DeLisi: Part 121 Has Laid Roadmap for Bizav Safety

Highlighting the fact that Part 121 fatal accidents have become almost nonexistent the U.S., a senior NTSB official expressed the belief that Parts 91 and 135 can move in that direction as well by incorporating some of the lessons learned from the scheduled airlines.

The discussion about Part 121 fatal accidents in the U.S. “is a very short conversation,” John DeLisi, director of the NTSB’s Office of Aviation Safety, said during the Bombardier Safety Standdown in late October. “It’s the sound of crickets…they’re just not happening anymore in the U.S.,” he noted. “How did what was already the safest form of transportation become one in which accidents just got wiped off the map for nine and a half years? A lot of things came together.”

Factors in the dramatic boost in the Part 121 safety record include the adoption of safety management systems (SMS), he said, calling them an important player in improving the safety culture. Other improvements include weather forecasting and dispatching.

“Weather doesn’t bite us anymore; we know where it is with great accuracy” with the forecast tools now available, DeLisi said. Controlled flight into terrain (CFIT) training and equipment also have played key roles, he added, saying CFIT is “another category of accident that has almost been wiped off the map.”

Flight data monitoring (FDM) further has played a role. “I used to feel guilty about this requirement” for airlines, he said, adding that it originally involved collecting data after an accident. But it is now looked at for proactive collection of data that could be shared. In fact, data sharing, including efforts such as Aviation Safety Action Programs, have elevated safety overall.

Accidents Highlight Challenges

“Are we realizing those gains in Part 91 and 135 jet operations? Not yet,” DeLisi said, and traced through a series of fatal accidents that pointed to a need for many of the safety improvements already adopted by the airlines.

These included the June 25, 2015 crash of a Promech Air DHC-3 in Ketchikan, Alaska; the October 2, 2016 crash of a Hageland Aviation Services Cessna 208B in Togiak, Alaska; the November 10, 2015 crash of a Hawker 700A in Akron, Ohio; and most recently the May 15, 2017 crash of a Learjet 35A in Teterboro, New Jersey.

While each of these accidents had different circumstances, they pointed to many common threads, such as decision-making and the need for flight-data monitoring. Lack of CFIT training further arose as a factor in some of these, as did a need for safety management systems, he said.

In the 2015 DHC-3 Otter crash, the aircraft hit a mountain about 24 miles east-northeast of Ketchikan, killing the pilot and eight passengers. The operation was under time pressure that had financial implications through a cruise line. This was among the factors present when the pilot flying the tourists decided to take a shorter route through weather that other pilots had avoided. This accident further highlighted a lack of CFIT training, which wasn’t required, as well as a lack of requirement for SMS, DeLisi said.

The 208B Grand Caravan accident also involved CFIT, crashing 10 nm northwest of Togiak Airport and killing both pilots and a passenger. DeLisi said this accident further highlighted a lack of CFIT training. And similar to the Otter crash, the pilots chose a flight path that others had avoided. The weather was changing that day with a front moving through. Rather than flying around it, though, the accident pilot chose the more direct route. After the accident, Hageland installed FDM on its aircraft and has begun to call in pilots who don’t perform “turn backs.”

Nine people were killed when the Hawker 700A crashed into terrain in Akron, Ohio. The NTSB found multiple deviations from standard operating procedures and a “casual attitude toward compliance with standards” on the flight. The pilots were on a non-precision approach and descended below minimum descent altitude, even though the runway was not in sight. The first officer flew the accident flight despite a company policy against having new pilots fly revenue flights. The lack of FDM and SMS were brought up during this accident as well.

As in the Akron crash, FDM and a new first officer came up in the discussion of the Learjet 35A crash in Teterboro that killed both pilots.

But despite these common threads, DeLisi expressed the belief that with the lessons learned, Part 91 and 135 operators can achieve those goals. “It’s not going to be easy but if our goal is to prevent fatal accidents, what a great roadmap has been laid out before us.”