We don’t know much yet about the plane crash in Alaska that killed the pilot and 8 tourists from the MS Westerdam.  But the crash looks eerily similar to the Alaskan crash that killed Senator Ted Stevens and three others in 2010.

Like the plane that was involved in the Westerdam crash, the plane that crashed with Stevens Otter Senator Stevens Crashaboard was a de Havilland Otter retrofitted with floats and a turboprop engine. Both tour pilots encountered adverse weather that is common in Alaska:  Low Ceilings. Fog. Gusty winds.  

In the Steven’s crash, instead of turning around when he encountered the low clouds, the pilot pressed on.  Unable to see where he was going, he inadvertently flew into the side of the mountain. (The local papers were calling the pilot a "hero" because not everyone aboard was killed. I had to disagree.)

In last week’s crash at Ella Lake, the weather conditions were similar.  It looks as though the pilot,Promech Air Otter employed by tour operator Promech Air, inadvertently flew into the clouds and struck the side of a cliff.  

This sort of accident is not uncommon, particularly in Alaska and Hawaii.  The type of accident is called "controlled flight into terrain."  It is almost always due to pilot error. 

Blue Hawaiian helicopters was probably the last tour operator that flew a perfectly good aircraft into the side of a mountain due to low clouds.  Compare the photo of the weather conditions that contributed to the Blue Hawaiian crash (left) with the photo of the weather conditions that the Promech Air pilot tried to fly through.  Note how, in both photos, the clouds obscure the mountain tops.

Otter Crash near Ella Lake Alaska weather

 

 

Eddie Andreini’s plane slid to a stop at show center and caught fire.  Eddie was trapped inside. The crowd watched, prayed, and waited for fire trucks to arrive. Some bystanders wanted to rush to the plane to help Eddie get out, but the announcer warned everyone to stay back and "let the firefighters do their job."

But the firefighters didn’t do their job. By the time the trucks showed up, almost 5 minutes had passed and it was too late. Eddie survived the impact unharmed, but died of burn injuries.

The Travis Air Force base fire trucks were supposed to be positioned at show center so that, in case of a crash, they would have immediate access to the runway.  Where were they? Those who were at last year’s "Thunder Over Solano" air show want to know and so does Eddie’s family.  But within hours of Eddie’s death the Air Force closed ranks.  Since then, it has simply refused to explain itself to anybody.

  • The Air Force declined to answer any questions at all from the family in the days and weeks following the accident.
  • Though it had by law only 20 days to respond to our formal request under the Freedom of Information Act, the Air Force ignored that deadline altogether and gave us nothing.
  • The Air Force had six months to respond to the family’s official claim under the Federal Tort Claims Act. That deadline has also long passed.  The Air Force hasn’t offered so much as a phone call in response.

So what is the Air Force hiding?

It looks as though there are three three things the Air Force doesn’t want to talk about.  

First, Travis didn’t place its trucks at show center as it was supposed to.  Instead, it parked them more than a mile away. 1.3 miles away, to be exact. 

Second, Travis brass told the firefighters that, in responding to any fire, they could drive their trucks down the taxiways no faster than 25 miles per hour.  That speed limit applied to all the fire trucks, including the Air Force’s so-called "Rapid Intervention Vehicle," designed and built to get to the scene at top speed and start applying foam before the big trucks arrive.  

Third, the Travis firemen may not have been in their station and ready to respond like they were supposed to be.  Rather, it looks as though they may have been out across the field taking pictures of airplanes parked on the grass.

Today we filed suit against the Air Force on behalf of Eddie’s family.  The Air Force has 60 days to respond. 

Andreini vs. Air Force

Dr. Ken Gottlieb’s Cessna 182 took off from Napa Airport with only Dr. Gottlieb aboard. As the Cessna climbed from the runway, it turned in the wrong direction. It collided with high terrain just north of the airport. Dr. Gottlieb was killed on impact. His body was ejected and the aircraft exploded and burned.

The NTSB ruled the crash was caused by pilot error, finding that Gottlieb encountered poor weather, became confused, and failed to follow the correct instrument departure procedure.Dr. Ken Gottlieb

The family asked us to investigate. We learned that Gottlieb’s instructor had flown with Gottlieb a few days before the crash. The instructor found Gottlieb (pictured right) to be well-versed in the Napa departure procedure and otherwise meticulous in his flying. The instructor felt it unlikely that Gottlieb would become confused and turn in the wrong direction. As far as the instructor was concerned, whatever caused the crash was “out of Ken’s control.”

