Safety management system use is being urged by NTSB
It’s rare to hear about accidents involving modern business jets these days. The advanced avionics, technology, and excellent pilot training are second to none and have worked together to reduce the accident rate dramatically over recent years. But now and then, one of these jets ends up on the evening news and the cause of the accident is, more often than not, related to human error. For this reason, the NTSB is urging pilots and private companies to adopt Safety Management Systems (SMS) for their flight departments, both for business purposes and private flying.
I can remember several recent accidents that should never have happened and wouldn’t have happened if the pilots were following Standard Operating Procedures (SOPs). Remember when the crew left the control lock-in and attempted an unsuccessful takeoff? They all died in the accident. There have been multiple accidents where pilots continued landing, even though they were high and fast on a very UNstable approach.
What is so hard about following procedures? Procedures make life as a pilot easier and quite a bit safer. This is how we fly approaches; we use the checklist before takeoff and landing….it’s private pilot stuff here. Checklists are one of the first things we ever learn when we take our first few lessons. So why do we forget how to read a checklist when we get 5000 hours in the air?
A recent Business Aviation Safety Summit Seminar emphasized the importance of flight data monitoring (FDM) and SMS for operators, both private and business. David Lawrence, a senior accident investigator with the NTSB, presented a case study of a recent accident to show why these principles are so critically important to flight safety.
Lawrence talked about the fatal 2017 crash of a Learjet 35A on approach to Teterboro. The crew made countless mistakes and omissions throughout the short repo flight from Philadelphia to New York, including ignoring checklists, filing an improper flight plan, disregarding SOP’s, failure to follow ATC instructions, and just overall poor airmanship and decision making.
Several broken links to the accident chain were visible and all contributed to the tragedy, and as always, eliminating one or two would have changed the outcome. For one thing, the crew filed for 27,000 feet for their very short flight, which doesn’t make any sense whatsoever. In addition, the Second in Command was supposed to monitor the Pilot Flying, but he was the one at the controls the entire flight. Finally, the Captain tried to take over for the final 15 seconds, but he was too late to save the airplane.
It is evident from the ATC tapes that the SIC was weak, although I’m not sure why he was doing all the flying AND talking; I guess that is just one more link to think about. Unfortunately, they also disregarded ATC instructions to circle and their last-minute attempt to correct that error led to an unrecoverable stall.
The accident investigation revealed that the operator had no SMS or formal safety culture in place before the accident. According to Lawrence, they also had no way of monitoring if the crew was following SOPs, which is a recurring problem with 135 operators. And here’s an eye-opener….pilots who deviate from SOPs are THREE times more likely to commit errors! Half of all CFIT accidents involve a failure to adhere to standard operating procedures. HALF!
It is usually not difficult to safely operate an aircraft, especially the modern jets so popular today; Standard Operating Procedures and Safety Management Systems save lives. If your company does not have one or both of these in place, maybe now is the time to speak up and get busy setting them up.
