Episódios
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The preliminary accident report on the August 9, 2024 crash of a Voepass ATR72 near Sao Paolo, Brazil has just been issued. John Goglia, Todd Curtis and Greg Feith apply their expertise to examine the findings and critical aviation safety issues.
The report has detailed facts, including a summary of the flight, but several key pieces of information are missing. One big issue – no detailed transcript of what was said in the cockpit during the flight.
The report focuses on the aircraft's deicing and anti-icing systems, including its apparent malfunctions. This system was first activated after the crew received an alert from the aircraft's ice detection system, and was turned off less than a minute later.
The crew did not react appropriately after turning off the deicing system warning. Rather than leaving the altitude where the icing was occurring or disengaging the autopilot, the crew did neither.
Based on the portions of the crew's conversation during the flight in the report, John concludes that the crew was not paying enough attention to flying the airplane. They did not address warnings from the aircraft.
There is a potential conflict of interest that may impede getting all the details of this accident. The Brazilian Air Force runs CENIPA, the aviation accident investigative authority, and the Brazilian air traffic control organization. Greg and John share their firsthand experiences with investigators dealing with outside influences using the example of the 1994 Roselawn, Indiana ATR72 accident.
Key takeaway here: pilots, especially professional pilots, need to educate themselves about how icing affects their aircraft.Related documents are available at the Flight Safety Detectives website.
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In March, a Mooney airplane door opened in flight, causing a loss of control and two fatalities. Todd and John examine this incident and three other Mooney events. Instead of a fault with Mooney aircraft, they find a pattern of very experienced pilots having issues and crashing when a passenger or baggage door opens in flight.
Doors open in flight often. The outcome depends on pilot action.
The pilot in the most recent crash had commercial and instrument ratings and nearly 800 hours of experience. Besides the door opening in flight, the NTSB found no other issues with the aircraft. The door alone should not have caused the plane crash.
In the earlier cases they discuss, all the pilots had at least a hundred hours of flight experience and there were no issues with the aircraft other than the doors opening in flight. One of those accidents had an instructor pilot on board, and between the student and instructor, they had over 9,000 hours of flight experience.
Todd shares an early similar flight experience when an oil access door came open during the takeoff roll. He aborted the takeoff. His current process during his flight training focuses on flying the aircraft and assessing the situation before taking any other action.Related documents are available at the Flight Safety Detectives website.
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Get the highlights of the Experimental Aircraft Association's AirVenture 2024 in Oshkosh, Wisconsin!
Hundreds of thousands of attendees attended the multi-day event. All sectors of aviation were represented, from the military to general aviation, from exotic and experimental aircraft to flight demonstrations by military and civilian aircraft.
John Goglia attended once again this year and chatted with pilots, mechanics, elected officials, and aviation enthusiasts of every age. He met several people who regularly listen to the podcast, including some who offered ideas for future shows.
AirVenture is a unique airshow experience, but there are opportunities to visit other airshows around the country. Many local airports also offer opportunities for the general public, to see airplanes up close and speak to local pilots, flight schools, and others involved in aviation.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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What led to the deadly crash of a Voepass Linhas Aereas in August? Video of the flight's final moments show the aircraft rapidly descending in a flat spin. Early reports on the accident mention that icing conditions were present in the area at the time of the crash.
Recovering from a spin in a large airliner is a significant challenge for pilots. Understanding how to avoid situations that lead to stalls and spins is the best way to avoid these tragedies.
Flight training typically does not require pilots to experience actual spins. Even full-motion simulators do not provide the full range of physical experience on an actual airplane. Pilots need to understand their aircraft's stall and spin characteristics and the situations that make an aircraft's wings more prone to stalling.
John Goglia shares his experience as an NTSB Board member investigating a 1994 icing-related crash of an ATR72. That investigation included an FAA test involving another ATR72 in controlled icing conditions, which revealed that certain icing conditions could result in icing that the ATR72's deicing system could not control.Todd Curtis and John also delve into an incident at Boston Logan Airport where the pilot of a Brazil-registered Embraer Phenom 300E who had difficulties communicating with an air traffic controller. The pilot could not follow several ATC requests, resulting in altitude and speed deviations during a landing approach.
