Flight Safety Detectives

Carbon Fiber in the Air and Under the Sea – Episode 177

Todd Curtis and John Goglia discuss the use of carbon fiber in the Boeing 787 airplane and the Titan submersible. Prompted by listener questions, they explain why the carbon fiber is subjected to completely different – and riskier - conditions in the case of the sub that got international attention when it imploded on June 18, 2023.

The Titan accident is under investigation by American and Canadian authorities. The submersible used a novel design that included using carbon fiber to construct a major portion of the hull.

Todd and John compare the use of carbon fiber in a submersible compared to the use in aircraft, specifically the 787. They explain the radically different effects that a rapid decompression would have on an airliner at cruising altitude versus a catastrophic implosion in the depths of the ocean.

They also compare the unique design of the Titan with more traditional submersible designs. Two aspects that get the attention of these safety experts:

• Lack of a way to get in our out without removing bolts
• The vessel was not built in compliance with existing standards

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NYC Air Crash Shows Danger of Wing Contamination – Episode 176

A F28 airliner crashed shortly after takeoff from LaGuardia Airport due to icing that degraded the lift on the wings. Just 3% leading edge wing contamination would have been enough to cause this aviation disaster.

Todd Curtis, Greg Feith, and John Goglia highlight the safety findings related to the 1992 plane crash of USAir Flight 405. The aircraft had no devices to keep the leading edge of the wing clear in the cold and snowy weather conditions. The crash caused 27 fatalities.

John shares firsthand knowledge of the deicing procedures in place in 1992. Those procedures have have changed, in part because of this accident.

Greg, Todd, and John compare this plane crash with similar events to provide insights related to this aviation disaster. The result is valuable aviation safety insight for pilots, mechanics and anyone involved in aviation today.

Find related documents and more at the Flight Safety Detectives website.

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Charter Flight Safety Boosted with Part 135 Certification Rules – Episode 175

Dollars over lives? Greg Feith and John Goglia discuss Part 135 and “Part 134 ½” charter operations. They offer numerous aviation safety benefits of being (and using) a properly certificated charter company. It costs more but leads to safer operations.

John and Greg cover the plane crash of Lear 25A in Teterboro, New Jersey to illustrate the value of proper charter operations.  They review key findings of the NTSB report, including the lack of planning for a short repositioning flight and lax enforcement of Part 135 rules.

The first officer was only cleared to act as second in command of this flight, but the captain allowed the first officer to fly all but the last 15 seconds of the flight. At that point of the flight, the aircraft was in an unstable approach, and crew actions allowed the aircraft to stall and crash short of the runway.

Hear how increased use of flight data recorders with quick access recorder capabilities can help Part 135 operators as well as safety investigators improve the aviation safety of charter flights. John and Greg argue the equipment can help avoid aviation disasters.

Related documents available at the Flight Safety Detectives website:

NTSB Accident Report 2017 Lear 25A crash in Teterboro, NJ
NTSB Accident Report 2001 King Air OSU basketball team
NTSB Accident Report 2004 Dick Ebersol fatal crash
Public Docket

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Aviation Safety Lessons from First Flight into a Special Use Airport – Episode 174

A flight instructor chose to have a pilot take his first flight in an airplane into a special use airport and the result was a different learning experience than planned. The aircraft experienced a hard landing that led to a fracture of the right wing spar.

Todd Curtis, Greg Feith, and John Goglia discuss this accident in Puerto Rico that involved a Britten-Norman Islander aircraft. The instructor pilot chose to take a new pilot on his very first flight with the airline to a small airport that had a very challenging approach.

The new pilot was a highly experienced 737 pilot who had no recent experience flying this aircraft model. The instructor allowed the new pilot to continue the approach even though the aircraft was about 100 feet above approach altitude shortly before landing.

The Flight Safety Detectives question the instructor pilot's decision to choose this challenging approach for the transitioning pilot's first flight with the operator as well as the decision to allow the landing to continue. Also discussed is the NTSB's decision to not investigate or nor report key issues about events leading up to the crash, including the aircraft operator's training and procedures.

Related documents at the flight safety detectives website:

• NTSB Aviation Investigation Final Report
  pdf
• NTSB Airworthiness Factual Report
  pdf
• NTSB Form 6120 Accident or Incident Report
  pdf
• NTSB Docket Culebra pilot interview
  pdf
• Operator Training Manual
  pdf
• Aircraft operator CPX Airport Training Materials
  pdf
• NTSB Public Docket

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Aircraft Cargo Door Headaches – Episode 173

This episode dives into the design and maintenance of aircraft cargo doors. Many aviation safety incidents with cargo doors are documented as maintenance issues, but some have caused notable air crashes.

Todd Curtis and John Goglia focus on the 1989 plane crash of an Evergreen International Airlines DC9. The first officer did not properly close the main deck cargo door. The door came open shortly after takeoff, which led to a loss of control and a crash.

John shares his long history dealing with cargo door issues. He shares how door engineering has evolved over time. He also explains the rush to convert passenger aircraft to cargo aircraft that came about in the 1980s due to many airlines getting into the air cargo business.

Todd and John discuss several aviation disasters involving cargo doors, including one involving a United Airlines plane near Honolulu.

