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

Bill King
Vice President of Business Administration
Cirrus Aircraft
Duluth, Minnesota 55811
 

Dear Bill: 

I own one of your aircraft. There are some nice things about the Cirrus. But a few things, from a safety standpoint, really suck. First, the doors don’t stay closed. Second, too many pilots and passengers are getting killed when pilots try to land the thing. Third, the fuel gauges don’t work.

I read your comments on each of these issues in today’s Duluth News Tribune. Considering that they come from a company that prides itself on “celebrating safety,” I found some of the comments disturbing.

The doors.

Bill, they pop open. A lot. It’s always a distraction when it happens. If they pop open at a bad time, it can spell real trouble. More on that here. 

I read how you flew from one airport to another a few weeks ago with a door that wasn’t shut, and you handled it without any problem. Congratulations on some good piloting. By the way, was the weather low IFR on your flight? Was it at night? Was your engine running rough? Did you have a scared passenger to deal with?

No? Then maybe it’s no surprise that you found the open door to be a "non-event."

You point out that doors pop open on other aircraft too.  That's true.  But we know that most of those "other" aircraft are “legacy” aircraft and that, unfortunately, lots of people have died as a result of the 50 year-old door designs used in those aircraft.

Now, as I understand it, Cirrus doesn't accept the old ways of the industry.  Rather, Cirrus’ mission is to “challenge conventional assumptions to find ingenious new improvements,” right? 

Great. Please gather your most ingenious people and have them figure out an ingenious way to keep the doors of your super-modern and ultra-safe $600,000 aircraft closed.

Landing accidents.

Next, this stuff about people getting killed when they try to land the plane. I find it troubling. I guess Cirrus does too. I received from Cirrus a safety alert (pdf), asking pilots, in light of all the accidents, to review the landing speeds spelled out in their Pilot's Operating Handbook.  And to get recurrent instruction.

That’s always good advice.  But I don't think it's a solution to the problem.  With all due respect, Cirrus pilots are not, as a group, especially stupid. They are just as likely as Beech and Cessna and Mooney pilots to read and follow their handbooks.  They are just as likely to get recurrent instruction. In fact, from what I can tell, they may even be more so.  Yet, for some reason, they are having more landing accidents.

Can Cirrus consider the possibility that there might be something about the airplane itself that contributes to its poor safety record? Or does Cirrus believe that it’s all the fault of Cirrus pilots who, Cirrus seems to think, are not as conscientious about doing their homework as the pilots who fly the competition?

You say that “all airplane models have their idiosyncrasies.” Agreed. That’s my point. Maybe there are some idiosyncracies about the way the Cirrus behaves in the landing phase that need to be uncovered and dealt with. Maybe the speeds the Pilot Operating Handbook specifies need to be re-evaluated. Please take a hard look and tell us what idiosyncracies your engineers and test pilots find. Don’t just tell us to follow the Handbook, because I think we are.  Something else is going on.

Fuel Gauges.

Buy a new airplane and you’d expect it to come with fuel gauges that work. But in the Cirrus, they don’t. Your comments totally avoid the issue. Rather than ‘fess up and get on the problem, you stated that the aircraft’s other “sophisticated electronic monitoring makes the gas gauge superfluous.”

Huh?

The reporter, John Lundy, then asked “Then why even have a gas gauge?” Your response: 

You know what? I don’t know. . . I think it’s probably an FAA requirement.

News flash: fuel gauges are an FAA requirement. That’s because the FAA thinks it’s really important for pilots to know how much gas is in their tanks. And, Bill, none of the “sophisticated electronic monitoring” on board the Cirrus makes the gauges superfluous, because none of it tells the pilot how much fuel is in the tanks. The only thing that does that is the fuel gauge. 

Any questions on this, you may want to spend some time with the Pilot's Operating Handbook.

Sorry, Bill. A working fuel gauge is high on this pilot’s wish list. Call me nutty.

Will Cirrus please fix the problem? Please? Before someone gets hurt?

Thanks.  Looking forward to Cirrus' response.

Mike Danko

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The pilot of the Otter that crashed in Alaska on Monday, killing Senator Stevens and three other passengers, encountered some very bad weather.  Low ceilings.  Fog and rain.  Gusty winds.

Rugged terrain only complicated things.  Fortunately, the pilot had tons of experience  -- tens of thousands of hours.  According to the Alaska Dispatch, had any less talented pilot been at the controls, the death toll surely would have been higher.

The fact there were four survivors is testament to [the pilot's] skills. [He] maneuvered that plane like no other mere pilot to save lives.

So is the pilot a hero?  No.  Not quite.

There's an old saying in aviation: "a superior pilot is one who exercises superior judgment so as to avoid having to exercise his superior skills."  In this case, a pilot exercising superior judgment might have turned around before tangling with the worst of the weather.  Or, better yet, never left the comfort and safety of the lake lodge in the first place.

The Weather was Bad 

When the pilot took off from the lake where the lodge was located, the weather was bad.  It was bad at nearby Dillingham airport.  It was bad at the river camp that was to be their destination.  And it was bad everywhere between.

A pilot who flew the same valley where the crash occurred confirmed to the LA Times that it was bad there too.  "It was just awful weather. . .I came through that valley at about 100 feet off the ground with about a mile of visibility."

Now, bad weather doesn't mean a good pilot must stay on the ground.  For example, the airport at Dillingham has various instrument approach procedures that will allow planes to land safely in some pretty crappy weather. No undue risk. No sweat.

But this pilot wasn't headed to Dillingham.  He was headed to a fishing camp on a nearby river.  No instrument approach procedure would guide him through the clouds.  If this pilot was going to get there, he’d have to do it without instruments. He’d have to do it by looking out the window.  Seat of the pants stuff.  All perfectly safe, as long as the weather is good enough for you to see where you are going.

Controlled Flight into Terrain

So what exactly happened?  What we know about the accident is consistent with "controlled flight into terrain."  Opting out of the instrument flight system, the pilot had to stay under the clouds.  He couldn't go through them because once inside, he wouldn't be able to see and might bump into something hard and pointy.  So he had to stay in the clear and visually pick his way around the terrain in his path.  But as he maneuvered under the low clouds and around the fog, he suddenly came upon a mountain's steep up-slope.  He shoved the throttle forward, pulled the nose up and began a climb.  But the terrain rose faster than could his aircraft.  He bellied onto the rising slope while in full control of a perfectly functioning aircraft.

At least that how it looks.

According to John Bouker, the pilot who found the wreck: 

The Otter had plowed into the hill. He bounced up the mountain. He looked like he was in a full-power climb. . the plane appeared mostly intact.

That’s a classic "controlled flight into terrain” scenario.

Poor Decision Making   

This morning a pilot who used to fly search and rescue out of Dillingham called me to talk about the crash.  He pointed out that the state of Alaska accounts for more than a third of all commuter and air taxi crashes in the entire country.  That's right: one state accounts for a third of all the nation's crashes.  And more than 80 percent of those crashes are due to poor decision-making.

Alaskans seem to accept aviation tragedies as part of life in the wilderness.  My caller suggested that poor decision making seems to be not just tolerated, but sewn into the very fabric of Alaskan aviation community. 

The question is not the whether the pilot had the skills to “maneuver” the aircraft around difficult terrain. Or whether he had the experience necessary to pick his way around the obstacles along the route. Or whether he brought the aircraft down with the least impact possible.  The question is whether, given the weather, he should have attempted the flight at all.

I can easily imagine that a nice fire was burning in the lodge fireplace when the pilot loaded up his passengers. If ever there was ever a flight that didn't need to be made, it was this one. 

Yet it was.  

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Cirrus N146CK crashed on August 4 at Deer Valley, Airzona.  The pilot was killed.  Just before the accident, the aircraft's door popped open.  We know that because the pilot reported to air traffic control that his door was open and that he needed to return to the airport to close it.  Plus, surveillance cameras confirmed that the pilot's door was indeed ajar. 

