typically applies full throttle only when going missed.

Related Post: Piper Saratoga Crash at Pine Mountain Lake   

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Lisa Krieger of the San Jose Mercury News writes on a variety of issues related to this crash: 

• Pilot's Insurer Meets with East Palo Alto Residents.  Residents who suffered property damage can make a claim against the pilot's estate or his insurance policy.  The families of his passengers, however, probably cannot.  Workers compensation laws prohibit a passenger's family from suing the passenger's co-employee (in this case, the pilot) or, for that matter, the passenger's employer (Tesla).  The families are, however, permitted to sue anyone else who may be responsible for the crash, such as a negligent mechanic or a manufacturer of a defective aircraft part.
• Palo Alto Airport Proposes New Routes to Avoid East Palo Alto. The airport can suggest that pilots avoid over-flying hours near the airport, but it cannot require them to.  Only the FAA can do that. 
• Palo Alto Plane Crash Likely Caused by a Lethal Combination of Factors.  A pilot flying a heavily loaded twin-engine piston aircraft from a short runway in the fog is unlikely to be able to avoid disaster when one engine fails.

Related posts:  Tesla Crash: NTSB Probable Cause Investigation

                       Tesla Crash: The Paradox of the Twin

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The runway at Pine Mountain Lake is oriented east-west, and is surrounded by rugged terrain.  In poor weather, pilots are permitted to execute instrument approaches to the airport.  The approach procedures guide pilots as they descend through the clouds to the runway.  The procedures, flown properly, will place the pilot in a position to land straight ahead without having to maneuver.  When the pilot pops out of the clouds after flying the instrument approach to Pine Mountain Lake, his view out of the windshield should be something like this:  

The procedure the pilot must follow when approaching from the east is set forth below.  A pilot may descend in the clouds no lower than 770 feet above the runway.  To descend further, the pilot must be clear of the clouds and have the runway in sight.  If he cannot see the runway, he must "go missed."  That means he must abort the landing, and climb straight ahead by reference to his instruments until reaching a safe altitude.

Once the pilot has reached a safe altitude and has established radio contact with air traffic control, the pilot may attempt the approach procedure again.  He may obtain a clearance to fly a different approach procedure from the opposite direction, or he may opt to fly to a different airport where the weather is better.  

Investigators report that the accident aircraft, N4175A, "went missed" on his first approach to the airport, and that the accident occurred near the completion of its second approach.  On the second approach, the aircraft had successfully descended beneath the clouds.  We know that because

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The initial investigation was conducted by local law enforcement in conjunction with the FAA. Now the National Transportation Safety Board will take over.

The NTSB’s job will be to examine the wreckage and attempt to determine if the crash was caused by a defective aircraft part, negligent maintenance, or pilot error. The NTSB concedes, however, that it lacks the manpower, the technical expertise, and the funding to do that job properly on its own. Therefore, as a matter of long-standing policy, it will seek engineering assistance from the companies that manufactured the aircraft components in question. In this case, the NTSB will recruit the help of Cessna Aircraft, which manufactured the aircraft involved in the accident, Cessna N5225J, and Teledyne Continental Motors, which manufactured each of the aircraft’s two 260 horsepower engines. The NTSB will exclude members of the victims’ families and their technical representatives from the investigation, feeling that they have nothing to offer. (Sad but true.)

Of course, the NTSB’s practice of asking the manufacturers for help – a practice it calls “the party system” -- presents a conflict of interest.  After all, the manufacturers themselves might be the ones responsible for the accident. Some say that the NTSB’s party system is akin to asking the suspects for help in solving a crime. Nonetheless, the conflict – discussed further here – is ingrained in all NTSB investigations.

It’s no surprise that most NTSB final reports often favor the manufacturers who have “assisted” the NTSB investigators in their work. But perhaps it doesn't make any difference because, by federal regulation, the NTSB’s probable cause findings are not binding on anyone. The families are free to conduct their own investigation, and in the event of a lawsuit, the NTSB’s conclusions are given no deference whatever. In fact, in the event of litigation, the NTSB conclusions are not even admissible. Aviation attorneys who conduct their own independent investigations find that the NTSB’s conclusions are wrong about 50% of the time.

In one recent example, a Teledyne Continental engine similar to those installed on N5225J quit

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One might think that a twin-engine aircraft is safer than a single-engine aircraft.  After all, if one engine fails, you still have the other to bring you home safely.  That's the whole point of the second engine, right?

