At first glance, one might expect that high density altitude was the cause of last week’s fatal Comanche crash at Truckee-Tahoe airport.  The pilot first attempted to depart with three aboard, but aborted the takeoff.  He then offloaded his two passengers and tried again.  It was on the second attempt that the pilot crashed into hangars.

No doubt about it:  Because of its altitude, Truckee is a difficult airport, especially in the summer whenTruckee-Tahoe Airport the air is thinnest.  In fact, last week’s crash was the ninth at the airport in the past four years.  High density altitude played a role in a number of those crashes, including the Karen Trolan crash.

But the facts don’t quite add up on last week’s accident.  The pilot flying the accident aircraft (Piper N8218P) was very experienced – he reportedly had in excess of 6000 flight hours.  And though a departure with three aboard may have taxed the abilities of the plane and its pilot, with only the pilot aboard, there shouldn’t have been much of a problem.

Whenever an aircraft crashes on takeoff, the NTSB tests the fuel supply at the departure airport.  It’s always possible that an engine failure contributed to the crash, and one possible cause of an engine failure is contaminated fuel.

Today word is out that the fuel supply at Truckee did not meet the standards.

From an email I received from San Mateo County Airport: 

After a fatal accident at Truckee (KTRK) on the 2nd of August, the industry-standard practice of halting fuel service and testing the fuel in all tanks and trucks revealed that the 100LL fuel stored at KTRK did not meet the American Society for Testing and Materials (ASTM) standards for 100LL.  As a result of these tests, 100LL fuel service at the airport continues to be suspended pending new fuel and testing of its quality.

Truckee Airport has been trying to get in touch with all pilots who purchased fuel between July 20th (the last fuel delivery) and August 2nd (the day of the accident) and have asked us to pass along this information to pilots at San Carlos/Half Moon Bay.  Questions about the above-mentioned issue should be directed to World Fuel Service’s area representative Mike Montalvo at: 510-604-6511.

The test results don’t prove that bad fuel caused the Comanche crash but, at this point, bad fuel can’t be ruled out.

 

No, he didn’t buy next to the airport. But for this property owner, he might as well have.

I thought I’d write to you, what do I have to lose at this point?

These tour helicopters "buzz" my property 7 days a week. I’m literally losing it. Highest count so far, 42 flights in a 6 hour period.

I’ve contacted the FAA, DOH, DOT, EPA, my local representative, the mayor, the Governor’s office, and the individual tour companies via e-mail. NOTHING has been done.

I live 12 miles from the airport and 30 miles from the volcano, the helicopters still fly in a half mile corridor creating a nuisance that to me is unacceptable. EVERYONE in my subdivision is irritated by it but NO government agency is willing to address the issue, the tour companies hide behind FAA rules that only address safety but not noise.

I don’t want to go on and on about this, I’m just hoping you’ve handled cases like this before and I can get some help.

I feel like I’ve lost the enjoyment of my property, my peace of mind, I’ve lost sleep and my anxiety attacks have come back after 2 years of being relatively free of it.

I realize that you primarily represent people who have been involved in crashes however it just boggles my mind that these companies are allowed to operate with little or no impunity and can conduct business in such a way to cause this kind of annoyance."

(Name withheld)

Unfortunately, it’s an uphill battle, as far as I’m concerned.  Some years ago, a property owner complained that a tour operator was not only driving him crazy with the noise, but was flying dangerously low over his property.  He reported the problem to the local Flight Standards District Office, which did essentially nothing.  The owner escalated the complaint to a mainland FSDO.  The mainland FAA inspectors came out a few times to watch from a hillside.  Funny thing – every time they came out, the overflights stopped.  

Seems that the local FSDO was tipping the operator off. 

Shortly after that, a Big Island Air tour came through, flying too close to the terrain. 10 people were killed when the aircraft crashed onto the northeast slope of Mauna Loa. 

We sued the FAA for failing to enforce the minimum altitude requirements.  Unfortunately, the FAA asserted its various immunities to block the suit. 

Let’s face it.  The tour operations are big business.  And the FAA seems more inclined to promote that business than to regulate it. 

I’m not exactly sure what it will take before there’s some sanity brought to the industry. 

The Minnesota Supreme Court has now spoken, bringing to an end the litigation against Cirrus for its alleged failure to train pilot Gary Prokop.

