Aircraft Accidents and Lessons Unlearned XVIII: AirNow 352
There is an Aesop Fable titled, The Boy Who Cried Wolf; it is a story about a shepherd boy who twice tricks the local villagers to come running to help him by falsely crying an alarm of “Wolf! Wolf!”, thus amusing him. When the real wolf did show up, his cries for help were ignored, leaving the villagers to say, “We will not be fooled again. Pah! If there is a wolf, then let the animal satisfy itself on mutton and boy.”
The last statement (“… then let the animal satisfy itself on mutton and boy.”) acts as a metaphor. The boy – the National Transportation Safety Board (NTSB) – has been crying “Wolf!” for years; they do this when they cry, “Pilot Error” or “It’s the FAA’s fault”. This is indicative of indolent investigating; ‘phoning in’ the Probable Cause to avoid investing more time or energy. What results? The Industry and manufacturing do not take the NTSB seriously – or serious enough – to warrant further effort.
The AirNow 352 accident investigation demonstrated the NTSB’s inability to understand the Industry, Manufacturers and the Federal Aviation Administration (FAA). However, this was not just a failing on the NTSB’s part; unlike the NTSB, the FAA does not have the luxury of Industry ignorance. Their weak response is inexcusable. This accident is indicative of how politics destroys the FAA’s effectiveness.
Business Air, Incorporated (as AirNow) flight 352 was an Embraer 110P1 flying under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135: Air Taxi and Commuter, from Manchester, NH (MHT) to Portland, ME (PWM) on November 8, 2005. The cargo aircraft was taking off out of MHT when the number one (left) engine failed. The pilot could not stop the aircraft from making a shallow left turn; the aircraft crashed into a Walmart garden center.
The Probable Cause of the accident final report for Accident Number NYC06FA027 read:
“The pilot’s misapplication of flight controls following an engine failure. Contributing to the accident was the failure of the sun gear, which resulted in the loss of engine power. Contributing to the sun gear failure were the engine manufacturer’s grandfathering of previously recommended, but less reliable, maintenance standards; the FAA’s acceptance of the manufacturer’s grandfathering; the operator’s inadequate maintenance practices and the FAA’s inadequate oversight of the operator.”
The pilot is accused of misapplying flight controls following an engine failure; it would take a pilot to verify that allegation. The allegation is another way of crying “Wolf!” i.e. ‘Pilot Error’. However, as will become evident, the questionable FAA oversight would suggest: inadequate training of the pilot and/or operation of the equipment (Embraer 110P1).
The Probable Cause then spoke to maintenance. The first-stage sun gear did fail, mainly because it was reused beyond its physical lifetime, instead of being discarded after it exceeded its life cycle, it was removed and then … reversed – placing it back in position, to wear the opposite side of the sun gear’s teeth.
An impact on the sun gear failure was the engine manufacturer’s – Pratt and Whitney Canada (P&WC) – grandfathering of previously advocated maintenance standards, i.e. Business Air’s On-Condition program. NOTE: The term ‘grandfathering’, as per the Merriam and Webster Dictionary, refers to ‘permitting to continue under a grandfather clause’. In the case of AirNow 352, overhaul times were escalated based on Business Air’s unreliable maintenance standards per dubious data from the On-Condition maintenance program.
An On-Condition program means, “Engine manufacturers provide a time limit for when their engines should be overhauled. This limit, which consists of a certain amount of Flight Hours and Calendar Months, is the point at which they recommend the engine should be removed from the aircraft and sent to the factory/engine shop for overhaul.” Because the manufacturer, P&WC, grandfathered the overhaul requirements of AirNow 352’s number one engine, the sun gear was not replaced for 22,000 hours instead of the recommended 12,000 hours. Furthermore, it was not replaced, but reversed.
However, it is the last independent clause (italicized) in the Probable Cause that is the cry of “Wolf!” Like the term: ‘Pilot Error’, the NTSB used the ambiguous term: ‘the FAA’s inadequate oversight’, too often. The phrase becomes an overused string of buzz words without supporting evidence. What about the FAA’s oversight was inadequate? Where did they fail? Because of these “Wolf!” cries, there is no urgency in finding solutions to real problems.
The AirNow 352 accident was indicative of what could and would go wrong with the FAA’s oversight of an oft overlooked operator. Despite Business Air falling under the radar with regards to popular air operators known to the public, Business Air, AirNow’s parent company, was located in Bennington, VT, near the western border of the state. The Certificate Holding District Office (CHDO) responsible for Business Air’s certificate oversight was located in PWM, a full workday’s drive from Bennington. Each time the Principal Inspectors conducted on-site surveillance of Business Air, the travel expenses included four nights for hotels and per diem.
In contrast, the Flight Standard District Office (FSDO) in Albany was located less than an hour from Bennington, VT, and Business Air; its location would have provided better oversight and more frequent on-site inspections. However, the politics of office funding for CHDOs and FSDOs is dependent on their assigned certificates and territory; the quantity of certificates versus quality of certificate management.
The Principal Maintenance Inspector (PMI) assigned to Business Air at the time of the accident was temporary, swapping out with other PMIs on a rotational basis, changing one Principal for another. This guaranteed no FAA Principal consistency, resulting in bad decisions; unfamiliarity due to a complete lack of understanding of Business Air’s culture.
As mentioned previously, the engine overhaul times were being grandfathered by P&WC based on unreliable data from Business Air’s engine monitoring program; as Business Air applied for extensions to overhaul times, the data they provided was not accurate. Each FAA PMI, having just come on to his/her assignment, did not get a consistent picture of what Business Air was doing, blindly giving maintenance exemptions based on unfamiliar data.
It is important to note that Business Air was a Title 14 CFR 135 operator; the aircraft was single pilot hauling cargo. There are no headlines here; the pilot survived, they hauled cargo and no more than one pilot flew at a time. In the world of public interest, this was no more than a shrug of the shoulders in the news. No one outside of New England, indeed, Bennington, Vermont, would have been aware of the accident past the second week and even less interest as time continued to pass on.
However, this was not the only accident Business Air’s pilots had experienced; there were three others, two of them fatal. One Business Air aircraft flipped on the runway during approach to an airport; a second one slammed into the side of a mountain near Bennington while approaching at night; the third was forced to land in a field because of fuel starvation when the pilot did not request enough fuel.
Four accidents demonstrated that Business Air’s oversight was lacking. Fueling and flight training all fall under the purview of the Principal Operations Inspector; engine overhauls are the responsibility of the PMI. Substantial breaks in the surveillance practices and continuity of oversight of Business Air could arguably be the cause of miscommunications between the Operator and the managing office. It also demonstrates why operators cannot be trusted to self-police their certificates, especially when they are considerably small, out of the geographical driving distance of the CHDO and can exploit the unfamiliarity of the Principal Inspectors with the operator’s culture.
AirNow 352 is the perfect example of opportunity ignored, both by the NTSB, who spent too much time making accusations to recognize the real deal when it presented itself; and the FAA, who discounted their weaknesses (consistent oversight of Business Air) to maintain a feeble grip on Business Air. Since November 2005, nothing has been done to rectify the omission. It’s what happens when you cry, “Wolf!” too often.