English is the language used by ATC at international airports, but pilots from countries where English is not the language used to communicate can have difficulties. The English used for air traffic control is not the same English used in normal conversations. Even native English speakers have challenges when communicating with ATC, particularly those performing a single-pilot IFR flight.
Related documents are available at the Fight Safety Detectives website.
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NASA's Aviation Safety Reporting System (ASRS) can be used by pilots, mechanics, flight attendants, and others in the aviation safety community to report UAP or UFO encounters without revealing their identity or the identity of their employers.
Todd Curtis discussed this in a June 2024 presentation at the Contact in the Desert Conference in Palm Springs, California. In this episode, he and John Goglia dig deeper into the issue of reporting of these encounters in the aviation community. While neither of them has seen an incident report that mentioned a UFO or UAP, that it does not mean that they have never happened.
Based on his experience in both industry and academia, Curtis believes that if he had come across this kind of information, he would not have included that fact in any report because it would not have been well received by his colleagues.
UAP and UFOs are legitimate risk concerns, but civilian organizations like the FAA have not formally started to collect this kind of data. Todd and John share the factors that they think are barriers to such data collection.NASA's ASRS database already has at least 13 UAP events, each involving an unidentified phenomenon, an aerospace vehicle with unconventional capabilities, or a conventional aerospace vehicle in an unconventional location or situation. Todd and John discuss the most unusual report, involving an aerospace vehicle that was too small to carry a pilot and that exhibited extraordinary speed and maneuverability.
Anyone with an aviation-related UAP encounter should submit a report to the ASRS to help the aviation community better understand UAP risks.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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Issues from the NTSB investigation of a 2023 railroad accident are used to discuss the voluntary party system. The system is designed to encourage cooperative efforts in an investigation, which does not always work.
In the party system, an organization or an individual with relevant expertise or information is invited to participate directly in an NTSB investigation. These parties are required to follow basic rules. They are expected to provide the NTSB information or expertise that helps the investigation and limit discussing details with the media and others not involved in the investigation.
In the NTSB investigation of a 2023 rail accident involving a Norfolk Southern train in Ohio, Norfolk Southern was a designated party. Late in the investigation, Norfolk Southern submitted information that the NTSB rejected because of how and when it was submitted.
Based on statements in the final report and in the public docket, Norfolk Southern did not operate properly as a party to the investigation. They conducted an independent investigation and held information that should have been given to the NTSB.
Should inappropriately late submissions be included in an NTSB investigation? The NTSB did not state if this late submission had critical information. Greg Feith and John Goglia favor analyzing all information to determine whether it helps the investigation.Related documents are available at the Flight Safety Detectives website.
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A YouTube video showing fireworks fired from a low-flying helicopter at a speeding Lamborghini has led to federal charges for the creator.
Suk Min Choi was charged in June by the U.S. Department of Justice with one count of causing the placement of an explosive or incendiary device on an aircraft. At least four other people were involved, including two or three people in an apparent Robinson R44 helicopter and the drivers of two vehicles.
Replicating a sequence from a video game, Choi presses a “fire missiles” button while people in the helicopter shoot fireworks at the Lamborghini. In the video posted to YouTube, it appeared that there were cameras in the helicopter, the Lamborghini, and a second vehicle on the ground.In addition to law-breaking activities, this event has scary aviation safety risks. The helicopter pilot may have violated one or more FAA regulations concerning flying for commercial purposes. And, the helicopter was clearly flown in a hazardous manner. The pilot may have problems finding employment if their involvement becomes public.
Even stunts in the air need to follow appropriate laws, regulations, and safety procedures and should be done after consulting with partners like insurance providers, the FAA, and other appropriate authorities.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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A fatal midair collision involving a Cessna 172 illustrates several aviation safety concerns related to pilot training in and around airports with commercial operations. The incident involved a student and instructor on board performing touch-and-go landings and a Dash 8 departing on a passenger flight.
While the event happened in Kenya, the circumstances that led to this accident could happen in any location where airliners and small training aircraft operate out of the same airport. In this case, the midair collision occurred only about 500 feet above the ground and 1500 feet below a broken cloud layer in an area with over 10 km of visibility.