The plane's door popped open? What's with that? 

The Cirrus doors are poorly designed.  It's that simple. They just don't stay shut in flight.  

The plane flies okay after a door pops open.  But the distraction can be dangerous, and can lead to a loss of control, as demonstrated by this 2009 Cirrus crash.  Following the 2009 accident, John Ewing, a Cirrus flight instructor, blogged about his experience with the Cirrus doors:

Quite frankly, I found the performances of [the Cirrus] door latches stinks. Cirrus, in an apparent quest to make the aircraft seem as much like an automobile as possible, tried to implement a slam-and-shut-style automobile door. This just in: A high-performance single-engine aircraft is not a car.

Others feel the same way.  Cirrus owner Hamid Shojaeen, after taking delivery of a brand-new Cirrus SR22 in 2007:

Are you kidding me with this? . . .Even when the door is shut and appears to be latched properly, the door can still unlatch during flight.  That too happened to us twice during training!  . . . all of a sudden there was a loud bang and you could hear the gushing air coming in. . .

The slipstream keeps the door from opening more than a few inches. See the photo, below. (Note: this is not the accident Cirrus.)  But the event can nonetheless be down-right terrifying.  You hear a loud bang.  Then a whooshing noise. The pressure in the cockpit feels like it changes in an instant and, if you're wearing contact lenses, you can almost feel them jump off your eyeballs.  The adrenaline rush is quite impressive. Especially the first time it happens.

Don't ask me how I know.

Once a door pops open, it cannot be closed in flight.  The pilot must land to get the door closed.

So bad is the problem that an after-market supplier offers a "Door Warning System," similar to a "door ajar' light on a car, to let you know before take-off that your Cirrus door isn't really closed right.  At $875, it almost seems worth it. (See ad, above.)

When you pay $600,000 for an aircraft, as did the pilot of the aircraft that crashed at Deer Valley, you might expect that it would come with doors that shut right and stay shut. You shouldn't need to add extra stuff to your new aircraft to make sure the doors don't open in flight.

We don't know what caused the Deer Valley crash.  Some witnesses reportedly heard the engine sputter. Whatever challenges the pilot faced, a door popping open couldn't have helped. 

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An FBO is not supposed to rent an aircraft to a pilot who the FBO knows isn't competent to complete the planned flight safely. If it does, and a passenger is hurt or killed by the pilot's mistake, the victim or his family can hold the FBO responsible. That's the law of "negligent entrustment."

A pilot who doesn't hold the proper license or rating to operate the aircraft he is seeking to rent is probably not competent to complete the planned flight safely.  But what if the pilot is properly licensed and meets all the FAA's other requirements? If the FBO rents the aircraft to the pilot, can the FBO still be held responsible for what turns out to be the pilot's mistakes?

Sometimes, the answer is yes.

The landmark case is White v. Inbound Aviation. A young pilot had just recently received his private pilot's license. He was comfortable flying the FBO's Piper Archer in which he had been "checked out" by one of the FBO's instructors. The FBO felt the renter was a good pilot.  It felt, however, that the pilot should obtain some additional instruction in "mountain flying" before flying to an airport in the mountains nearby.  The FBO felt that without the instruction, the pilot might not be able to handle the special challenges presented by "high density altitude" airports. 

One day the pilot showed up to rent the Archer. He told the FBO that he wanted to fly two friends to Lake Tahoe airport, an airport in the mountains.  The pilot hadn't obtained the mountain-flying instruction, but the FBO rented the aircraft to him anyway.

The pilot landed at Lake Tahoe airport without incident. But he wasn't prepared for the effects of the altitude, heat, and weight of the aircraft on takeoff.  When he attempted to depart, he crashed, killing himself as well as his two passengers.

The family of one of the passengers sued the FBO, arguing it should never have rented the plane to the pilot for this particular trip. The jury agreed and held the FBO liable.

The FBO appealed.  It argued that the pilot held a license that legally entitled him to fly anywhere he wanted, including mountain airports like Lake Tahoe. That, the FBO argued, should have been the end of the matter. If the pilot was competent in the eyes of the FAA, he should have been deemed competent in the eyes of the court.

The court of appeal disagreed, and affirmed the jury's verdict against the FBO.  Though the young pilot may have been a competent pilot generally, that wasn't the issue.  The FBO knew that, notwithstanding his license, the pilot wasn't competent for the particular flight he had planned.  As the court of appeal noted:

[The issue as plaintiffs framed it] was not whether [the pilot] was competent in general to pilot an aircraft but whether [he] was competent to 'operate the aircraft that he operated on the day he operated it and in the manner in which he operated it under the conditions he experienced ... on July 3rd with three people on board going to Lake Tahoe.'

The FBO knew that, even though he was properly licensed, the pilot was not competent to conduct the particular flight he had planned under the conditions that existed on the day of the accident.  The court of appeal ruled that, therefore, the jury properly held the FBO liable for the accident under the law of negligent entrustment.  

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When Cory Lidle's widow sued Cirrus Design, it caused a bit of an uproar in the aviation community.  Her suit alleges that it was a defect in the aircraft's flight controls that caused the Cirrus SR-20 to slam into a Manhattan hi-rise.  That claim led many to call the suit frivolous.  After all, the NTSB determined the accident was caused by pilot error, plain and simple. Right?

Cirrus asked the federal judge who is hearing the case to toss it out as being based on "junk science." Cirrus argued that under legal precedent known as Daubert v. Merrell Dow Pharmaceuticals, the judge must act as a "gatekeeper."  That means she must review the expert testimony supporting plaintiff's case and make a preliminary determination as to whether the experts' opinions are reliable enough to even present to a jury.  If the judge determines that the opinions are not sufficiently sound, then the case gets tossed due to lack of admissible evidence. Cirrus argued that Lidle's experts are unqualified and their opinions as to the cause of the crash are based on speculation. In other words, that Lidle's "defect" theory is "junk."

Yesterday, after reviewing the opinions of Lidle's experts, the federal judge refused to grant summary judgment.  She expressly found that Lidle's experts are adequately qualified, and that their opinions are reliable. 

That ruling doesn't mean that Lidle wins her case.  It means only that Lidle may present her expert evidence that the crash was caused by a defect in the Cirrus' flight control system to a jury. 

The most relevant stuff starts at page 11. 

Download pdf of opinion here. 

Order Denying Cirrus Design's Motion for Summary Judgment

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Many airports in the western United States are located at altitude.  In the thin air, a departing aircraft's propeller and wings are less aerodynamically efficient.  And without a turbocharger, the aircraft's engine won't be able to produce full power.  All of that hurts the aircraft's ability to climb. Unless the aircraft is handled properly, after lifting off the runway it may travel for a distance on a cushion of air existing between the aircraft's wings and the runway, and then ultimately crash. 

Hot weather makes the air even thinner.  Thus, in hot weather, the airplane behaves as though the airport is at an even higher altitude than it actually is.  The altitude at which an aircraft "thinks" it is operating is called the "density altitude." 

When a pilot combines a high "density altitude" with a heavily loaded aircraft, it can lead to a challenging situation.  In fact, unless the pilot is experienced in "high, heavy and hot" operations, the combination can be a recipe for disaster.  Just a few examples of "high density altitude" accidents involving heavily loaded aircraft can be found in the NTSB database here, here, and here. 

The airport in this video sits 1,300 feet above sea level. That's not particularly high.  However, the temperature on the day of the accident was almost 100 degrees.  That made the airport's "density altitude" more than 4,100 feet.  Add a heavy load and, and even with a turbocharger, the density altitude was too much for this pilot to handle.

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A passenger injured in an aircraft accident can't sue the aircraft manufacturer if the part that caused the crash is older than 18 years. Any such suit would be barred by the General Aviation Revitalization Act, or GARA.