Related documents at the Flight Safety Detectives website:

• NTSB Accident Report Evergreen International Airlines Flight 17
• NTSB Accident Report United Airlines Flight 811
• UK Accident Report THY Flight

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Flight Plan Creates Aviation Safety Risks – Episode 172

Some flight plans have aviation safety risks baked in. Todd Curtis and John Goglia discuss a runway excursion accident involving a student pilot who in the same flight was attempting to satisfy both a night currency requirement and a 250 nautical mile training flight requirement for an instrument certification.

The plan literally went off track during the attempted takeoff at the fourth stage of the flight plan.

“They bent some metal, no one was injured, but there is a lot to learn from this incident,” John says.

The original plan involved a flight of well over 400 nautical miles of night flying, well exceeding the training requirement. The plan also involved landing and takeoff at two busy airports. Due to traffic, weather, and fueling station issues, two unplanned fuel stops were added.

Todd and John talk about the decisions made before this flight began that created unnecessary safety risks. Among the takeaways was the need to make better flight plans and to change those plans as circumstances unfold.

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John Goglia’s Unique Insight into USAir Plane Crash – Episode 171

You had to be there to know the full story of the plane crash of USAir Flight 5050. John Goglia was, and he shares the experience.

Todd Curtis and John discuss the fatal 1989 crash of USAir Flight 5050 at La Guardia Airport in New York. John directly participated in the accident investigation as a mechanic with USAir. He shares accident investigation details well beyond the official report.

The extraordinary amount of media attention around the accident and the flight crew impacted the sequence of events. The reported “missing pilots” were only missing to the media, having been moved away from the scene by investigators to protect them from the frenzy. John also reveals how the media got recordings of investigation team status meetings.

Hear details behind key findings:

• Taking off with an improperly trimmed rudder
• Misuse of the autobraking and auto throttle systems
• Crew fatigue and other human factors

John developed an ongoing relationship with the first officer on the flight, who became a fierce advocate for aviation safety. He notes that aviation disasters have a profound impact on the people involved.

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Keith Green Plane Crash Shows Value of Accident Investigation – Episode 170

The fiery plane crash that killed Christian music star Keith Green and 11 others resulted in safety lessons for every pilot. The NTSB accident report also has safety takeaways for anyone who rents or uses aircraft and pilots that are not their own.

Greg Feith, Todd Curtis, and John Goglia talk about the circumstances of the fatal 1982 air crash. The thorough NTSB accident investigation (NTSB_FTW82AA299_Keith_Green.pdf) documents the roles that the overloaded and unbalanced aircraft and the pilot’s experience played in the tragedy.

Greg and John compare the detailed findings in this report with the more superficial summaries that are the norm for today’s NTSB accident reports. This report contains valuable aviation safety findings that can help pilots avoid similar mistakes.

• Importance of preflight planning and inspection
• Need to check and verify loaded aircraft weight and balance
• Understanding aircraft performance data

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Small Hardware Causes Big Aviation Safety Problems – Episode 169

The NTSB has a message for mechanics – pay attention to B-nuts! Todd Curtis, Greg Feith, and John Goglia dig into NTSB Safety Alert 086, which highlights four accidents that were caused in part by improperly tightened b-nuts.

Small parts led to big problems. Two of the accidents were fatal.

They focus on one accident that involves a very experienced pilot who also performed maintenance on the accident aircraft. The Bell 206 helicopter crashed following a fuel leak. The NTSB found that when he did maintenance on the aircraft, he failed to properly torque the nut.

Failure to follow defined procedures in the maintenance hangar and in the cockpit is the leading cause of aviation accidents. The pilot in this accident was fortunately able to walk away from the accident caused by not following the engine repair steps outlined by Rolls Royce.

The Flight Safety Detectives offer advice and details not found in the NTSB report and safety bulletin to help every pilot and mechanic avoid similar issues. Of the “dirty dozen” workplace mistakes, John believes complacency is the most prevalent and dangerous.

Related documents at the Flight Safety Detectives website:

• NTSB Incident Report, NTSB_Incident_Report_ERA21LA023_102161
• NTSB Aviation Investigation Final Report, NTSB_Final_Report_ERA21LA023.pdf
• NTSB Safety Alert 086
• FAA Avoid the Dirty Dozen Workplace Mistakes, FAA_Avoid_the_Dirty_Dozen.pdf
• Rolls-Royce Maintenance Manual Excerpts, Rolls-Royce_maintenance_manual_excerpts.pdf
• NTSB Public Docket for Accident ERA21LA023

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Aviation Maintenance & Real-World Safety – Episode 168

Aviation maintenance professionals are critical to safety. John Goglia helped put the spotlight on aviation maintenance and safety programs at Embry Riddle Aeronautical University recently. John did a presentation on Aviation Maintenance Technician (AMT) Day and witnessed first-hand some safety operations in place at the university.

Greg Feith also reviews lessons learned from the fatal June 1999 crash of American Airlines Flight 1420 in Little Rock, Arkansas. The NTSB investigation showed the role that being in a rush played in the crash that involved 9 fatalities.

• A rush to beat 2 converging thunderstorms
• A rush to finish within duty hour limits
• A rush to maintain the flight schedule

Greg shares important research that provides insight into why the pilot may have made the decisions that led to this air crash.

NTSB Final Report

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