The Cessna 172 was performing touch-and-go landings on from one of the airport's runways. Shortly after the Dash 8 departed from an intersecting runway, the stabilizer of the airliner collided with the Cessna. The Cessna crashed, killing both on board. Todd Curtis and John Goglia analyze the preliminary report, which came out three months after the accident.They examine the transcript of ATC communications around the time of the accident. Anyone who operates aircraft in similar circumstances could learn something useful from studying this event.
Immediately after the collision, the transcript of the ATC communications stated that during 97 seconds, there was "unrelated transmission from other traffic." Any transmissions to or from aircraft near the collision could provide useful clues into what was known or not known by ATC and aircraft crews in the vicinity.
Related document is available at the Flight Safety Detectives website.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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Boeing should use a third-party organization that would act on behalf of the FAA to monitor the design and production of its aircraft. That’s the proposal of special guest and Kilroy Aviation CEO Mike Borfitz published in a June 28, 2024 editorial in Aviation Daily.
This kind of oversight had been provided in the past by Boeing employees who acted as the eyes and ears of the FAA. The process is based on FAA regulations created in 2005 that allowed manufacturers to create Organization Designation Authorizations (ODAs), groups of employees who were paid by the manufacturer and who worked for the FAA.
The effectiveness of this organizational setup for Boeing was questioned in the wake of the 737 MAX crashes in 2018 and 2019. Borfitz's proposal would address the weaknesses of the previous setup by having a third-party organization outside of Boeing's control act as Boeing's ODA. This would make it more likely that concerning issues would be brought to the attention of the FAA.
This episode includes a wide-ranging discussion of how aircraft are certified to FAA standards. Todd Curtis and Borfitz, both of whom worked for Boeing when the company merged with McDonnell Douglas, relate that the merger led high-level Boeing managers to focus more on shareholder value.
Borfitz expresses his belief that the current Department of Justice sanctions against Boeing that require an independent monitor to oversee compliance and safety for three years would be ineffective because it allows Boeing to return to its previous management policies in three years.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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Hypoxia is a significant danger in aviation and an insidious killer of passengers and pilots. Special guest Miles O'Brien hosts a discussion with aviation experts Todd Curtis, Greg Feith, and John Goglia that covers how hypoxia impacts all forms of aviation. They discuss personal experiences with hypoxia and share insights from several hypoxia-related accidents.
Hypoxia is a condition where the human body is deprived of oxygen which can reduce mental function. Hypoxia can be particularly hazardous for pilots because someone experiencing hypoxia may not be aware of its symptoms or its effects on their performance.
One high-profile incident in 1999 took the life to golfer Payne Stewart. He was a passenger in a Learjet 35 that took off from Orlando Executive Airport and became non-responsive to air traffic control. Fighter jets intercepted the plane and determined the crew was unconscious. After 1500 miles the jet ran out of fuel and crashed over South Dakota.
Greg, Todd, Miles, and John have all experienced hypoxia in controlled altitude chambers. They share their experiences, which include feelings of euphoria, reduced mental capacity, reduced physical performance, and even a case of high-altitude bends.
Key to understanding hypoxia is the concept of time of useful consciousness, which is the amount of time a person can spend at altitude without feeling the effects of hypoxia. That period of time gets smaller as altitude increases. Age, stress, and other factors may shorten those times.
Related documents are at the Flight Safety Detectives website.
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Planes that experience turbulence in flight are getting a lot of headline attention lately. During one widely covered incident of turbulence in May 2024 a passenger aboard a Singapore Airlines flight was killed.
Serious turbulence leading to injuries is not uncommon. Todd Curtis and John Goglia discuss several notable in-flight turbulence events, including the death of 1950s era test pilot Scott Crossfield.
Specific and useful information about turbulence conditions is often not readily available. However, pilots can avoid turbulence, either by adjusting the planned flight to miss major areas of turbulence or by deciding not to take off if the risks are high.
Airline passengers also have a role in dealing with turbulence dangers. Seatbelts and keeping items stowed in flight minimize the risks in bumpy conditions.
Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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As Boeing continues to be the subject of investigations and congressional hearings the concept of criminalization has come to the forefront. This could have a devastating impact on aviation safety in the U.S. Special guest and aviation attorney Mark Dombroff focuses on efforts to criminalize the investigation of aviation accidents and incidents.
The effort to use criminal prosecutions to address aviation safety issues in the U.S. would dramatically impact the process of getting to the facts, including making witnesses more reluctant to come forward with details. Criminalizing will make the safety investigation process more difficult and less effective.
While some in the legal community favor criminalization, it is not the approach used in most of the world. Aviation accident investigation focuses on understanding what happened and how to prevent similar events in the future. A criminal investigation would shift the goals to assigning blame and handing out punishment.
Several notable past investigations came up during the discussion, including a fatal 2006 midair collision in Brazil involving a 737 and a corporate jet. The corporate jet pilots were detained in Brazil for several months and threatened with prosecution for almost 18 years. When TWA Flight 800 crashed, there was tension over whether the FBI or the NTSB would conduct the investigation.
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Missing equipment and inexperience led to a plane crash that killed 3. Precipitation, turbulence, and icing were factors in the crash of a Piper PA-30 Comanche in Oklahoma. The pilot did not have an instrument certification and was not able to handle the conditions.
The pilot had a private pilot and multiengine rating but did not have instrument training. Todd Curtis, Miles O’Brien, and John Goglia discuss what may have driven the pilot to fly into deteriorating weather. “Getting there” seems to have been the focus rather than planning and preparation.
The pilot was cruising at about 8,500 feet and climbed to as high as 16,500 feet. While the aircraft could provide supplemental oxygen, the equipment to use that system was not on board.
The pilot likely climbed to escape a storm. He flew to an altitude where supplemental oxygen was required. The plane crashed and all 3 people on board were killed.Related Documents are available at the Flight Safety Detectives website.
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The fatal crash of Hughes 369 helicopter being used to trim trees has a backstory that gives insight into what went wrong. This workhorse of a helicopter apparently had damage from previous incidents.
The NTSB investigation found cracks in an engine mount that were likely present before the crash. John Goglia and Todd Curtis look beyond the fatal accident and share three previous investigations involving this helicopter. Two involved a crash with serious structural damage or a hard landing. These events may have stressed the engine mounts.
The fatal crash happened when the helicopter was in use for an operation that used a large 10-bladed saw to trim trees close to power lines. The helicopter went into a spin and low altitude and crashed, killing the pilot.
This episode highlights the importance of knowing an aircraft's history. Studying previous events involving a particular aircraft could reveal issues that should be inspected more closely or more frequently. The required 100-hour and 300-hour inspections were completed for the helicopter at the center of this discussion. However, additional inspections would have been smart given the previous accident history of the helicopter.
Related documents are found at the Flight Safety Detectives website.
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Training flight gone wrong! An examination of a February 2024 accident that involved an unstable approach, a tail strike, and a near collision with an airplane hanger.
Both the instructor and student involved in the Cessna 172 accident survived. Their account of the event provides insights into how a routine training flight turned into a near disaster. The instructor's decision-making created a dangerous situation.
Shortly before landing, ATC redirected the aircraft to a much shorter runway, and the instructor allowed the student to bring in the aircraft too high and too fast. The instructor then allowed the student to land instead executing a missed approach.
After the student put the aircraft on the runway and braked hard enough to lock the brakes, the instructor took control of the aircraft, continued to apply brakes and pulled back on the control column hard enough to cause a tail strike.
The instructor turned onto a taxiway near the end of the runway and took off again, barely missing a nearby hanger. Fortunately, the instructor was able to land the damaged aircraft.
The Australian authorities reference FAA criteria for a stabilized approach in the accident report. The detectives share anecdotes that reinforce the importance of judging whether an approach is stable and being consistent with landing procedures.
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The crew of a United Airlines 727 tried to turn back shortly after takeoff from Los Angeles, but did not make it back to the airport. The plane crashed into the Pacific Ocean.
Greg Feith, Todd Curtis, and John Goglia discuss the crash of the 727-22QC in 1969. Electrical failures and electrical system design contributed to the plane crash. The accident happened on a night with limited visibility due to the weather.