Prokop flew his new Cirrus SR22 into conditions of poor visibility and crashed, killing himself and his passenger.  The passenger’s family sued Cirrus, as will as Prokop’s estate, claiming that Cirrus didn’t properly train Prokop on the use of the plane’s autopilot.  The wrinkle is that Cirrus had agreed by contract to provide the pilot a full course of training but, when the time came, Cirrus skipped the lesson on using the autopilot to exit bad weather.

A jury awarded more than $10 million to the families of the pilot and passenger.  The jury felt that, had Cirrus provided the contracted-for training, the accident wouldn’t have happened.

The Minnesota Court of Appeal reversed. It ruled that Minnesota law permits no claim for injuries suffered as a result of "educational malpractice" and, when you boil it all down, "educational malpractice" was exactly what plaintiffs were claiming.  A dissenting judge reasoned that plaintiffs were not claiming that the training was in error, but rather that it wasn’t provided at all. Thus, Minnesota’s bar to "educational malpractice" claims shouldn’t apply.

The Minnesota Supreme Court agreed to review the case. In its decision, handed down just yesterday, the Supreme Court more or less agreed with the dissenting appellate court judge that the case didn’t involve the educational malpractice doctrine. Rather, the Supreme Court felt that the case was really a traditional products liability case.  Nonetheless, it ruled for Cirrus.

The Supreme Court reasoned as follows:

  • The Cirrus aircraft is a dangerous product;
  • Therefore, Cirrus was required to provide instructions on how properly to use the aircraft, including the autopilot, to avoid injury;
  • Cirrus provided such instructions in its manuals and other written materials;
  • No one argues that the written materials were wrong or otherwise inadequate; and
  • The fact that Cirrus failed to provide flight training on the use of the autopilot is irrelevant.

Case closed. In short, the Court ruled that while a manufacture has a duty to warn the user about the dangers of a product and how to avoid injury, it does not have a duty to train the user.  Finally, the Court ruled that, even if Cirrus had agreed to train the pilot, the failure to do what it agreed allows for only contract damages, not wrongful death damages.  While damages for breach of contract are inadequate and ill-suited for cases involving personal injury, the Supreme Court ruled that only contract damages were available under the circumstances.

A dissenting judge disagreed:

a party should not be "immunized[d]. . .from tort liability for his wrongful acts" just because those acts "grow out of" or are "coincident" to a a contract ..  .If the mere presence of a contract foreclosed all tort liability, medical malpractice claims would cease to exist.  A passenger injured in a car accident while riding in a taxi cab would have only a breach of contract claim against he cab driver and cab company.  A paid babysitter who failed to prevent injury to a child would be liable only in contract. . . "

 

Prokop Supreme Court Opinon

Pilots have come to accept that aircraft fuel gauges just don’t work well. In fact, many pilots simply assume the fuel gauge is wrong, believing it’s safer to rely on their own calculations concerning the amount of fuel remaining rather than on the gauge. As the old saw goes,  “never trust your life to a gauge.”  Pilot (left) and passengers

Good idea. Usually.  But sometimes skepticism about fuel gauges can lead to an accident.

The pilot and one of his passengers were killed when the Cessna 172 crashed in Tennessee. The second passenger survived. The NTSB determined that the plane ran out of gas. How can this happen? According to the NTSB report, it seems the pilot may have miscalculated the amount of fuel necessary for the trip because he didn’t know the engine horsepower had been increased by an STC, and thus burned more fuel than an unmodified aircraft..

But still, the aircraft did have a working fuel gauge. What the NTSB’s report does not discuss is why the pilot ignored it.

The pilot and passengers were apparently from the U.K.  Last week, the Welch coroner held an inquest, at which the surviving passenger testified. The passenger explained that he had been sleeping in the back seat. He woke up and:

I glanced over to look at the instruments and just noticed the fuel gauge had a low indication. I brought it to the knowledge of [the pilot]. He said ‘I’ve done a maths calculation about the distance and I trust my maths more than a 1969 fuel gauge’.

Was the pilot arrogant?  Or was he just sucked in by the common belief that aircraft fuel gauges are seldom accurate?

Domestic travelers can hold the airline liable only if their injuries are caused by the airline’s negligence. But if the passenger is traveling internationally, then treaties called the Montreal and Warsaw Conventions apply. Under the Conventions, whether the airline was negligent is for the most part irrelevant. An airline is responsible only if the passenger’s injury was caused by an “accident.” So, for an international traveler, the key question is what, exactly, qualifies as an “accident.”

The U.S. Supreme Court has defined “accident” to mean “an unexpected or unusual event or happening that is external to the passenger.” Certainly, an aircraft running off the end of the runway would qualify as an accident. But there are plenty of injury-producing events which present more difficult questions.