What if the accident was caused by a mistake in one of the aircraft's manuals rather than a defect in the aircraft itself?  If the manual is older than 18 years, does GARA protect the manufacturer from liability for its error? 

It depends.  The manufacturer is off the hook if the manual is properly considered a "part" of the aircraft.  Some manuals are. Some aren't.

A flight manual (sometimes called a "pilot's operating handbook" or "flight handbook") is properly considered "part" of the aircraft, and so GARA protects the manufacturer. For example, in Caldwell v. Enstrom Helicopters, the pilot's family blamed a helicopter crash on the flight manual's failure to say that the last two gallons of fuel in the helicopter were unusable.  As a result, the pilot believed he had sufficient fuel but in fact did not.  He crashed just minutes from his destination.

The Caldwell court said that manufacturers are required by regulation to provide a flight manual when it delivers the aircraft to the customer.  The manual must be carried in the aircraft at all times thereafter. Therefore, the manual was properly considered to be an aircraft "part."  Because the manual at issue was more than 18 years old, GARA applied to protect the manufacturer from liability for any errors. 

But the situation is different when the manual is a maintenance manual. A manufacturer can sell an aircraft without providing to the buyer a maintenance manual.  Thus maintenance manuals, unlike flight manuals, are not a "part " of the aircraft, and GARA doesn't apply. At least according to Rogers v. Bell Helicopters Textron, a case decided earlier this month by a California appellate court. 

In Rogers, the pilot claimed the accident resulted from faulty instructions in a maintenance manual for balancing the helicopter's tail rotor. The court ruled that, despite the fact that the manual was more than 18 years, GARA didn't apply and so the pilot was entitled to sue.  

Unlike a flight manual that is unique to the aircraft, used by the pilot, and necessary to operate the aircraft, a maintenance manual applies to different aircraft models, is used by the mechanic, and only for troubleshooting and repairing the aircraft.

According to Rogers,, GARA won't protect a manufacturer from liability for mistakes in its maintenance manuals, regardless of how old the manuals are. 

The plaintiff in Rogers was represented by Louis Franecke of San Rafael. 

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The General Aviation Revitalization Act immunizes aircraft manufacturers from liability for defects in their products once those products turn 18 years old.  GARA was enacted in 1994.  Back then, more than half the general aviation fleet was older than 18 years. 

In other words, in 1994, the manufacturers were allowed to "walk away" from the majority of the fleet they had produced, as well as any defects that they had built into them. But once relieved of that financial responsibility, the manufacturers were supposed to spring into action and start cranking out new aircraft at more affordable prices. 

True, anyone injured by a defect in an older aircraft would be left without a legal remedy against the manufacturer that caused the injury.  But GARA proponents argued that the flood of new piston aircraft would lead to the older aircraft being removed from service.  In short order, GARA proponents argued, the average age of the aircraft in the fleet would drop and manufacturers would 

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A Philadelphia jury has determined that a defective carburetor caused the 1999 crash of single-engine aircraft that killed four and injured one. The aircraft, a Piper Cherokee Six, was manufactured in 1968. The jury’s verdict included $25 million for compensatory damages and $64 million as punitive damages against the engine manufacturer Avco Lycoming, a division of Textron.

Since the Aircraft was Older than 18 Years, Why Didn’t the General Aviation Revitalization Act Protect Lycoming from Liability?

There are a number of exceptions to the General Aviation Revitalization Act (known as GARA). In particular, GARA doesn’t apply when the manufacturer, in obtaining FAA certification of its part, conceals from the FAA information about defects in the part's design. The jury in this case determined that Lycoming did just that. Thus, GARA was no defense.

The NTSB Determined the Cause of the Crash was Pilot Error. Its Report Didn’t Say Anything About a Defective Carburetor. Why Wasn’t the Jury Bound by the NTSB’s Findings?

The NTSB’s accident reports almost always favor the manufacturers. That’s because the NTSB relies on the manufacturer for help in determining the cause of the crash it is investigating. The NTSB calls this method of investigation the “party system.” 

Of course, asking the manufacturer for help in figuring out if there was a defect in its engine is much like asking the fox for help in determining what happened to the chickens. There’s a built-in conflict of interest. The NTSB is aware of the conflict, but continues using the party system anyway.

Here, after consulting with Lycoming’s experts, the NTSB decided not even to examine the carburetor. Since the NTSB never tore down this critical component, it’s no surprise that the NTSB did not discover any problems with it.

Fortunately for the victims’ families, the NTSB’s conclusions are by regulation inadmissible in court.

Why Did the Jury Award Punitive Damages?

A jury cannot award punitive damages simply because the defendant was negligent, or just

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The NTSB has released its preliminary report of the off-airport landing of Lancair IV-P N9JE at Hilton Head.  The accident killed a jogger but left the plane’s two occupants uninjured. According to the preliminary report, 

Further examination of the airplane revealed that the propeller assembly separated from the crankshaft flange and was missing.

In other words, the crankshaft failed.

One wouldn’t expect a crankshaft to break absent some sort of defect. If that proves to be the case, could the manufacturer of the crankshaft be held liable to the jogger’s family?

The aircraft was built from a kit and was thus "experimental." The engine, however, was not. Rather, according to FAA records, it appears that the engine was an FAA-certified, turbocharged piston engine manufactured by Teledyne Continental Motors, a company that has had its share of lawsuits related to its engines coming apart in flight. 

The General Aviation Revitalization Act, or GARA, protects aircraft engine manufacturers from liability for defective engine parts older than 18 years.

We don’t know how old the engine was in this case.  However, the Lancair builder had reportedly taken the engine from a Piper Malibu.  Piper stopped using the Teledyne Continental TSIO-520 engine in its Malibus due to reliability problems. In 1988, it switched and began installing Avco Lycoming engines instead. Thus, if it turns out that the engine was an original equipment Malibu engine, then it had to be at least 20 years old -- 2 years beyond GARA's age limit.

So is Teledyne Continental Motors off the hook, regardless of whether the jogger's family can prove that the engine was defective? 

No.

There is one important but little-known exception to GARA.  Regardless of the defective part's age, GARA doesn’t protect its manufacturer from lawsuits brought by the families of those killed on the ground.  

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That's the number one question I've been asked about this accident.  Not "why did the accident happen," but "why didn't the pilot use the parachute?"

As I note here, most Cirrus pilots would say that the parachute should be deployed in the event of engine failure, unless there is a long, paved runway beneath the aircraft such that a safe on-airport landing is assured.  But that doesn't mean that, if there is no airport within range, a pilot who opts to glide to a field rather than pull the chute is negligent.

Pulling the parachute has serious risks.  The aircraft's rate of descent under the parachute is high.  Ground impact forces are severe. Cirrus warns that the decision to deploy the parachute should not be made lightly because parachute deployment may result in "severe injury or death to the aircraft occupants."

The Cirrus, like every aircraft, comes with a Pilot Operating Handbook.  That's the "bible" that the pilot is supposed to follow.  The emergency checklist for an "engine out" scenario does not mention the parachute system:

Forced Landing (Engine Out):  If all attempts to restart the engine fail and a forced landing is imminent, select a suitable field and prepare for the landing.

A suitable field should be chosen as early as possible so that maximum time will be available to plan and execute the landing. . .

The checklist then sets forth the 12-step "forced landing" checklist.  No mention of the parachute, anywhere.

In the back of the Handbook, there is a separate section on the use of the parachute.  This section lays out various scenarios in which the pilot should consider deploying the parachute, such as after a mid-air collision, aircraft structural failure, or loss of aircraft control  One scenario deals with engine failures:

Landing Required in Terrain not Permitting a Safe Landing

If a forced landing is required because of engine failure, fuel exhaustion. . .or any other condition, [parachute] activation is only warranted if a landing cannot be made that ensures little or no risk to the aircraft occupants.  However, if the condition occurs over terrain thought not to permit such a landing, such as: over extremely rough or mountainous terrain, over water out of gliding distance to land, over widespread ground fog or at night, [parachute] deployment should be considered.