If one of the twin engines fails in cruise flight, maybe that's true.  But if it quits right after takeoff, the twin can be extremely difficult to handle.  With its landing gear down, its flaps set, and its airspeed just above the minimum flying speed, the asymetric thrust generated by the operating engine can flip the aircraft onto its back and out of control.  A "Vmc roll", as it is called, is almost always fatal.  When an engine quits during the critical takeoff phase of flight, a pilot -- even one who does everything right --  may not be able to land the twin-engine aircraft safely.  Fog and a short runway (such as Palo Alto's) make matters only worse.

It's too early to tell, but it's possible that the Twin Cessna in which the Tesla employees were flying experienced an engine failure.  First, a witness at Palo Alto Airport reported hearing the unmistakable thrumming sound of two engines as Cessna N5225J rolled down the runway.  That was followed by what sounded like just one engine running, and then an impact. 

Second, having flown out of Palo Alto many times, I know that Air Traffic Control instructs pilots flying on instruments to proceed straight out, then turn right to a heading of 060 degrees within one mile from the airport.  (The airport was fogbound when N5225J took off, so the pilot would have been making an instrument departure.)  But as depicted below, the aircraft crashed well left of the expected course.  That's consistent with a loss of control following an engine failure on takeoff.

Because it's so hard to fly a twin-engine aircraft after one of its engines fail, many pilots feel safer taking off in a single-engine aircraft.  First of all, the chances of a single-engine aircraft experiencing an engine failure on takeoff is only half that of a twin.  Second, if the single engine does fail, the aircraft can still be flown like a glider.  Its heading is just as easy to control as if its engine were running normally.  In this case, a landing straight ahead onto the mud flats, or even a right turn toward the water, might have been accomplished successfully in a single-engine aircraft.  Either path would have provided a better chance of survival than the Twin Cessna's turn to the left.

February 20 Updates:

          Tesla Crash: NTSB Probable Cause Investigation

          Crash Likely Caused By Lethal Combination of Factors (Merc News)

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A tail rotor system malfunction may have caused the crash of the EC135 helicopter that killed five on board the Food Service of America EC135 helicopter at Cave Creek, Arizona.  At least, that's where the current information seems to point.

Here are the key bits from an MSNBC report:

Witnesses saw parts flying off the stricken aircraft just before it crashed. Parts of the helicopter's rotors were found more than a half-mile from the main wreckage. . . witnesses reported hearing a popping sound, then seeing the helicopter rotate at least three times before the nose pointed down and it crashed.

The rotor parts that were found must have been tail rotor parts.  The helicopter could not have continued in flight for another half mile if it had lost any part from one of its main rotor. Instead, it would have crashed immediately.

The main rotors keep the helicopter in the air. The tail rotors keep it from spinning in a direction opposite to the rotation of the main rotors. Reports that the helicopter rotated are therefore consistent with a malfunction of the tail rotor or the tail rotor drive system.

The weight of the helicopter is balanced under the main rotor mast.  The fact that the helicopter suddenly pointed down indicates that a heavy part, such as a tail rotor transmission, fell off the tail, thereby rendering the helicopter too "nose-heavy" to remain in the air.

Investigators will be looking closely at the helicopter's maintenance history. In 2007, another EC 135 crashed in Japan.  That crash was attributed to a failure of a tail rotor drive component.  As a result, the FAA issued an emergency airworthiness directive (reproduced below), requiring that all EC135's be inspected and that parts be replaced as necessary to prevent similar tail rotor failures and loss of control.  

This Emergency Airworthiness Directive (EAD) is prompted by a report of a fatal accident involving the failure of a tail rotor control rod (control rod). This condition, if not corrected, could result in the failure of a control rod and subsequent loss of control of the helicopter.  

AD2007-26-51

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Cirrus aircraft are now available with "flight into known icing" (FIKI) capability.  That's a great feature. I've written before, however, that Cirrus is asking for trouble with its marketing.  Cirrus sells the feature as one that both enhances safety and increases the aircraft's utility.  But Cirrus can't have it both ways.  If a pilot uses the FIKI capability by, for example, flying in conditions that would otherwise keep him on the ground, he necessarily undermines that feature's safety benefits.  I discuss why Cirrus' marketing is a problem here.