Here’s what the courts have said:

  • Accident: A passenger is injured when a fellow passenger opens an overhead bin and liquor bottles fall out.
  • Not an Accident: A passenger slips and falls on plastic bag left in aisle (reasoning: after long flight, it would not be “unusual” to encounter trash in the aisle).
  • Accident: A passenger burned by tea when tea spilled from tray table because the passenger seated directly in front of the injured passenger caused a “jolt” that upset the tray table.
  • Not an Accident: A passenger falls while trying to walk up a broken escalator.
  • Accident: A passenger seated near the smoking section asks to be moved, the flight attendant refuses, the passenger has an asthma attack and dies.
  • Not an Accident: A passenger dies from an airline-induced blood clot.
  • Not an Accident: One passenger falls on and breaks the arm of another passenger (reasoning: the passenger decision to try to climb over his fellow passenger not related to the aircraft’s operation.)

More at Chris Cotter’s excellent article: Recent Case Law Addressing Three Contentious Issues in the Montreal Convention.

In 2008, a safety inspector determined that nearly half of the nation’s EMS helicopter fleet–about 300 aircraft–have improperly installed night vision systems. As installed, the systems are a hazard to the air ambulance crews and the patients they carry. The inspector felt the aircraft should be grounded until they were fixed. The FAA initially agreed, but then changed its mind. Apparently, the FAA decided to look the other way because of the "negative publicity" a grounding would generate.

Pretty alarming.  Ultimately, the United States Office of Special Counsel became involved, taking the unusual step of writing to President Obama.

[The United States Office of Special Counsel] found a substantial likelihood that FAA officials and employees engaged in violation of law, rule or regulation, gross mismanagement and an abuse of authority, all of which contributed to a substantial and specific danger to public safety.

It’s been three years, but the White House has done very little.  So now the OSC has written the President again.

The OSC continues to be concerned about the improperly installed night vision goggle systems that plague the nation’s EMS helicopter fleet.  But it is also concerned about a litany of other whistleblower complaints against the FAA that the OSC has received, investigated and substantiated.  The complaints range from FAA personnel allowing Delta Airlines to perform improper maintenance to air traffic controllers sleeping on the job.  The FAA is aware of the complaints, but has done little about them.

One senses a bit of frustration in the Special Counsel’s latest letter:

This transmittal is the final chapter in OSC’s formal oversight process. . .additional enforcement action rests with Congress or the White House.  Given the recurring and serious nature of these concerns, I write with a strong recommendation that more rigorous oversight measures be put in place at DOT and FAA to ensure a higher standard for aviation safety. 

OSC Letter FAA 2012

More than 30 Cessna 208 and 208B Caravans have crashed when their wings iced up in flight. Victims’ families have filed many product defect lawsuits against Cessna, claiming that Cessna concealed from the pilots defects in the aircraft’s deicing system. Silvey v. Cessna is the first case to reach trial. At least the first that I know of.

Silvey, which is pending in federal court in Fort Worth, Texas, involves a Caravan that crashed near Parks, Arizona in November 2002.  The pilot reported encountering light icing. According to the NTSB report, a short time later, a witness saw the aircraft come spinning out of the clouds with its nose pointed down. All four on board were killed on impact.Cessna Caravan

After that crash, the FAA issued at least three airworthiness directives against the Cessna Caravan, all concerning the aircraft’s deicing system.  Cessna asked the Silvey trial judge, the Honorable Terry Means, to keep the airworthiness directives from the jury.  Cessna argued that since the FAA didn’t issue the airworthiness directives until after the accident, they are not relevant. The judge declined to rule whether the evidence will come in or stay out. Instead, he ruled that he’d have to see how the trials goes before deciding.

Three of the airworthiness directives at issue are:

  • AD 2005-07-01, prohibiting takeoff when there is any ice on the aircraft, and requiring pilots to feel the wings for ice rather than simply inspect visually;
  • AD 2006-01-11 requiring owners to modify the aircraft’s deicing system to legally fly in icing conditions; and
  • AD 2006-06-06 prohibiting flight in anything other than “light” icing conditions, requiring pilots to maintain higher air speeds when climbing through ice, and advising pilots that the aircraft’s stall warning system cannot be relied on in icing conditions.