The pilot was not over "extremely rough or mountainous terrain." He had apparently picked out what he believed to be a suitable field for a forced landing.  The Cirrus Pilot Operating Handbook does not require pilots to deploy the parachute in the situation this pilot faced.  To the contrary, the Handbook leaves that decision to the pilot's discretion:

It is the responsibility of you, the pilot, to determine when and how the [parachute system] will be used.    

Related Post: Cirrus Crash at Morton, Washington

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A Cirrus SR-22, N224GS, crashed yesterday in Washington state.  The pilot was killed.  The passenger was critically injured.  The aircraft departed Concord, California (CCR) in good weather, bound for home.  It crashed in Morton, 60 miles from its destination, which was presumably Renton (RNT).

The accident appears to have been the result of engine failure:

• Witnesses said it was flying "low and silent" just before impact.
• A pilot on frequency says he heard the Cirrus pilot report to Air Traffic Control "saying he was dead stick "no engine" and he didn't think they were going to make the airport."

Facts suggesting that the engine failed because it ran out of gas:

• Fuel exhaustion is the leading cause of engine failure.
• The pilot reported to his wife that he was battling a "stiff headwind." Unexpected headwinds are common to many fuel exhaustion accidents.
• The aircraft was only about 20 minutes from landing, Most fuel exhaustion accidents happen close to the intended destination.
• There was no post-crash fire. No fire suggests that there was no fuel on board to burn.

Facts suggesting that the engine failed because of a mechanical problem:

• Assuming the Cirrus was fully fueled at Concord, the Cirrus should have been able to make Renton even with "stiff" head winds.
• The pilot's widow reports that the aircraft had engine problems that were recently repaired.

Why didn't the pilot deploy the Cirrus parachute? 

There is no consensus among Cirrus pilots as to exactly when the parachute should be deployed. 

• Some pilots say it should not be deployed in the event of engine failure.  Rather, it's safer for the pilot to glide the aircraft to a safe off-airport landing area. 
• Other pilots say the parachute should be deployed in all cases of engine failure unless the aircraft is directly over a long, paved airport runway.

The wreckage photos show that the parachute was, in fact, deployed.  An NTSB investigator has told the press that it cannot be determined at this point whether the parachute was deployed before impact or instead as a result of impact forces.  But the photos strongly suggest that it was deployed by impact forces and not by the pilot. 

March 26 Update:  The NTSB has released its preliminary report of the accident.  Investigators drained 7 gallons of fuel (about half-hour's worth) from the left tank.  That rules out fuel exhaustion -- there was definitely fuel on board the aircraft.  The right tank was ruptured in the crash.  That means it could not be determined if there was any fuel in it before impact.  As a result, while fuel exhaustion can be ruled out, fuel starvation is still a possibility.

In a "fuel exhaustion" accident, the engine stops because there is no fuel left on board the aircraft.  In a "fuel starvation" accident, there is fuel on board, but the engine stops because the pilot has not positioned the fuel valve or valves properly to allow the fuel to flow to the engine.  For example, fuel starvation results when the pilot tries to feed the engine from a tank that is empty.  Fuel starvation most commonly happens after the pilot runs one tank dry, and then fails to switch properly to another with fuel in it.

Fuel starvation is common in aircraft with complex fuel systems.  The Cirrus' fuel system, however, is a model of simplicity.  Point the valve to the left fuel gauge to feed from the left tank, point to the right gauge to feed from the right.  There's not much chance of confusion.

Unfortunately, the NTSB report doesn't say what position the fuel valve was found in: "left," right" or "off."  If the valve was found in the "right" position, fuel starvation remains a possibility.  If it was found in the "left" position (as shown in the photo), that would suggest the engine failed for reasons unrelated to fuel starvation.

Related Post: Should the Pilot Have Deployed the Parachute?

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Only modifications that carry a Supplemental Type Certificate may be legally installed on an aircraft. The Supplemental Type Certificate guarantees that the FAA has thoroughly tested and reviewed the modification. And it's the Supplemental Type Certificate that insures that the modification is safe and compatible with the particular model aircraft on which it’s being installed. Right?

Maybe not. Owners really shouldn't place too much stock in an STC. Or so says one former NTSB accident investigator. The investigator, now retired, explained to me that most owners might be surprised by how little work the FAA does before issuing an STC. Sure, the STC process is a huge paperwork shuffle for the modification's manufacturer. But it's little more than that. The process seldom entails any real independent engineering cross-check on the FAA's part.

"Give me an example", I asked. "OK,' he said. "Let's talk tip tanks."

A popular modification for many models of Cessna single-engine aircraft are wingtip extensions that

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Most general aviation aircraft manufactured today come with "glass cockpits."  Instead of being equipped with mechanical gauges and indicators, they are equipped with computer screens.  The screens integrate and display all sorts of useful flight information.  The information displayed may include satellite weather, synthetic vision, infrared vision, terrain awareness information, traffic information, and moving maps. Glass cockpits are supposed to help improve the pilot's "situational awareness." 

Not surprisingly, glass cockpits have been marketed as a safety advantage.  From the website of one manufacturer, Cirrus Aircraft:

We included new safety features to reduce your work load and anxiety by giving you more time to think and improving flight environment manageability. Ultimately, with [our glass cockpit] you get a smoother, more precise flying experience while all the time knowing you are flying smarter, flying safer.

The NTSB agrees that glass cockpits have the potential to improve safety.  But to the surprise of many, the NTSB has now found that, to date, they have not.  To the contrary, aircraft equipped with glass cockpits have a higher than fatal accident rate than comparable aircraft equipped with the old-fashioned, hard-to-decipher mechanical gauges.

Study analyses of aircraft accident and activity data showed a decrease in total accident rates but an increase in fatal accident rates for the selected group of glass cockpit aircraft when compared to similar conventionally equipped aircraft during the study period. Overall, study analyses did not show a significant improvement in safety for the glass cockpit study group.

How can this be?  More information, presented to the pilot in an easy-to-understand fashion, is supposed to be a good thing.  The NTSB's findings have left many scratching their heads.

I've written before that the poor safety record may simply be the result of "Risk Homeostasis" at work.  Risk Homeostasis theory suggests that, when given the opportunity, pilots will use a safety feature to enhance the aircraft's utility rather than enjoy the increased level of safety the feature could provide.  In other words, pilots use the the glass cockpits to fly into conditions that they would otherwise avoid.  And, instead of painstakingly preparing for the flight before they depart, they prepare "on the fly" (so to speak), relying on the glass cockpit to tell them what they need to know.

A feature - whether it is a glass cockpit or an airframe parachute - can serve as a safety feature or one that enhances an aircraft's utility.  It can't do both.

Related Content From the NTSB:

• NTSB Overview Report (pdf)
• Findings & Recommendations (pdf)
• Closing Comments (pdf)

Related Content From this Blog:

• Recent Crashes Stoke Debate on Cirrus Safety
• Cirrus FIKI Marketing Irresponsible?

Related Content from Max Trescott:

• Glass Cockpits: NTSB Concludes Pilots Need More Training

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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 homes 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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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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The FAA has instituted new rules designed to keep sightseeing helicopters from colliding with airplanes that are transitioning the Hudson River Corridor near the Statue of Liberty.  The San Francisco Daily Journal, California's largest legal newspaper, published this column on how the new rules came to pass, and why they aren't enough.

FAA and NTSB Battle Over Aviation Safety

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The NTSB's preliminary report on the crash contains little more than what was in the news accounts. The report does, however, offer one bit of new information.  The helicopter impacted on a magnetic heading of 230 degrees.  That heading is not in line with the route from Reno to Susanville.  While that might ultimately prove to be important, little can be made of that information without a careful examination of the layout of the terrain near the accident site and the roadway that the pilot might have been using to aid in his navigation.     

