Aircraft Accidents and Lessons Unlearned LXIII: Massachusetts State Police, Registration N20SP

On February 22, 1995, at 09:37 eastern standard time, a Massachusetts State Police (MSP) Eurocopter AS-350-B helicopter, registration number N20SP was destroyed when, in the process of reconciling a forced emergency landing from approximately 600 feet of altitude, the aircraft struck two metal structures before colliding with a boat house on the north bank of the Charles River in Cambridge, MA. The National Transportation Safety Board (NTSB) assigned accident number NYC95GA060 to this event.

The NTSB determined the probable cause(s) of this accident to be, “1) The Massachusetts State Police management’s failure to provide adequate oversight of its air wing; 2) Fuel contamination and obstructed fuel injector nozzles, due to inadequate fuel storage and storage requirements by the MSP, resulting in a loss of engine power; and 3) the failure of the pilot to execute a proper autorotation, which resulted in a loss of rotor RPM [rotations per minute] and subsequent loss of helicopter control.”

The NTSB’s website docket had no information beyond the final accident report. It is impossible to find any other accident report that explains, in explicit detail, the failings of so many with so few responsibilities. There would not be enough room in multiple reports to list the safety failures that occurred to this aircraft and its pilots. There was a myriad of findings with the MSP air wing while the various directions those documented findings could go were too numerous to list. To put this in perspective, the MSP had to keep two Eurocopter AS-350-B helicopters in an airworthy condition – not a fleet of AS-350-B helicopters – just two. Furthermore, the MSP had no organization of its helicopter program; training, including autorotation recovery, was inadequate, while air wing management was non-existent. Aircraft fuel tanks, the fuel storage and the fuel truck were each fouled with corrosion and water-to-fuel levels were at unacceptable limits. Pilots were moved in and out of the program without retraining and requalification. The list goes on and on.

This Aviation Lessons Unlearned website dedicates itself principally to major category aircraft accidents. This website draws out fundamental accident contributors that are regularly missed by the NTSB major accident investigators or Go-Team members. As a result of this focus, the true NTSB investigators, most of the field investigators who address the accidents too small or less media friendly for the major accident investigators to handle, are missed, an oversight a former Federal Aviation Administration (FAA) coworker pointed out to me, an oversight I wished to rectify.

In July 2018, over four years ago, I wrote a root cause analysis article concerning LAX02GA201 and DEN02GA074, two firefighting aircraft owned and operated by Hawkins and Powers out of Greybull, Wyoming. These two aircraft crashed mid-mission when their wings departed the aircraft. These accidents – aviation lessons unlearned XV – brought a most important category to light, one shared with this MSP helicopter accident, specifically that each aircraft was operating in Public Use.

The existence of Public Use aircraft was an anomaly. I remember the first (and only) time I dealt with Public Use was January 8, 2003. I sat in an FAA conference room in 800 Independence Avenue, asking the only FAA expert for Public Use (a man on the brink of retirement with no one to replace him) about the two firefighting Public Use aircraft. My interview ended because I was launched on the Air Midwest 5481 accident, and I never had the chance to continue my meeting. The point was that Public Use was as misunderstood then – even by the FAA – as it is today.

In that meeting, I learned that only the Operations side of Public Use answered to the regulations, specifically Title 14 Code of Federal Regulations (CFR) Part §91: General Operating and Flight Rules, as did the accident aircraft and the two firefighters. How Public Use answered to the Airworthiness side was a lot more confusing.

The definition of Public Use blurs because ‘Public Use’ became ‘Public Aircraft’ in October 2018. It was redefined as Public Aircraft under 49 United States Code (USC) §40102(a)(41)(C), “An aircraft owned and operated by the government of a state, the District of Columbia, or a territory or possession of the United States or a political subdivision of one of these governments, except as provided in section 40125(b).” This redefinition was done quietly with Public Law 115-254, under the FAA Reauthorization Act of 2018, Section 519: FAA Data Transparency. The definition for Public Aircraft is now found in 49 USC §40125 (a) Definitions, (2) Government Function: The term governmental function means an activity undertaken by a government, such as national defense, intelligence missions, firefighting, search and rescue, law enforcement (including transportation of prisoners, detainees, and illegal aliens), aeronautical research, or biological or geological resource management.”

The primary concern was control, as in there was no mandatory control, not just at the MSP air wing, but at any Public Use operator. This led to two problems with Public Use/Public Aircraft. First, no clear rules were set to determine how Public Aircraft were to be maintained. According to Advisory Circular (AC) 00-1.1B, Public Aircraft Operations – Manned and Unmanned, adopted 9/21/2018, Paragraph 10.1, a conformity inspection is required before the aircraft can be operated, and included the advice, “For more information, contact the appropriate FSDO [Flight Standards District Office].” To begin with, an AC is not regulatory and therefore holds no power. It is ‘advisory’ and can be dismissed by anyone wanting to use an alternative method of certification. Even so, was there any guidance in the AC for consistency between FSDOs across the country to require comparable maintenance programs? To be clear, this wasn’t a Boston FSDO problem nor was it a problem indigenous to any FSDO. This was a headquarters – Washington, DC – problem and it was immersed in ambiguity. Why wouldn’t headquarters create guidance for local FSDOs to require a proper maintenance program for Public Aircraft? Furthermore, what were comparable maintenance programs and why were there no responsible parties?

The second problem was that Title 14 CFR Part §91 does not – did not – speak to fuel farm testing and oversight. Subpart §91.1507 speaks to fuel tank issues on the aircraft … but makes no provisions for fuel farm or truck auditing and testing. Since the MSP helicopter crashed with severe fuel contamination problems, why didn’t the FAA address this critical topic in regulation or order? Who was supposed to provide consistent oversight and surveillance? Who was in control?

The MSP helicopter accident preceded the two firefighter accidents by seven years, yet the NTSB and the FAA failed to hold hearings to determine why the MSP helicopter program was so poorly overseen, how an event that defied the basic principles of safety in both Operations and Maintenance was allowed to continue threatening public safety. Consider that the firefighters crashed into the forest they were treating, in essence, starting new fires while delivering the aviation fuel that would aggravate the situation. The MSP helicopter crashed into a building normally occupied or could have just as easily crashed into the streets of the city of Boston. Instead, the only FAA and/or NTSB responses were hidden in the political nonsense that accompanied the FAA Reauthorization Act of 2018, where ‘Public Use’ was silently renamed ‘Public Aircraft’, confusing safety issues with as absurd a solution as a name change. Was this done to confuse the public by erasing Public Use and thus the stigma that went with it?

The MSP accident was a learning experience gone wrong in many ways. Public Use should have been better defined and organized before being changed to Public Aircraft. The NTSB missed a big chance to make safer the skies above our citizens and the FAA ignored its responsibility to capture uncontrolled safety issues. What else is there to say?