No conclusion yet as to exactly what caused the Galloping Ghost to crash last September at the Reno Air Races. But the interim report the NTSB issued today disclosed that the Galloping Ghost experienced an “upset” 6 seconds before it lost its left elevator trim tab. That, in turn, caused the aircraft to go out of control.  None of that  information is really new, and was discussed shortly after the accident in this post and in the post’s many thoughtful comments.Galloping Ghost vs. Unmodified P-51D

The NTSB also issued safety recommendations that specifically questioned whether the Galloping Ghost had been properly tested at race speeds or otherwise evaluated for resistance to “flutter;” an aerodynamic phenomenon that can destroy an aircraft in seconds. But that’s not news either — flutter and its possible role in this crash was discussed the day after the crash here.

There is one fact, however, that we didn’t know before. Race officials inspected the aircraft just before the race and determined that the aircraft’s trim tab’s screws were too short. But the NTSB could find no documentation that the screws had been replaced and the discrepancy resolved before the race started. Though the race inspector stated that he verified that all the aircraft’s discrepancies had been resolved, the NTSB recommended that, in the future, race organizers develop a system that tracks discrepancies found during pre-race technical inspections and ensures that they have been resolved before an aircraft is allowed to race As the NSTB put it:Trim Tab - Reno NTSB

without a method to track discrepancies to resolution, conducting pre-race inspections is of limited value.

The NTSB’s interim report doesn’t say whether the screws were, in fact, replaced. For that, we’ll have to wait for the NTSB to issue its factual report. But even without a system for race officials to track discrepancies, whenever a mechanic performs any work on an aircraft, he is supposed to record that work in the aircraft’s maintenance logs.  If there’s no entry in the Galloping Ghost’s logbooks showing that the screws were changed, that’s evidence that the work wasn’t done, or at least wasn’t done properly.

Besides recommending that race officials establish a better system of ensuring that aircraft discrepancies are repaired before race time, it issued recommendations that would, among other things:  

  • Require race pilots to be trained to tolerate or avoid high g-loadings;
  • Revise the mathematical formulas used to lay out the race courses;
  • Require aircraft to be tested at race speeds before they be allowed to compete; and
  • Require pilots to practice on the actual race course before being allowed to compete.

 

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The NTSB blamed the helicopter crash that killed 9 firefighters on the the helicopter’s operator.  Basically, the NTSB concluded that the helicopter crashed because it was overloaded.  But today a jury disagreed, deciding that the Sikorsky helicopter crashed because one of its two engines failed.  The jury handed down a $70 million verdict against GE, the engine’s manufacturer.

Why is a jury allowed to come to a conclusion totally opposite to that reached by the NTSB?  In short, because the NTSB’s findings are inadmissible in a court of law.  And there’s good reason for that.  For starters, a victim’s family is not allowed to participate in the NTSB investigation, while the manufacturers who may be to blame for the accident are.  As a result, the NTCarson Helicopter Iron 44 CrashSB’s findings frequently favor the manufacturers. 

Is that what happened here? Did the NTSB unfairly favor GE?  It seems that it may have. 

I spoke today with one of the participants in the trial held in Portland.  He explained that, originally, the NTSB had determined that one of the helicopter’s engines did, in fact, fail in flight.  That report mysteriously "disappeared," however, shortly after it was published.  As did the engine’s fuel control unit.

The NTSB ultimately took the position that losing the fuel control unit was no big deal, because it believed the engine hadn’t failed.  But plaintiffs introduced at trial substantial evidence that it had, including an audio recording made during the crash sequence which helped proved that one of the engines "rolled back," or shut down, just before the impact.

In December, 2010, the helicopter’s operator issued a press release complaining that the NTSB proceedings were unfair.  Given today’s verdict, it makes for particularly interesting reading.

 . .  the facts clearly show that the primary cause of this accident was a loss of power to the #2 engine of the aircraft. There is a strong chain of physical evidence in the [NTSB’s evidence] that indicates a high probability that a malfunctioning fuel control unit (FCU) caused a sudden loss of power as the aircraft transitioned to forward flight. Extensive independent real-world flight testing has confirmed that even [if overweight, the helicopter should] have had enough power to fly away from . .  with two properly operating engines. The co-pilot has confirmed much of this evidence with his recent testimony.  . . The NTSB has ignored his testimony in favor of supposition. . .

Unfortunately, early in this investigation the NTSB lost custody of several fuel control parts, and conducted a filter inspection incorrectly, which they have acknowledged. Since that time, the NTSB has chosen to ignore the physical evidence and flight parameters that indicate a possible blockage in the FCU. They repeatedly refused to participate in independent flight testing, and they have not given proper consideration to the copilot’s direct testimony of conditions and available power just prior to the crash.