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.

Can any question remain about the R44’s tendency to roll over and catch fire?  It happened again yesterday, in Glendale Arizona.  This time, the helicopter had barely gotten off the ground. R44 Fire

Fortunately, no one was hurt.  But the story is becoming all too familiar. According to the Arizona Republic:

A mechanic was testing the engine of the Robinson R-44 helicopter when he lost control and it came down on its side and caught fire.

Helicopters aren’t supposed to catch fire in survivable accidents.  But Robinsons do just that because their fuel tanks are defectively designed.  This latest fire happened little more than a few weeks after an R44 accident killed filmmakers Mike deGruy and Andrew Wight.  That crash led well-known aviation attorney Ladd Sanger to call the Robinson R44 the "Ford Pinto" of helicopters.

Seems as though there may be something to that.

Robinson Helicopter Company likes to say that its helicopters are safe in crashes. According to an excerpt from Robinson Safety Notice SN-10:

The R22 and R44 have demonstrated excellent crashworthiness as long as the pilot flies the aircraft all the way to the ground . . .The ship may roll over and be severely damaged, but the occupants have an excellent chance of walking away from it without injury.

As it turns out, that’s not quite true. When they roll over, Robinson helicoptdeGruy/Wright R44 Wreckageers, in particular R44’s, have a tendency to catch fire and explode.  That makes walking away from a crash pretty much impossible.

Robinson fixed the problem beginning with helicopters it manufactured in 2010 by installing better fuel tanks.  But that didn’t help Mike deGruy and Andrew Wight, who were aboard VH-COK, a 2004 model that crashed February 4 in Australia.

A photograph of the aircraft (above) shows that the ship rolled over on its side, just as Robinson says.  There’s little crush R44 Wreckage at Mammothdamage to the cockpit and so the crash looks survivable.  Except for the devastating post-crash fire.

The photo of the deGruy wreckage looks remarkably similar to the wreckage of the September 2010 R44 crash in Mammoth, California (left).  That helicopter rolled over and burned as well.

There’s no reason for anyone to be burned in an otherwise survivable helicopter accident. Looks as though deGruy and Wright may be added to the list of those who died needlessly due to the dangerous and defective Robinson fuel system.

Some pilots believe that their insurance won’t cover them if it’s their own screw-up that causes an accident.  They believe, for example, that if they inadvertently violate an FAA regulation, their policy will be "voided."

That’s seldom correct.  The purpose of insurance coverage is to protect the pilot who makes a mistake, regardless of how "stupid." When it collects the premium, the insurance carrier signs on to pay for pilot error. Falcon N914DD

But there are some situations where an owner or pilot can jeopardize his coverage. Like when he fudges his experience or training on his insurance application.  Tell the insurance carrier that you are instrument rated when you aren’t and you may find that the policy won’t cover you even if your accident occurs on a perfect VFR day.   

Pilot qualifications and training were at issue in a case just decided by the Ninth Circuit Court of Appeal, Trishan Air v. Federal Insurance Company.  In that case, a pilot ran a Falcon 900 jet off the end of the runway at Santa Barbara.  It appeared that the accident was caused by the captain’s error, plain and simple. 

The insurer denied coverage on the grounds that the co-pilot was supposed to have received motion-based simulator training with respect to the aircraft but did not.  His only simulator training was static-based. 

The operator argued that the static-based simulator training the co-pilot had received was substantially the same as the motion-based training the policy specified. More importantly, the pilot who was responsible for the accident had received the specified training. And no one suggested that the co-pilot’s training (or lack of training) had any role in the accident at all. 

The court ruled that whether the co-pilot’s training played a role was beside the point.  The carrier had agreed to underwrite a certain risk only. That risk involved a crew that had received motion-based simulator training. The carrier would not have issued the policy without the training requirement or, at least, would have charged a higher premium.

To make the carrier pay for the accident would be to force it to cover a risk for which it did not bargain.