Though the information in the NTSB's official report is sparse, an NTSB spokesman did offer his expanded comments to Mary Pat Flaherty, a reporter for the Washington Post who has been following the poor EMS safety record during the past months. The NTSB's Ted Lopatkiewicz told Flaherty that the Mountain Lifeflight helicopter didn't have certain important safety equipment.  Lopatkiewicz was referring to the helicopter's lack of an autopilot, a ground proximity warning system, night vision goggles (discussed in this post), and other equipment necessary to navigate in poor weather.

But in this case the pilot was flying in good weather.  He did not collide with the ground because he could not see it.  Rather, as discussed here, it appears that the pilot crashed because of some type of mechanical problem with the helicopter.  It's unlikely the helicopter's lack of advanced equipment played any role in the accident at all. 

Related Posts:

Compensating the Families of the Mountain Lifeflight EMS Crash

Mountain Lifeflight EMS Helicopter Crash at Doyle, California

EMS Helicopter Safety: NTSB Pushes the Envelope

OSC: FAA Ignoring EMS Helicopter Dangers For Fear of Negative Publicity 

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Aircraft engine manufacturers recommend that owners overhaul their engines when they accumulate a certain amount of operating time, usually between 1200 and 2400 hours depending on the engine's make and model. For example, Teledyne Continental Motors suggests that owners overhaul its IO-550 model engine at 2000 hours. Textron Lycoming suggests that owners overhaul its O-235 engine, like the one pictured, at 2400 hours.

Overhauls are expensive.  Some can cost $40,000 or more.  An increasing number of owners opt to run their engines 200, 400 or more hours past the manufacturer's recommended "time between overhauls," or TBO.  Once past TBO, they may take extra precautions by, for example, regularly sending out engine oil samples for spectrographic analysis, checking the engine’s compression, and looking inside certain parts of the engine with a boroscope to insure that  things look good. They feel the manufacturer's TBO recommendations are somewhat arbitrary. By running their engines past TBO they are squeezing more life out of them, and that just makes good economic sense.

The FAA does not require private owners to comply with the manufacturer’s stated TBO interval. The manufacturer's TBO is therefore advisory only.  As long as a properly certified mechanic has

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Burdett v. Teledyne Continental Motors involved the forced landing of a Beech Bonanza after the Teledyne Continental IO-550 engine installed in the aircraft came apart in cruise flight. The passenger was severely injured.

The National Transportation Safety Board blamed the engine failure on the mechanic who last worked on the engine, and cleared the engine manufacturer, Teledyne Continental, from any liability. 

We suspected that the NTSB's determination had been influenced by Teledyne's engineers, who the NTSB had allowed to assist in the investigation, despite the obvious conflict of interest that presented.  We thus conducted our own, independant investigation.  We concluded that, contrary to the NTSB's findings, Teledyne Continental was to blame.  After a six-week trial, the jury agreed.

At its annual convention in San Francisco, the California Trial Lawyers Association, known as the Consumer Attorneys of California, honored aviation accident attorney Mike Danko as a Trial Lawyer of the Year finalist for 2009 in recognition of our work in the Burdett case. The Trial Lawyers Association showed this video presentation during the ceremony.

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An A-Star AS350B air ambulance helicopter crashed November 14 at Doyle, California, killing the three crew members on board.  According to an article in the Reno Gazette Journal, the pilot made a distress call before the crash. That indicates that the pilot was likely experiencing a mechanical emergency. The photographs accompanying the article show that the wreckage was spread over a fairly large area.  That indicates that the pilot lost control of the helicopter well before he was able to attempt an emergency landing.

Under the circumstances, the NTSB will be looking at the helicopter's hydraulic actuator system carefully.  The actuators move the helicopter's rotor blades, allowing the pilot to control the flight of the aircraft. The AS350B's hydraulics -- similar to a power steering system in a car --  help move the helicopter's actuators. 

The A-Star helicopter's hydraulics have a troubled history. The hydraulic system seems to fail frequently.  Without hydraulic assistence, the pilot may find it hard to move the actuators and thus the helicopter can be difficult to control.  In fact, one of the country's largest operators of A-Star helicopters is on record as saying that the design of the helicopter's hydraulic system is so prone to failure that it is defective and dangerous and needs to be redesigned.  

While a problem with the hydraulic system can make the helicopter difficult to control, a disconnected actuator control rod will make the helicopter impossible to control. That's what happened in 2007, when an AS350B just like the one in involved in this accident crashed in Hawaii, killing four tourists.

Days after the accident in Hawaii,  the A-Star helicopter's manufacturer, Eurocopter, issued a Special Airworthiness Bulletin (see below) prompted by two previous fatal accidents, warning of the consequences of loose servo control rod end fittings. 

This condition could lead to flight control disconnect and subsequent loss of aircraft control. Two fatal accidents have occurred after the servo-control rod end-fitting became detached from the servo-actuator. 

Of course, it's far too early to say what caused the Mountain Lifeflight accident.  But the helicopter's hydraulic actuator system is certainly something that needs to be looked at very carefully.

December 6 Update: More on this accident here.

January 14 Update: On Compensating the Mountain Lifeflight Families here. 

AS350BService Bulletin

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This past April, the NTSB called upon the FAA to ground the entire fleet of Zodiac aircraft because their wings tend to fall off in mid-flight.  As it turns out, a defect in the Zodiac's design induces an aerodynamic phenomenon known as flutter.  Flutter can destroy a wing or other control surface in a matter of seconds.  This well-known, dangerous, but rare condition is shown occurring in the tail surfaces of other aircraft types here and here. 

When the NTSB's issued its "urgent recommendation," a total of ten people had already been killed in Zodiacs due to flutter-induced failures.  Back then, the NTSB was under heavy fire for sitting on a long list of NTSB recommendations pertaining to a number of different aviation industry sectors while lives were being lost. Because of that, I figured that this was one recommendation the FAA would act on, and fast.

The FAA will see Zodiac's manufacturer as an easy target and move against it -- if for no other reason than to quiet its critics.

I was wrong.  The FAA refused to ground the aircraft.  Even I was surprised.

Of course, it was just a matter of time.  On November 6, another Zodiac crashed in Arkansas.   It looks like another flutter-induced failure.  That brings the death toll to 11.  On November 13, the NTSB issued an official "I told you so."

The Safety Board's urgent recommendation to the FAA was to "prohibit further flight of the Zodiac CH-601XL, both special light sport aircraft and experimental, until such time that the FAA determines that the CH-601XL has adequate protection from flutter." The FAA replied in July that they lacked "adequate justification to take immediate certificate action to ground the entire fleet." 

The NTSB's unstated question:  Just how many deaths are required before the FAA finds "adequate justification" to act?

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The families of the victims of the Zodiac crash near Oakdale, California, have filed suit against the aircraft's maker, Zenith Aircraft, alleging that the Zodiac's design is defective. The Zodiac is the two-seat aircraft whose wings tend to break off in flight due to a design-induced aerodynamic phenomenon known as flutter.  That appears to be exactly what happened in the Oakdale crash. The design has caused at least 10 deaths so far. 

According to the Modesto Bee, Zenith Aircraft is blaming the pilot and passenger for getting into the airplane it designed.

 Zenith Aircraft said the crash was caused by the "negligence" of [the pilot and his passenger]. The company said both had "full appreciation" of the risks involved.

As discussed here, months ago the NTSB called upon the FAA to ground all Zodiacs. The FAA, however, has yet to do so.  Unfortunately, the NTSB has no power to ground an aircraft on its own.  It doesn't matter how bad the design of the aircraft is; only the FAA can ground a fleet. 

The FAA refuses to act, and Zenith Aircraft won't accept responsibility for the fatal flaws in its aircraft's design.  Lawsuits brought by aviation accident lawyers like the families' lawyers in this case seem to be the only way to prevent others from being killed in the Zodiac. 