Steve Wilson, who is an air safety investigator (among other things), now slams Cirrus' marketing even harder.  According to Wilson, some aspects of Cirrus' marketing encourage pilots to use the FIKI capability to take risks that are simply foolish.

Some say that Wilson's criticisms should be discounted because he sells Cessna aircraft and Cessna competes with Cirrus.  But Wilson isn't criticizing Cirrus' product, just its marketing.  It seems hard to argue with him. 

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Updated February 12:

A Cirrus SR-20 single engine aircraft collided with a Pawnee tow plane that was pulling a glider. The Cirrus reportedly ran into the Pawnee's tow line. The Pawnee crashed and the pilot was killed.  The occupants of the Cirrus were also killed.  The glider pilot, however, recognized the impending collision, released his aircraft from the tow line, and landed without injury to himself or his two passengers.

Each Cirrus aircraft is equipped with a rocket-propelled parachute.  One purpose of the parachute is to safely return the aircraft to earth if it is damaged in a mid-air collision.  Unfortunately, the parachute didn't help in this case. Video of the Cirrus wreckage, on fire, descending beneath its canopy is here.

Some questions:

Who had the right of way?

Gliders and tow planes have the right of way over other aircraft.

Why couldn’t the Cirrus pilot see and avoid the Pawnee's tow line?

The tow lines are nearly invisible in the air. But despite the news reports, the Cirrus most likely collided with the Pawnee tow plane itself, not with the tow line.  [The glider pilot has now confirmed to the NTSB that the Cirrus collided with the Pawnee’s fuselage, not the towline.] That explains the tremendous damage to the Cirrus and the Pawnee, and the immediate fireball that resulted, as reported by the glider pilot.

Doesn’t the Cirrus have radar to help avoid other aircraft?

No radar, but some Cirrus aircraft are equipped with other devices to detect and help avoid other traffic.  That equipment is optional, however, and may not have been installed in this particular Cirrus. [Reports are that the Cirrus was not so equipped when it left the factory.]  Even if it was installed, it only detects aircraft that have an operating transponder. Most gliders don’t have transponders. We don’t know whether the Pawnee’s transponder was on.

What good is the Cirrus parachute if the aircraft burns after a mid-air collision?

Some argue that the Cirrus is not crashworthy because it is prone to post-impact fires.  That's because it is made largely of fiberglass rather than aluminum.

It is true that aircraft should be designed so as not to burn after an accident.  However, that standard applies only when the crash is otherwise survivable. The impact forces in this accident appear to have been so great that the accident was not survivable. That makes it hard to blame the design of the aircraft for the post impact fire.  In fact, the occupants were likely killed on impact, making the fire irrelevant to the tragic outcome. (The parachute was likely deployed as a result of impact forces acting on the parachute's igniter cable, not by the aircraft's occupants.)   

Was this a freak accident?

Maybe, maybe not. Here is a video of a remarkably similar accident. The camera plane hit a tow plane's cable, rather than the tow plane itself.  The camera plane was equipped with a parachute, like the Cirrus was in this case.  The pilot deployed the parachute and ultimately walked away from the crash. 
 

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This week, aviation accident attorneys from across the country met on Maui to discuss current topics in aviation law. This was part of the American Association of Justice's Winter Convention. I was honored to have been asked to speak. My talk was on Hawaii helicopter crash litigation -- a topic with which we are -- unfortunately -- perhaps too familiar.

I covered the profits, accident statistics, the poor safety record, lack of insurance, the popular equipment (including the Eurocopter AStar); and the FAA's unfortunate lack of heli-tour industry oversight. Powerpoint available here.

As it turns out, my presentation was a bit controversial. The tour industry was a sponsor of the convention. And I ripped into it. On the flight back to San Francisco, someone asked me whether that made me uncomfortable, given that AAJ actually promoted the tours. In fact, the blogosphere was chiming in about it before I even spoke. Carter Wood, blogging on PointofLaw.com, questions the appropriateness of my topic:

That's the way you pay back Hawaii's hospitality? 'Fly like a tropical bird, and then sue!'

First, the risks are, for the most part, unknown. Unknown to people travelling to Hawaii, and unknown even to the AAJ, a group which is, generally speaking, keenly aware of industries that place profits over consumer safety. Thus, the title, "Under the Radar."

Second, I want to get the word out. It's too important. Too many people's lives have been torn apart by this industry. I really don't care what “sponsors” I offend.

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