Faride Khalaf (pictured below) was the plane’s mechanic.  We learned that Khalaf began working on general aviation aircraft only after he was fired from United Airlines. We uncovered evidence that Khalaf had performed maintenance on Gottlieb’s aircraft without properly recording the work in the aircraft’s logs. In fact, Khalaf performed undocumented repairs on the pilot’s seat just a few weeks before the crash.

We examined what little remained of the wreckage and found two things that were unusual. First, we saw evidence that, at the moment of impact, the pilot seat was in the full aft position. Second, the pilot’s seat belt was unbuckled.

Based on their forensic work, our experts testified that as Gottlieb climbed away from the runway, his seat suddenly and unexpectedly slid to its full aft position and jammed. Gottlieb’s hands and feet could not reach the aircraft’s controls and the aircraft flew off course, out of control. Gottlieb unbuckled his seat belt so that he could scoot on his knees up to the aircraft’s control wheel.  But before Dr. Gottlieb could regain control of the aircraft, it crashed into the hillside.

Faride KhalafThe pilot seat slid back and jammed because Khalaf’s undocumented work was improperly performed.  He charged the aircraft owners for new seat parts, but did not install them. Instead, he illegally jury-rigged the existing seat release mechanism. The faulty repair held up for a while, but failed just as Gottlieb took off, causing the seat to slide back and jam in place.

Making matters worse, we found emails from Khalaf on Gottlieb’s hard drive. Gottlieb had asked Khalaf to perform an annual inspection of the aircraft just days before the crash.   Khalaf’s emails confirmed that he had in fact "finished with the annual" and that the plane was "good to go."  Based on Khalaf’s confirmation that the plane was safe to fly, Gottlieb departed on his flight from Napa. But, in fact, Khalaf never inspected the plane at all. All he did was change the oil, to make it appear as though he had serviced the aircraft when in fact he had not.  Had Khalaf performed the inspection, he might have learned that his previous improper repairs were about to fail.  

Earlier this afternoon, the jury entered its verdict against Khalaf for $13,360,000. The verdict is believed to be a record amount in California for the death of someone over age 65.

Khalaf’s attorney quit the case one year before the trial was set to begin. Khalaf elected to representCessna 182 N23750 himself during the 7 day trial. Adbi Anvari of Air West Aircraft Engines testified as Khalaf’s expert.  Khalaf called Dr. John Kane to testify about medical issues that Khalaf contended afflicted the pilot, but the judge ruled the doctor to be unqualified and refused to allow him to take the stand.

Dr. Gottlieb was a prominent San Francisco forensic psychiatrist.  He left his wife Gale, daughter Tamar, and son, Mike who is a lawyer and special assistant to President Obama.

Before trial, Gottlieb’s family offered to drop the suit entirely if Khalaf agreed to surrender his mechanic’s license. Khalaf refused.  That means despite the verdict, Khalaf is still legally entitled to work on aircraft and return them to service.

 

 

Khalaf Verdict

Here are six ways an aircraft owner can be found liable even if he was not on board when the plane crashed:

  1. Vicarious liability for acts of permissive user.   In many states, an aircraft owner is liable by statute for any injury caused by a pilot who was flying the aircraft with the owner’s permission. The owner need not have done anything wrong — the owner’s liability is automatic.  But that liability is generally capped.  For example, in California, the aircraft owner is automatically liable for death or injury resulting from the pilot’s negligence, but that liability is  limited to $15,000 per person killed or injured, up to a total of $30,000.
  2. Liability as Partner or Joint Venturer.  In some circumstances, if the pilot was the owner’s partner or was engaged with the owner in a joint venture, the owner can be held fully responsible for any accident caused by the pilot’s negligence.
  3. Owner’s negligent conduct. Of course, if the aircraft owner was himself negligent, he may be held liable for the accident, once again without regard to any cap.  For example, if the owner performed maintenance on the aircraft (as permitted by FAA regulations), but didn’t perform it properly, the owner can be held fully responsible for any accident that results.  Even if the owner never touches the aircraft, he might still be held responsible if he makes unreasonable maintenance decisions that, though permitted by FAA regulation, were not those that a reasonably careful owner would have made. One  such maintenance decision might be running the aircraft past TBO
  4. Non-delegable duty.  Mechanics are typically independent contractors.  Generally, we aren’t responsible for their negligence.  But the federal aviation regulations make the owner of an aircraft primarily responsible for its airworthiness, That means the owner may be held responsible even when the accident was solely the mechanic’s fault.
  5. Negligent entrustment.  An owner can be held liable for an accident if he allows a pilot to use an aircraft when he knows the pilot isn’t competent to complete the planned flight safety.  For example, an owner may be held liable to those injured for allowing a pilot to fly to a high-density altitude airport if that pilot hasn’t had a high-density altitude checkout. In the negligent entrustment context, the "permissive user" liability caps don’t apply.  
  6. As the manufacturer of an amateur build aircraft.  Needless to say, if the owner was the builder of the aircraft that is involved in the accident, he can expect to be held liable, at least if the accident was the result of faulty workmanship.

Airport fire trucks must get to a burning plane within three minutes if they are going to save any lives. That’s the maximum response time allowed by the National Fire Protection Association, the organization that sets the standard for airport firefighters, including those working at U.S. Air Force bases. 

The survivable atmosphere inside an aircraft fuselage involved in an exterior fuel fire is limited to approximately 3 minutes if the integrity of the airframe is maintained during impact. This time could be substantially reduced if the fuselage is fractured. . . rapid fire control is critical. . .

Aircraft flown in air shows are usually smaller and less fire resistant than transport category aircraft.  At air shows fire trucks need to get to crash sites even quicker – within 60 seconds or less.

The key to getting fire trucks to a crash quickly is to station the trucks near to where an accident is most likely to occur.  Normally, that might be the end of the active runway.  But most air show crashes occur at “show center” rather than the end of the runway.  As one Travis Air Force witness put it, show center is where ‘the majority of dangerous events focus.”  At air shows, that’s where fire trucks should be waiting.

Eddie’s Accident

On May 4, Eddie Andreini was flying a routine at the Travis Air Force Base open house.  He was attempting a stunt known as an inverted ribbon cut.  Something went wrong.  Eddie’s Stearman slid upside down along the runway, coming to a stop at smack dab show center. Eddie was uninjured but was trapped inside.  A fire started almost immediately.  Air Force personnel say that they saw Eddie struggling to get out as he waited for the fire trucks to save him.  One minute passed, then two, then three.  But the crash trucks didn’t come.  When they finally did, it was too late.

What happened?

The Air Force refused to explain why it took so long for its fire trucks to reach Eddie.  So we sued it under the Freedom of Information Act.  We now have internal Air Force documents showing that the brass didn’t understand the Air Force’s own regulations.  They mistakenly believed regulations prohibited them from stationing fire trucks near show center.  So instead, the Air Force positioned the fire trucks more than a mile and a half away. 

The Travis speed limit for fire trucks is 45 mph.  So it took the first fire truck (a “Rapid Intervention Vehicle”) more than four minutes to get to Eddie.  Had the Air Force positioned even one truck at show center–as it was supposed to–firemen would have gotten to Eddie within a minute and Eddie would have been saved.

Regulations can be confusing. Was the Air Force’s mistake understandable?  Not really. The manual that Travis show organizers had in hand–and agreed to follow–makes clear that fire trucks belong at show center.  According to that manual, the personnel who were permitted in the “aerobatic box” (the area in which performers fly) included “demonstration teams and fire/rescue.” (Page 28.) The manual goes on to direct that fire trucks should be located “with immediate access to the show line” (page 34) – not a mile and a half away.

To the extent the Air Force brass was confused, the FAA cleared things up for them when, a week before the air show, it told Travis that crash trucks did indeed belong “in the box” near show center.

Our team, specifically the air ops staff, was led to believe that we could not put an emergency vehicle (or anything else) inside the Show Box at Show Center, because it was sterile and protected.  We learned that this was not correct about a week before the show after [name redacted] discussed it with [name redacted] of the FAA.  We learned that we could place airshow official vehicles or people in the aerobatic box.”