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1. The National Transportation Safety Board Secures the Wreckage on Site. The wreckage usually remains at the site of the aircraft accident until the National Transportation Safety Board arrives. The Board investigator immediately secures the wreckage and makes sure no one tampers with it.  The Board investigator inspects, documents, and photographs the wreck.

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Maintenance manuals tell the mechanic when to perform an inspection or service, and how to perform it.  Many mechanics believe that the regulations require them to follow the book exactly. But in an excellent column on this murky subject, mechanic and aviation author Mike Busch sums up the regulatory requirements nicely:

The manufacturer's “how-to” instructions are compulsory, but the manufacturer’s “when-to” instructions are not.

Let's say, for example, that the manual requires the aircraft’s spark plugs to be removed and regapped every 100 hours. If a mechanic decides to service the aircraft’s spark plugs, he must do it exactly as instructed in the aircraft manual. The regulations, however, do not require the mechanic to follow the manufacturer's instructions at all concerning when or how often to service the plugs, regardless of how much time the engine has accumulated. As Busch explains:

No manufacturer can mandate any maintenance requirement on a part 91 aircraft owner; only the FAA can do so.

There is another part of the story, however, that Busch's column doesn't address. The FAA regulations are bare minimum requirements only.  If an accident occurs because the mechanic failed to comply with the manufacturer’s recommendations, questions can arise as to whether the mechanic was negligent – that is, not reasonably careful -- and thus liable to those injured as a result.  A jury may conclude that, though the regulations didn't require him to, a reasonably careful mechanic would have followed the manufacturer's recommendations anyway.  After all, does a reasonably careful mechanic believe he knows better than the manufacturer? 

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We count on the NTSB to get the facts right. That confidence is, unfortunately, sometimes misplaced. The truth is that the NTSB gets it wrong. A lot. I’ve written about that here, here, and here.

The NTSB has now given us further reason to question whether it deserves the confidence we place in it. On Friday, the NTSB came out with a block-buster press release condemning the Teterboro air traffic controller who had cleared the Piper airplane for takeoff. According to the NTSB's report, the Teterboro controller could see on his radar screen that the Piper pilot was on a possible collision course with the Liberty Tours helicopter. In fact, according to the NTSB, the controller could see the conflict before the Piper pilot switched off from the Teterboro controller’s frequency. Yet, according to the NTSB, the controller failed to warn the Piper pilot.

At 1152:20 the Teterboro controller instructed the pilot to contact Newark on a frequency of 127.85. . . At that time there were several aircraft detected by radar in the area immediately ahead of the airplane, including the accident helicopter, all of which were potential traffic conflicts for the airplane. The Teterboro tower controller, who was engaged in a phone call at the time, did not advise the pilot of the potential traffic conflicts.

That was wrong. True, the controller was on the phone when he should not have been.  But the helicopter did not appear on the controller’s radar screen until after the Piper pilot was supposed to have switched to a new frequency. Of course, by then it was too late for the controller to advise the pilot of anything. In other words, it appears that there was nothing the controller could have done -- whether he was on the phone or not.

Over the weekend, the air traffic controllers’ union privately asked the NTSB to correct its error. The NTSB refused. So today the union issued its own press release setting the record straight.  The press release claims that the NTSB's account, which implies that the controller should have prevented the accident, is "outright false" and "misleading."  Worse, it charges that the NTSB knows it, but refuses to correct its error.

This afternoon, after the controllers' union went to the press, the NTSB finally conceded that it was, in fact, wrong. It thus issued a new press release, explaining that the controller could not have seen the helicopter after all.

The accident helicopter was not visible on the Teterboro controller's radar scope at 1152:20 [when the controller instructed the Piper to change frequencies]; it did appear on radar 7 seconds later - at approximately 400 feet.

The NTSB offered no apology for its error. Nor did it offer an explanation. Rather, despite that the union was right, and the NTSB was wrong, the NTSB’s only reaction was to kick the union off the investigation.

The NTSB’s blunder was a whopper. It laid blame for the accident where it does not appear to belong.  The NTSB's only interest is supposed to be in getting the facts right. If that’s so, why did it not correct its error when the union asked it to?  Why did it require the union to force the issue? 

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Compared to pilots in other countries, pilots in the US have extraordinary freedom. Of course, to keep commercial airliners safe from collisions, pilots of small aircraft are excluded from certain airspace near major airports unless they have first obtained a clearance from air traffic controllers.  If a pilot obtains the necessary clearance, controllers will dictate the pilot's path and use radar to monitor the pilot's every move. 

But that still leaves many places where pilots are permitted to fly without being supervised or controlled in any way.  One such area, appropriately enough, is near the Statue of Liberty.  As long as the pilot stays below 1100 feet -- outside the airspace used by airliners -- the pilot doesn't need a clearance, doesn't need to have filed a flight plan, and doesn't need to communicate with any tower or other air traffic control facility. The pilot is totally on his own.

Many non-pilots are surprised to learn that the method used to prevent collisions in such uncontrolled areas is called "see and avoid."  The pilot is supposed to look out his window, "see" the other aircraft, and "avoid" them.  Pilots talk about having to "keep their head on a swivel" when flying in uncontrolled airspace. Though this method of collision avoidance may sound primitive, over the years it has worked well.

There is one problem.  Helicopters and airplanes don't mix well in a "see and avoid" environment.  Helicopters fly slower than airplanes.  And because they have a small cross section, they are hard to spot -- especially when viewed from directly behind. That puts them at risk of being rear-ended.  It doesn't help matters that helicopters tend to manuever in a fashion that most airplane pilots find to be unpredictable. 

Because of all that, helicopter pilots are supposed to "avoid the flow" of airplane traffic.  In other words, as best they can, they are supposed to stay out of the way. Unfortunately, when both a helicopter and airplane are headed to the same spot, or are both looking at the same feature on the ground, that can be difficult to do.

We don't know what factors combined to result in the midair over the Hudson.  But the NTSB has long recognized that when it comes to uncontrolled airspace, helicopters -- especially tour helicopters -- don't mix well with airplanes.

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The G36 Bonanza's closest competitor is probably the Cirrus SR22. Would the outcome of this accident have been different had the Beechcraft been equipped with a ballistic parachute system, like the system installed in the Cirrus, depicted here?  Probably not.  For the Cirrus' ballistic parachute to work, the plane needs at least 400 feet of altitude.  Although we don't know how high N618MW climbed before its engine quit, it's unlikely it reached 400 feet.  That's an altitude the aircraft probably wouldn't have achieved until well after crossing the end of the runway. As this illustration shows, the Bonanza never made it that far.

The NTSB has now released its Preliminary Report.  The report can be found here.  There's no new information in the report, and certainly nothing that causes us to rethink the analysis we wrote about here.  

As usual, the NTSB report contains no conclusion concerning the cause of the crash.  For that, we have to wait until the NTSB issues its Probable Cause report.  Some news sources, such as the one here, are reporting that the probable cause report will be issued in the next 6 to 9 months.  That's doubtful. Except in the simplest of cases, it takes the NTSB at least 18 months to issue its probable cause report.  Sometimes, it can take as long as four years.    

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Bonanza N618MW, a Beechcraft like the one pictured below, was doing "touch & goes" at Jack Northrop field in Hawthorne.  "Touch and goes" are practice landings where the pilot does not stop on the runway.  Instead, after the wheels touch down, the pilot advances the throttle, takes off again, and then circles around for another landing.  Everything appeared to be fine until, on one of the "goes", the Bonanza's engine quit.  The Bonanza crashed into a parking lot.  The three people on board were killed. 

Why did the engine quit?

Fuel?  Most engine failures are the result of either fuel exhaustion (no avgas in any of the aircraft's tanks), fuel starvation (pilot fails to switch to a full tank when the one he is using runs dry), or fuel contamination (water or jet fuel has found its way into the avgas).  So in any case involving engine failure, fuel has to be considered.