Foreign countries routinely bring criminal charges against pilots after an accident. But in the US, criminal charges are very rare. And that’s a good thing because "criminalizing negligence" usually does little to promote safety.  

But perhaps there are exceptions.

Pilot Steven Fay bought his 1960 Cessna in June 2010.  He crashed it after dark on New Year’scessna 310 Day 2011. He survived with minor injuries but, sadly, his 35 year-old daughter — the passenger on the plane — did not.

A Massachusetts grand jury has now indicted him for involuntary manslaughter, which carries a possible 20 year prison term.

Fay’s Cessna, a Cessna 310, was a "multi-engine, complex, high-performance airplane." Trouble is that:

  • Fay was not licensed to fly a twin-engine aircraft;
  • Fay did not hold a high performance aircraft endorsement;
  • Fay did not hold a complex aircraft endorsement;
  • Fay’s last night landing was ten years earlier, and thus he was not legally entitled to carry a passenger in any aircraft at all.

According to the NTSB report, neither weather nor mechanical problems played a factor. 

 

The pilot says he warned Lauren Scruggs away from his propeller.   According to the NTSB’s preliminary report:

After [the pilot] opened the door, [Scruggs] started to get out of the airplane.Aviat Husky Upon noticing that she was exiting in front of the strut, the pilot leaned out of his seat and placed his right hand and arm in front of her to divert her away from the front of the airplane and the propeller. He continued to keep his arm extended and told [Scruggs] that she should walk behind the airplane. Once he saw that [Scruggs] was at least beyond where the strut was attached to the wing, and walking away, he dropped his right arm and returned to his normal seat position. The pilot then looked to the left side of the airplane and opened his window to ask who was next to go for a ride.

The pilot then heard someone yell, "STOP STOP," and he immediately shut down the engine and saw [Scruggs] lying in front of the airplane.

While the pilot apparently tried to keep Scruggs from the propeller, it wasn’t enough.  Sadly, the accident likely would have been avoided had the pilot followed the the general safety guidelines set forth here.

  • The aircraft engine should be shut down before boarding or deplaning passengers. This is the simplest method of avoiding accidents. Unfortunately, the pilot elected to keep his engine running.
  • The pilot should instruct passengers, before they exit an aircraft with an engine(s) running, the path to follow to avoid the propeller or rotor blades. The pilot apparently failed to instruct Scruggs of the path to follow before she exited the plane.  Once she had exited the airplane, given the noise, he was left to rely on crude hand signals to get his message across.
  • When it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger’s route from the aircraft. Apparently, in this case, the propeller was in the path of the deplaning passenger’s travel.

 

The NTSB says that during tomorrow’s hearing, it will be looking to industry leaders to give it a “deeper understanding of regulations” bearing on the operation of the nation’s air shows. Of course, the only regulatory body that has the authority to control air shows is the FAA. But what the Board will find — if it asks the right questions — is that for the most part, the industry regulates itself. According to one veteran air racer, Howie Keefe, the FAA is more or less “hands off” when it comes to air show safety. From Martha Bellisle’s article in the Reno Gazette-Journal:

Keefe said the industry is largely self-regulated because the pilots and engineers are the most qualified to determine whether another pilot can handle a certain race or course or whether a certain design can handle the stress of a trick or race. ‘The classes themselves can say yes or no to a person who wants to race — if they can’t do a roll, they can’t race,’ Keefe said. ‘The FAA can’t do that. We rely on the expertise of the people in the industry to make the decisions.’

Perhaps a “hands off” policy is fine for the participants. But not so much for the spectators, who expect that if the FAA approves an event, it is overseeing the event’s safety in some meaningful fashion, and not merely turning the reins over to the event sponsors.

This Board says that the purpose of tomorrow’s public hearing is to help it investigate future air show accidents. But this Board is more assertive than past boards. There’s little doubt that it will find the FAA’s oversight lacking. The question is whether it will do anything about it.