Travis had time

The Air Force’s own documents prove that Travis officials had a week before the show was to begin to correct their mistake and arrange for the trucks to be stationed at show center. But the Travis officials had already decided that the fire trucks were going to be positioned where they couldn’t be of any use to a performer.  Having made a plan, they weren’t going to change, even if it put lives at risk unnecessarily.

“I’ll say it again, I need the trucks on the runway!  I need the trucks on the runway now!”

The Travis Command Post recording is difficult to listen to. After hearing it, it’s hard to believe that Travis still tells the public that its fire department responded to the crash in an “exemplary” fashion.

(Notes:  At 2:14, one of Eddie’s crew tried to fight fire with a hand-held extinguisher.  The extinguisher was too small and was expended in seconds.  By that time, the Rapid Intervention Vehicle had not yet even left its station.  The Air Force documents do not explain why it took so long for the truck to roll.  It finally arrives on scene after the 4 minute mark.  The time stamps were placed on the photos by Air Force.)

USA Today ran Thomas Frank’s story on the unnecessary risks posed by post-crash aircraft fires.  According to Frank’s article, small aircraft fires have killed at least 600 people since 1993, burning them alive or suffocating them after otherwise survivable accidents.  Hundreds more have survived post crash fires but have been horribly burned.

I’ve written many times over the years that no one should be burned in an otherwise survivable aviation accident.  The technology to prevent post crash fires has been around since the war in Vietnam.

The FAA has not required manufacturers to install such technology because it would be too costly – between $556 and $5,710 per aircraft.  That doesn’t sound like much, but according to the FAA, it doesn’t pencil out when compared to the dollar value of the lives that would be saved.  But the USA Today article points out that, in running the calculations, the FAA undervalued human life.  For example, while the EPA used a value of $3.3 million per life when it justified regulation to protect the ozone, the FAA used a lower value — just $1 million per life — when it ran the numbers on post-crash fires.  No wonder the costs didn’t pencil.

Of course, just because the FAA doesn’t require manufacturers to keep their aircraft safe from post-crash fires, it doesn’t mean that the manufacturers can’t do so on their own. 

Today the manufacturers responded to the USA Today article, suggesting that it was inaccurate and one-sided.

GAMA’s Greg Bowles talked for more than three hours with Mr. Frank [the article’s author] about general aviation safety to include preventing post-crash fires through improved crashworthiness and manufacturers’ efforts to mitigate the effects of accidents for Mr. Frank’s previous series, “Unfit for Flight.” Unfortunately, Mr. Frank chose not to include the bulk of Mr. Bowles’ remarks that chronicled our industry’s successful efforts to continue to improve our safety record.

The GAMA response goes on to talk about all the things the manufacturers are doing to help prevent planes from crashing.  It says nothing, however, about what it is doing to ensure that when they do inevitably crash, they don’t catch fire.  

Hall of Fame Aerobatic pilot Eddie Andreini died during the "Thunder Over Solano" air show at Travis Air Force Base in May.  There was a mishap during his routine, and his Stearman biplane slid to a stop on the runway. Eddie wasn’t hurt, but he was trapped in the plane.  He radio’d for help.

The Air Force had told the performers that its fire trucks would be positioned and ready to respond toEddie Andreini such an emergency within seconds.  But for some reason, the trucks were nowhere to be found during Eddie’s routine. Instead of getting to Eddie in a minute or less, as they were supposed to, the trucks didn’t get to Eddie for nearly five minutes.  By then, Eddie’s plane was engulfed in flames and it was too late.  Eddie was gone.

Where were the firetrucks?  What took them so long to get to Eddie?  When the family asked the Air Force these questions, the Air Force closed ranks and went mum.  So the family exercised its rights under the Freedom of Information Act. The family formally requested the Air Force to turn over to them the documents that would show why the Air Force fire trucks didn’t come to Eddie’s aid as it had promised, and instead let Eddie burn to death.  

Under the law, the Air Force had 20 days to respond to the family’s request. We had hoped that, out of respect for the family, it would have turned over documents right away.  But that was not to be. The family made its request to the Air Force four months ago. Yet the Air Force has yet to turn over to the family even a single piece of paper.

We’ve just filed suit against the Air Force for violating the Freedom of Information Act.  We want to know:  

  • Does the Air Force believe it is above the law?  
  • Does the Air Force believe that the family has no right to know why Eddie died?
  • What is the Air Force trying to hide from Eddie’s family and the public about it’s role in Eddie’s death?  