When, as here, there is no post-crash fire, fuel exhaustion is a prime suspect. No fire often means that there was no avgas (aviation gasoline) on board to burn. But it's unlikely this accident was caused by fuel exhaustion.  Though it didn't ignite, there was plenty of avgas spilled on the parking lot where the aircraft crashed. That means there was fuel on board.

Did the pilot fail to switch to a full tank when the one he was using ran dry? That, too, is unlikely.  Witnesses reported that the aircraft was streaming smoke.  An airplane doesn't stream smoke when it runs out of gas.  So both fuel exhaustion and fuel starvation can probably be ruled out as a cause of the engine failure..

Could the engine have quit because of fuel contamination?  If the avgas was contaminated with either water or jet fuel, the engine would have failed on the first takeoff. It would not have been able to perform multiple takeoffs before quitting. Nor would the engine have smoked. We can likely rule out fuel contamination.

Mechanical Failure.  Once fuel issues are ruled out, mechanical failure appears as the next most likely cause of the engine's quitting. Aircraft engines are not supposed to fail without warning. When they do, it is often because of something the engine manufacturer did or failed to do. For example, the manufacturer may have designed the engine improperly or carelessly assembled it. Some of the legal theories that the victims' families can assert to hold the manufacturer responsible are discussed here and here.

The engine installed in N618MW was a model IO-550.  It was manufactured by Teledyne Continental Motors.  Engine manufacturers such as Teledyne often try to avoid liability for causing an accident by asserting the protection of the General Aviation Revitalization Act, or GARA, discussed here.  However, the engine installed in N618MW was manufactured in 2005.  GARA does not apply to engines that are less than 18 years old, such as this one, and so the families will be legally permitted to hold Teledyne responsible for any defects in the engine.

The NTSB Investigation.  The NTSB is investigating the cause of the crash.  The NTSB will ask Teledyne Continental Motors to participate in the investigation, and to help it determine the cause of the accident.  As part of the investigation, the NTSB, along with representatives of Teledyne, will disassemble the engine and test its various parts. (Pictured right is an IO-550 engine being disassembled after a crash in 2001.) Of course, since Teledyne itself might be responsible for the crash, it's participation in the investigation presents a conflict of interest.   It is like the police asking the suspect for help in solving the crime. To make matters worse, the NTSB will not allow the victims' families or the families' lawyers to participate in the investigation at all. The conflict of interest is discussed further here.

The conflict of interest makes for biased NTSB reports that tend to favor the manufacturers.  In one recent case, a Teledyne model IO-550 engine -- just like the one in this case -- was installed in a Beechcraft Bonanza that had departed Van Nuys, Californa.  The engine quit and the plane crashed. The NTSB asked Teledyne Continental Motors to participate in its investigation and help it determine why the engine failed.  Not surprising, after hearing only Teledyne's side of the story, the NTSB determined that the engine failed because of poor maintenance, and not anything that Teledyne did.  In fact, the NTSB cleared Teledyne completely of any blame.  We investigated ourselves and later brought the matter to trial. After hearing all the evidence in the case -- not just the evidence favorable to Teledyne -- the jury disagreed with the NTSB.   The jury determined that the engine quit because Teledyne's IO-550 maintenance manuals were wrong, and awarded the injured passenger $15 million. 

What to do? Teledyne Continental Motors and its lawyers are already "investigating" the crash.  The families should consider retaining competent aviation lawyers immediately.  The families' lawyer can begin their own investigation and make sure that important evidence is preserved.  Unfortunately, the families cannot rely on the NTSB to find answers. They need to find their own.

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Special rules protect careless health care providers in California.  The rules, collectively known as MICRA, were designed to make it harder for medical malpractice victims to sue the doctors who injure them. For example,

• The medical malpractice victim must provide the defendant doctor a special notice before filing suit.
• At any trial, special rules of evidence apply that favor the doctor.
• There is a $250,000 limit on what the negligent doctor or his insurance company ever has to pay to compensate parents when the doctor causes their child's death.
• An injured party cannot recover against a negligent doctor more than the $250,000 limit for causing any sort of pain or disfigurement. 

But what do the MICRA rules have to do with helicopter crash cases?

In March 2008, a California court of appeal ruled that the medical malpractice rules apply to the claims of a someone injured in an ambulance.  In that case, called Cannister v Emergency Ambulance Service, the court ruled that a negligent ambulance company that injures a patient en route to the hospital was entitled to all the protections of MICRA, because the ambulance company was properly considered a “health care provider.” The ruling extended the umbrella of MICRA's protection from doctors to ambulance drivers, at least when those drivers are licensed as EMT’s.

An EMS air ambulance company will undoubtedly argue that Cannister -- regardless of how unfair -- applies not just to road-bound ambulances, but to air ambulances as well. The aviation lawyer must keep the MICRA rules in mind in handling EMS helicopter accidents in California, and he should be familiar with the strategies that medical malpractice lawyers use to minimize MICRA's unfair impact on his clients.  

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The pilot's original destination was Bozeman, Montana.  But the pilot amended his flight plan and diverted to Butte.  The pilot did not tell air traffic control why he was diverting.  About 25 minutes later, as the aircraft approached for landing at Butte, it went out of control and crashed. 

The NTSB is now investigating two things: (1) why the pilot diverted to Butte, especially when he was so close to Bozeman, and (2) why the pilot lost control and crashed so near the runway at Butte.

Some possible explanations for diverting include:

• Low fuel;
• Concerns about weather at the destination;
• Sick passenger;
• Need for a bathroom;
• Mechanical issues;
• Medical issue afflicting the pilot.

Some possible explanations for losing control of an aircraft on approach to landing include:

• Mechanical/structural issues;
• Icing;
• Improper weight and balance (aircraft load not properly distributed);
• Pilot error;
• Medical issue afflicting the pilot.

 “Occam’s Razor” suggests that a theory relying on one anomaly to explain an accident sequence is more likely to be correct than one relying on two anomalies. In other words, the simplest answer is usually the best answer.  Here, one anomaly that explains both the mysterious diversion to Butte and the loss of control 25 minutes later is a medical issue afflicting the pilot.

A Butte coroner, Lee LaBreche, autopsied the pilot. He found that the 65 year-old did, in fact, have heart disease.  He thus noted that "the presence of a pathologic condition of the heart causing this accident cannot be excluded."  Nonetheless, LaBreche felt a heart attack was unlikely because the pilot never reported any symptoms to air traffic control. According to Examiner.com:

Federal investigators have said that in [the pilot's] last recorded communications with air traffic controllers he gave no indication of any problems. LaBreche said that supports the premise that there was no medical emergency.

The coroner's reasoning is flawed. Pilots have little hesitancy about reporting mechanical problems.  However, a pilot would be very reluctant to report to air traffic control that he is having the symptoms of a heart attack.  That sort of report will keep a pilot grounded for a long, long time, even if the symptoms ended up being a false alarm. So, while the fact that the pilot reported no problems may support the premise that he had no mechanical issue, it says nothing about whether he had a medical issue.  For those who favor Occam’s Razor as an investigatory tool, a heart attack is the most likely cause of this accident.

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The General Rule

Mechanics are required by regulation to follow the instructions set forth in the manufacturer's maintenance manuals when working on an aircraft.  The mechanic is not allowed to deviate from the instructions covering the work he undertakes.  If he does deviate, and someone is injured as a result, the mechanic is liable.

Service Bulletins

Sometimes, a manufacturer learns of a problem with the way its product is performing in the field. The manufacturer may then issue a “service bulletin” to warn the industry of the problem and how to correct it.  For example, when it learned that its exhaust valves were failing at an unacceptably high rate, one engine manufacturer  issued a service bulletin requiring that those valves be inspected regularly (pdf) and, if necessary, repaired or replaced.  The service bulletin warns that failure to perform the inspection can result in engine failure.  Because the risk is so great, the manufacturer labeled this particular service bulletin "mandatory."