The aircraft had three electrical generators, but only two were working. Shortly after takeoff, the crew shut down one engine due to a fire warning. That move shut down one of the two working generators.
John discusses the complexities of 727 electrical systems and other aircraft of the era. The NTSB found that total power loss occurred after all the electrical loads were placed on the one remaining generator.
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Oil and oxygen don’t mix on airplanes. A crew doing maintenance on the Air Force One oxygen system ignored safety procedures resulting in $4 million dollars of damage the plane.
The damage was caused by maintenance activity on the oxygen system of a U.S. Air Force VC-25A, a 747 aircraft that regularly flies the President of the United States. This event occurred in 2016.
John Goglia and Todd Curtis share evidence that crew did not follow the VC-25A's aircraft maintenance manual procedures for cleaning the tools, parts, and components before performing leak checks on the oxygen system.
This is perhaps the highest profile incident of an aircraft damaged due to improper oxygen system maintenance procedures. John notes that failure to follow procedures is the FAA's top cause for maintenance problems in commercial aviation.
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New evidence calls into question the NTSB's conclusions – and our reporting in Episode 193 - about a 2020 midair collision. Video and other information shows that there were two helicopters in the area before the midair collision.
Miles O'Brien, Todd Curtis, and John Goglia revisit the 2020 midair collision of a drone and a helicopter. The NTSB used a video shot by the drone to conclude that a helicopter seen at the beginning of the video later collided with the drone.
When Todd recently used the video as part of a class he was teaching, he noticed a shadow that he could not explain. That led to lots of sleuthing and the realization of the involvement of a second helicopter.Safety concerns arise when one or more helicopters operate around a drone. In addition to this 2020 collision, a midair between two news-gathering helicopters in 2007 that killed everyone on both helicopters.
Miles shares his experiences flying in situations where multiple helicopters are covering a breaking news story. Pilots of manned and unmanned aircraft need to coordinate closely to maintain safe operations.
The NTSB should consider taking a second look and revising its report to address the aviation safety issues uncovered. John shares his experience on the NTSB Board and what it took to reopen an investigation when new information was available.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
https://flightsafetydetectives.com/2020-midair-collision-revisited-episode-221
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Two Piper airplane crashes show that pilots’ bad decisions can have devastating results. This episode covers two avoidable fatal crashes.
A 1991 accident involves a Piper Seneca in Florida. The NTSB found that the two occupants were partially disrobed and no evidence that either were wearing seat belts or shoulder harnesses. The report makes clear that the two occupants were attempting to join the Mile High Club.
In the second event, a Cessna 150 crashed in 2014 after the pilot took off at night with a very low ceiling. He was taking flash pictures. He crashed shortly after takeoff due to spatial disorientation. The pilot’s decision to fly in deteriorating conditions is similar to errors made by the pilot in the Kobe Bryant Crash.
The pilot had a commercial and an instrument rating but was not current to fly at night or in instrument conditions, a classic case of a VFR pilot taking off in IFR conditions. The visibility conditions were so low that the pilot may not have any chance of landing at the departure airport.
Pilots can be tempted to bend the rules in order to have some fun in the air. These lessons show that the results can be deadly.Related Documents are available at the Flight Safety Detectives website.
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Coming to you from the 2024 AMC Competition in Chicago! Miles O'Brien, Todd Curtis, John Goglia, Greg Feith, and aircraft mechanic and accident investigator Jason Lukasik share the experience of the competition. Every aspect of aviation maintenance and repair was on display as competitors worked to beat the clock.
This year more than 400 competitors from nearly 90 teams from maintenance schools, airlines, and the military tackled 27 aviation maintenance skills challenges. Hear about the displays of excellence and comradery witnessed at the event.
The high-energy event highlights the critical role of aviation maintenance professionals and gives the participants insights into opportunities in the industry. The event showcases the skill level of the participants. For some, it is a direct path to finding employment in the field.
John, who is one of the founders of the competition a decade ago, shares AMC's plans to expand the competition to more aviation industry conferences. More maintenance teams will be able to take part.Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
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