Saturday, August 19, 2006

Accident of the Week

This week's Accident of the Week (tm), brought to you slightly belated, actually involves two accidents. Although the apparent causes are completely different, they involve a common thread. Read them first and see if you agree with the IFR Pilot's subsequent analysis.

Accident #1
NTSB Identification: LAX06LA257
14 CFR Part 91: General Aviation
Accident occurred Thursday, August 10, 2006 in Tucson, AZ
Aircraft: Robinson R22 Beta, registration: N7059S
Injuries: 1 Fatal, 1 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.


On August 10, 2006, about 0930 mountain standard time, a Robinson R22 Beta, N7059S, descended into high mountainous terrain about 19 miles north of Tucson, Arizona. The helicopter was operated by Air Photo, Inc., Everett, Washington, during the aerial photography flight, and it was destroyed. The commercial pilot was seriously injured, and the passenger (photographer) was fatally injured. Visual meteorological conditions prevailed at the time, and no flight plan had been filed. The flight was performed under the provisions of 14 CFR Part 91, and it originated from Tucson about 0820.

The pilot reported to the National Transportation Safety Board investigator that after takeoff from the Tucson International Airport, elevation 2,643 feet mean sea level (msl), he proceeded on his aerial photography assignment. Federal Aviation Administration (FAA) radar flight following service was terminated about 0843. Thereafter, the pilot proceeded up a shallow valley-like area.

The pilot was initially cruising about 300 feet over ridgelines at 60 knots indicated airspeed, and was flying over rising mountainous terrain in a northerly direction. According to the pilot, he was proceeding toward the general area specified by the company photographer. The underlying terrain did not look like a gorge or deep valley, and in areas it appeared somewhat flat.

Regarding the meteorological conditions in the general area, the pilot reported observing a developing thunderstorm between 10 and 15 miles northeast of his location. The sky was clear along his flight route.

The pilot further stated that after he encountered a 1,000-foot-per-minute rate of climb (updraft), he performed a 180-degree course reversal left turn (toward lower elevation terrain) to exit the area. After completing the turn the low rotor speed warning horn sounded. Then, the helicopter encountered a downdraft, and it began descending. The pilot reported that he was not able to arrest the descent, and the helicopter impacted the terrain. The pilot stated that he recalled the outside air temperature gauge indicated it was 21 degrees Celsius. The pilot reported to the FAA coordinator that during the accident flight he had not experienced any mechanical malfunction with the helicopter.

The helicopter came to rest in a ravine, located in the Pusch Ridge Wilderness area of the Coronado National Forest. The estimated elevation of the accident site is 6,300 feet msl. The site is located about 32 degrees 23.500 minutes north latitude by 110 degrees 46.082 minutes west longitude.

Accident #2
NTSB Identification: LAX06FA258
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, August 11, 2006 in Saipan, Northern Mariana Islands
Aircraft: Piper PA-32-300, registration: N4509T
Injuries: 5 Serious, 2 Minor.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On August 11, 2006, about 0215 Saipan standard time (August 10, 2006 at 1615 UTC), a Piper PA-32-300, N4509T, experienced a loss of engine power during initial climb from the Saipan International Airport, Saipan, Northern Mariana Islands (NM). The pilot made a forced landing in a high vegetation area about 1/4-mile southeast of the departure end of runway 07. The airplane was destroyed during the hard landing and post impact ground fire. The single engine "Cherokee Six" airplane had a total of seven installed seats. The commercial pilot and four passengers received serious injuries. Two passengers received minor injuries. The airplane was operated by its owner, Taga Air Charter Services, Inc., Tinian, NM, under a passenger transportation contract on behalf of the Tinian Dynasty Hotel & Casino, which employed the pilot. According to Federal Aviation Administration (FAA) personnel, it was their understanding that the purpose of the on demand passenger-carrying flight was to transport five passengers and the operator's off duty company pilot to the neighboring island of Tinian, about 11 nautical miles away. The flight should have been performed under the provisions of 14 CFR Part 135. Visual meteorological conditions prevailed during the dark nighttime flight, and the flight was dispatched under a company visual flight rules flight plan. The flight originated about 0213.


Saipan air traffic control tower personnel reported to the National Transportation Safety Board investigator that seconds after the pilot became airborne, he broadcast "09T going down." No further communications were received by the control tower.

Parties assisting the Safety Board investigator reported that their physical examination of the airplane's structure and ground scar were consistent with the airplane impacting the terrain in a near level flight attitude. The airplane was found oriented on an approximate magnetic heading of 077 degrees. The site elevation was about 220 feet mean sea level. The global positioning satellite (GPS) coordinates of the accident site are 15 degrees 07.245 minutes north latitude by 145 degrees 44.842 minutes east longitude.

Taga Air's Director of Operations (DO) reported to the Safety Board investigator that the company only fuels the main (inboard) fuel tanks, and the outboard (tip) tanks are typically empty or nearly empty. The Safety Board parties reported observing that all of the fuel tanks had been breached. Several gallons of fuel were found in the left main fuel tank. The entire fuselage and empennage were consumed by fire.

Can you spot the connection? While the NTSB will have the final word, we can speculate a bit. Accident #1 may have been caused by the pilot's decision to continue flight in the vicinity of a thunderstorm. Accident #2 may have been caused by the pilot's decision to operate the aircraft in an over-maximium gross weight condition (depending on the total weight of the seven passengers).

How about this: Both pilots may have had their authority as Pilot In Command eroded by the pressures of their employers to "get the job done." We all know and understand that the profit margins in aviation are reed-thin. Passing up a paying aerial photography charter, or taking one less gambler to the casino, translates into a loss of real dollars to the companies operating these aircraft.

Although many of us may fly solely for pleasure, and therefore need not concern ourselves with this particular dynamic, the dreaded disease "get-there-itis" has similar qualities. We choose to push the envelope -- say, by flying a bit closer to the thunderstorm -- because we did so in the past and lived to talk about it. Obviously, the yardstick of "did it before, it'll be alright to do it again" should be the last standard we use to measure our aviation choices.

Some have accused the IFR Pilot of being overly conservative, unwilling to fly in adverse conditions, etc. I suppose there's some truth to that. But, I'd rather be here, writing about other people's accidents, than vice-versa. Normally, when it comes time to make a difficult choice, I apply a decision-making rubric that I read in a magzine article once: How would the NTSB accident report describe your actions as PIC? Seems to me the FAA should add this concept to its required knowledge in the area of aeronautical decision-making.

2 comments:

Anonymous said...

I know nothing about the R22 accident (funny how human misadventures are called 'accidents' - almost as if we humans don't know the risks - 'accident' should be replaced with 'failed calculated risk' or 'ignored risk' etc., however, I digress) but, I think (know) IFR missed the clue in the Piper act of incompetence... I suggest he carefully disect this sentence:

'Taga Air's Director of Operations (DO) reported to the Safety Board investigator that the company only fuels the main (inboard) fuel tanks, and the outboard (tip) tanks are typically empty or nearly empty.'

Then I suggest he check out the stated relationship of the passengers... mmm what could be the link here I wonder.

If you can't work it out hopefully the NTSB will eventually get around to giving a 'final' cause report and the basic PIC error will be revealed (no laughing please as serious injuries were sustained - well, I suppose a little giggle won't hurt).

Carol said...

With recent reports on people sleeping on airport watch towers, it scares me to think that the slightest neglect could terribly jeopardize a flight.