If a mechanic works on an aircraft but returns it to service without performing the "mandatory" inspection, is the mechanic responsible to those injured if the engine quits shortly thereafter due to valve failure?

You might think so.   After all, of all the manufacturer's instructions, those in the service bulletins might be the most important.   However, the regulations allow mechanics to ignore service bulletins entirely, even “mandatory” ones, and still pronounce the aircraft to be "airworthy."  That is, at least when working on aircraft operated under Part 91 of the FAA regulations—the section under which most general aviation aircraft are operated.   

The Industry Practice

When an aircraft is brought into the shop for service, many mechanics provide the owner with a written list of the service bulletins that apply to the owner's aircraft.  Unless the maintenance manuals expressly require the mechanic to comply with all service bulletins, the mechanics leave that decision to the owner. After explaining to the owner the work entailed, its cost, and its importance to flight safety, these mechanics require the owner to direct them, in writing, either to comply with the various service bulletins or to ignore them.

The mechanics keep the owner's written instructions on file.  In the event of an accident, the mechanic will argue that, although he was the one who pronounced the aircraft "airworthy," it was the owner who decided not to follow the manufacturer's recommendations.  The mechanic will argue that therefore the owner, not the mechanic, is the one responsible for the resulting injuries or death.  

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Cory Lidle's wife and Tyler Stanger's family are suing Cirrus Design, alleging that a problem with the plane's flight controls caused Lidle and Stanger's plane to crash into a Manhattan hi-rise.

Miles O'Brien, a former CNN correspondent, calls the lawsuit frivolous, because the NTSB concluded the cause was pilot error.  According to O'Brien, "in our litigious society, the facts don't matter for much."

O'Brien is missing the fact that the NTSB's conclusion is marred by a built-in conflict of interest. That’s because the NTSB allowed Cirrus to participate in the investigation, but not the families or the families’ experts. Is it any surprise that the NTSB’s final conclusions favored the manufacturer?

There is a known problem with the Cirrus ailerons jamming at full deflection. After this accident, Cirrus published a number of service bulletins in an attempt to correct the problem and, ultimately, the FAA issued an Airworthiness Directive against the aircraft. That doesn't necessarily mean that the aileron problem caused the Lidle crash. But the families are entitled to use the power of subpoena that comes with filing a lawsuit to investigate what happened. They don’t have to simply accept the NTSB’s conclusion — a conclusion the NTSB reached after closed-door meetings with Cirrus’ experts. 

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The Cirrus is a “new generation” aircraft loaded with safety features. For example, if a pilot flying after dark gets too close to a ridge line, the Cirrus' on-board Terrain Awareness Warning System generates a voice urging him to “Pull Up! Pull Up!”  The plane’s wings secrete fluid that helps prevent them from icing up in poor weather. The cockpit has airbags, and its seats protect the passengers in a crash by absorbing 26 times the force of gravity.  The Cirrus is the only aircraft of its kind that comes with a rocket propelled parachute that can shoot out of the back of the plane in an emergency. Partly as a result of all its safety features, the Cirrus has become the most popular general aviation aircraft, with sales surpassing long-time industry leaders Cessna, Beechcraft, and Piper.

Critics, however, say that the aircraft has a lousy safety record, with a fatal accident rate significantly higher than the “old style” Cessnas and Beechcrafts. They say that the Cirrus, made mostly of fiberglass rather than the traditional aluminum, is not crashworthy. Not only does the fiberglass splinter instead crushing to absorb impact forces like aluminum, but they say the fiberglass and the parachute are prone to catching fire after impact with the ground.  They point out that, unlike other aircraft, the Cirrus is not recoverable if the pilot enters an inadvertent spin.  

Cirrus owners say their aircraft is well-designed and that its safety record is not bad when compared to aircraft performing the same mission, rather than to the population of general aviation aircraft as a whole.  Some Cirrus owners argue that the critics should be disbelieved because they are either salesmen trying to sell Cessnas or, worse yet, plaintiffs' lawyers.

So, where does an owner who is also a plaintiffs' lawyer weigh in on the debate?

The Safety Record:  

Cirrus fans who parse the statistics miss the point.  Cirrus markets itself as a company dedicated to providing “unprecedented levels of safety.”   Spend some time with the statistics and you have to conclude that the Cirrus is, at best, only marginally safer than other aircraft.  But no matter how you look at it, Cirrus' safety record is nothing to brag about.  The aircraft may have been designed to provide “unprecedented levels of safety” but, in practice, it really doesn’t.

Why the Record Fails to Live Up to the Design’s Promise: 

My bet is that “Risk Homeostasis” is at work.  Risk Homeostasis theory suggests that, when given the opportunity, pilots will use a safety feature to enhance the aircraft's utility rather than enjoy the increased level of safety the feature could provide.  For example, a pilot without on-board weather equipment will go many miles out of his way to avoid a deadly thunderstorm, regardless of how inconvenient, because he is uncertain where the storm begins or ends.  If given weather depiction equipment, the pilot will use it to get closer to the thunderstorm than he otherwise would.  Because the equipment provides better information concerning the storms contours, the pilot will not give the storm the same wide berth and will instead cut his safety margins and shorten his trip.  

Similarly, a pilot who would not otherwise fly over inhospitable terrain due to fear of engine failure might make the flight if his plane has a built-in parachute, because the parachute improves the odds of surviving should the engine quit.  By choosing to make the flight, the pilot has used a safety feature (the parachute) to increase the plane's utility, but he takes a risk he would not otherwise have exposed himself to. 

The Marketing Should Be Changed:  

A feature should be marketed as either a safety feature or a feature that increases an aircraft's utility.  To blur the distinction is to invite trouble.  And that's what Cirrus' marketing does.  For example, Cirrus now sells an improved anti-icing system for its aircraft.  Should the system be used to increase safety?  Or to increase the aircraft's utility?  It can't do both.  But according to Cirrus' website: 

Cirrus again delivers increased aircraft safety and utility. With Known Ice Protection. . .pilots can now launch or continue flight with the peace of mind . . .that they're both legal and safe. . .

This type of marketing only invites trouble.   

The Training Should Be Changed: 

Pilots who fly Cirrus aircraft need to be trained on the differences between using a feature to enhance safety and to increase the aircraft's utility.  Using a feature to increase the aircraft's utility necessarily undermines the feature's safety benefits.

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The General Aviation Revitalization Act, known as “GARA,” immunizes general aviation manufacturers from lawsuits for defectively designed or manufactured aircraft that are more than 18 years old. Regardless of how serious the defect, if the aircraft is more than 18 years old, an injured victim cannot sue its manufacturer.

There are exceptions.  An injured party can sue the manufacturer regardless of the defective aircraft's age if:

• The aircraft, when first certified, seated 20 or more passengers;
• The aircraft is engaged in “scheduled” passenger operations;
• The victim was a passenger (not a crew member) in an air ambulance;
• The manufacturer misrepresented important information about the aircraft’s safety to the FAA during the aircraft certification process;
• The accident occurred as a result of a part that was replaced on the aircraft less than 18 years before the accident; or
• The victim was not an occupant of the aircraft.

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Today the NTSB issued an "urgent" safety recommendation, asking the FAA to immediately ground all Zodiac CH-601XL aircraft.  The reason:  their wings tend to fall off.  So far, six have broken up in flight, causing 10 fatalities.  The NTSB suspects that the design of the aircraft induces "flutter"-- an aerodynamic phenomenon that can destroy an aircraft in seconds.  This short NASA video depicts flutter nearly destroying the tail on a Piper Twin Comanche.

Will the FAA act on this recommendation or, like it has with regard to so many other NTSB recommendations, simply ignore it?  I'm betting that this is one the FAA will act on.  As I've noted before, the FAA has been under increasing fire for sitting on NTSB recommendations while lives are lost. The FAA will see Zodiac's manufacturer as an easy target and move against it -- if for no other reason than to quiet its critics.

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