 

Complaint – Travis AFB Re FOIA Request – FEC

I just returned from the American Association for Justice‘s annual convention in Baltimore, where Hudson River Corridor on the way to BaltimoreI spoke on the risks automation poses to the general aviation pilot.  As luck would have it, my autopilot failed departing San Carlos, so I ended up hand flying coast-to-coast.  No “deskilling” happening here.

Automation risk has become a popular topic over the past few years, but there’s relatively little research on the subject.  To prepare for the talk, I reviewed that research and summarized it below.

 

General Aviation Automation Risk

A few hours ago, USA Today published a lengthy investigative report devoted to small aircraft crashes. The conclusion:  aviation manufacturers have long concealed the fact that their defectively designed products cause aircraft crashes and injures. And the investigating agencies, including the NTSB and FAA, let them get away with it.

The report covers many of the issues we’ve touched upon before on this blog, from defective carburetors, to defective pilot seats, to faulty ice-protection systems. The report also covered a subject we’ve covered on this blog extensively – post crash helicopter fires in otherwise survivable accidents:

One of the most gruesome and long-standing problems has caused scores of people to be burned alive or asphyxiated in fires that erupt after helicopter crashes. Such deaths are notorious because they can occur after minor crashes, hard landings and rollovers that themselves don’t kill or even injure helicopter occupants. The impact can rupture helicopter fuel tanks, sending fuel gushing out, where it ignites into a lethal inferno.

Using autopsy reports and crash records, USA TODAY identified 79 people killed and 28 injured since 1992 by helicopter fires following low-impact crashes. In 36 non-fatal crashes, fire destroyed or substantially damaged helicopters after minor incidents such as rollovers, crash reports show.

The report didn’t mention the most recent Robinson fire that killed the R44’s pilot at Birchwood Airport in Alaska just two weeks ago.

Pilot error?

I’ve been saying for years that many crashes that the NTSB attributes to "pilot error" simply aren’t. The USA Today report backs that up.  The report discussed the fatal crash of a single engine Piper following engine failure.  The NTSB chalked up the engine failure to pilot error.  But, as it turns out, the crash was caused by a defective carburetor float. The judge handling the case noted that the carburetor manufacturer had received more than 100 warranty claims for similar problems before the crash. Yet none of that product history made it into the NSTB report.

Ruling against Lycoming  [the engine manufacturer] and Precision [the carburetor manufacturer], Philadelphia Judge Matthew Carrafiello found evidence both might be culpable. Precision received more than 100 warranty claims concerning carburetor defects, the judge said, and Lycoming continued to use the carburetors even though it "knew of ongoing problems" with the carburetors "and of numerous plane crashes resulting from such problems.

None of that information was included in the NTSB investigation, which was aided by Lycoming and Precision and blamed Andy Bryan, the pilot, for "failure to abort the takeoff" and "failure to maintain adequate airspeed during takeoff."

According to the report, many of the crashes that the NTSB concludes are due to pilot error are actually due to defectively designed aircraft.

Federal accident investigators repeatedly overlooked defects and other dangers of private aviation as they blamed individual pilots for the overwhelming number of crashes of small airplanes and helicopters . . . The failure of crash investigators to find defective parts, dangerous aircraft designs, inadequate safety features and weak government oversight helped allow hidden hazards to persist for decades, killing or injuring thousands of pilots and passengers . . .

Manufacturers mislead the FAA

Part of the problem is that the NTSB does not travel to the site of many small airplane crashes, leaving the on-scene investigation to the FAA. Unfortunately, according to a former NTSB investigator, the FAA personnel don’t have the same investigative experience as the NTSB investigators and are easily duped by the manufacturers.

Many times what happens now is that when the accident occurs, the technical rep of the (manufacturing) company will call the NTSB and say we’ll be party (to the investigation), we’ll go out there and let you know what we see … the only people on scene would be perhaps an FAA guy and the field rep of the manufacturer," said Douglas Herlihy, a former NTSB investigator who now reconstructs crashes, often for plaintiffs in lawsuits against manufacturers.

"If you (the NTSB) are not there, you’ve got the representative from the company at the scene. His job is to skew the facts, to ignore the product difficulties and to remove the question of liability," Herlihy said.