This month we are looking at another recent approach stall accident involving a large airplane with a highly experienced pilot serving as PIC. The NTSB says the FAA’s oversight of the operating company — Fresh Air Inc. — was lax, the operation of the airplane was sloppy and the crew coordination was poor. Training records were haphazard and de facto SOPs did not comply with the aircraft flight manual (AFM).
The accident airplane was a Convair CV-340/440-38 (N153JR) built in 1953. It was powered by two Pratt & Whitney R-2800-52W and -103W supercharged 18-cylinder radial engines equipped with full feathering hydromatic propellers, a fire detection and warning system, and an extinguishing system for the engines and nacelles.
Although this CV-440 was originally built for airline passenger carriage, it was now old and tired and used for hauling freight in the Caribbean under FAR Part 125. Several Convair CV-440-rated pilots told Safety Board investigators that the airplane’s single-engine climb performance was limited when fully loaded. One stated that when the airplane was not fully loaded, it would climb about 500 fpm with an engine out. However, he and several other Convair pilots believed that the aircraft would only hold altitude, at best, on a single engine when heavily loaded — and that only if the crew configured the airplane correctly.
A former Fresh Air Convair first officer stated that the airplane would not maintain altitude in a turn while heavily loaded and operating with a single engine, adding that, “Convair 340s and 440s were underpowered.”
The Accident
The accident airplane crashed into a lagoon about 1 mi. east of the departure end of Runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico, on March 15, 2012, at about 0740 (AST). VFR conditions prevailed and a VFR flight plan had been field for Princess Juliana International Airport at St. Maarten. Both pilots were killed and the airplane was destroyed by impact forces.
Moments after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane. The two tower controllers noted in post-accident interviews that they did not “see more smoke than usual coming from the airplane.”
The controllers cleared the flight to land on Runway 28, but as the airplane began to align with the runway, it crashed into Laguna La Torrecilla.
The 65-year-old captain was a co-owner of Fresh Air. Early on the morning of the accident, the captain repositioned another airplane from Henry E. Rohlsen Airport, St. Croix, U.S. Virgin Islands, to SJU. The captain then met the first officer at the accident airplane at SJU.
The accident airplane had been loaded with 12,100 lb. of bread products, bringing the estimated ramp weight to 47,710 lb. The maximum allowable takeoff weight of the airplane (as it was configured for that takeoff) was 40,900 lb.
Investigators determined that the captain had started both engines and conducted a 15- to 20-min. run-up. Ground personnel said they did not hear or see anything unusual.
ATC issued instructions to the crew to fly the standard eastern departure for VFR flight following to St. Maarten. The crew then requested a second engine run-up, which was typical according to a tower controller. The controller instructed the flight crew to conduct the run-up on Taxiway Charlie while holding short of Taxiway Bravo.
After completing the second engine run-up, the flight crew requested clearance to taxi to Runway 10, where the flight was cleared for takeoff at 0734:48. Visibility was 10 mi. with a 5-kt. wind from 120 deg. The Convair lifted off at 0735:45.
A Puerto Rico Port Authority (PRPA) official familiar with the accident airplane was in a truck near the south side of the airport terminal. He told investigators that he saw nothing unusual about the airplane’s departure.
At 0737:27, the first officer contacted the SJU departure controller to declare an emergency and the captain then requested a left turn back to the airport. He then asked if tower control personnel could see smoke coming from one of the airplane’s engines. The controller acknowledged the transmission, but did not verify the smoke and, at 0738:05, cleared the flight to land on Runway 10.
As the airplane continued to climb, the airspeed varied between 140 and 160 kt. The captain then asked again if tower personnel could see any smoke coming from one of the airplane’s engines before stating, “. . . we’re gonna need to land on runway, ah, two eight [unintelligible].”
At 0738:14, the airplane reached a maximum altitude of about 935 ft. MSL during a 30-deg. left-banked turn back to the airport. The tower controller cleared the airplane to land on Runway 28.
At 0738:32, the captain replied, “. . . affirmative, uh, is runway eight available, to[o] high . . .,” which was the last transmission from the accident airplane. The airplane then descended to 500 ft. MSL. It banked to the right starting at 0739:10 and the airspeed dropped to about 140 kt.
The Convair continued to bank to the right. Radar contact was lost at 0739:53. Estimated airspeed was 88 kt., and the altitude was 110 ft. MSL. ATC recorded the crash at 0740:23. A security video briefly captured the accident airplane’s initial climb over the departure end of Runway 10, and no smoke or fire was visible.
A witness on the second floor of an apartment complex about 1 mi. east of the airport and just south of the extended centerline of Runway 10 observed the accident airplane’s departure and heard “a strange noise” in one of the engines that he described as an “intermittent surge.” He observed the airplane losing altitude and then beginning a turn to the north.
The PRPA official observed the flight returning to the airport before entering a sharp right-descending turn toward Laguna La Torrecilla. A PRPA video camera captured images of the airplane impacting the lagoon. Witnesses then observed, and the video showed, a large black plume of smoke rising from the lagoon. Emergency vehicles and PRPA officials arrived on scene at about 0804, setting up a perimeter around the wreckage and beginning rescue operations.
Wreckage
The right wingtip of the airplane initially struck trees on the southern shore of the lagoon, and a 5-ft.-long section of the right wingtip and aileron were recovered there. The remainder of the airplane was recovered from the lagoon. The fuselage and wing sections were fragmented from impact with the water.
Post-accident examination of both engines found no mechanical failures that would have prevented their normal operation. No thermal distress or fire damage was observed on either the left or right engine or exhaust manifolds.
The left-engine throttle control lever and throttle valve were found in the fully OPEN position, and the engine mixture control was found almost against the FULL RICH stop — all consistent with the engine at takeoff or climb setting.
The right engine’s throttle control lever was found in the CLOSED position, and the throttle valve was consistent with the engine being shut down. The engine mixture control was found against the FULL RICH stop, which was not consistent with the engine being shut down.
A guarded automatic feather switch located on the pilot’s pedestal operates the feathering function for both propellers. This automatic feather switch was found in the DOWN position, and the guard was found impact-damaged but in the UP or unguarded position. The automatic feather switch in the DOWN position is consistent with it being in the UNARMED position.
The left propeller was found feathered, but the right propeller’s pitch was consistent with a high-rotation/takeoff power setting.
Airframe fire and thermal damage were found on the airplane’s right-wing rear spar, the nacelle aft of the power section, and in the vicinity of the junction between the augmentor assemblies and the exhaust muffler assembly. Damage to the airframe extended from the right-engine firewall aft to the flaps, with the damage greater on the outboard side compared to the inboard side.
The rear spar was intact with several areas of significant fire damage. Sooting was present on all of the rear spar aft surfaces, and the spar web exhibited evidence of burn-through in three areas concentrated toward the right side. The lower bulkhead that forms the aft end of the right wheel well remained attached, with several areas exhibiting heat damage. The right inboard flap had some melting and other heat-related signatures on the upper surface on the forward outboard corner, and sooting was present on the top surface of the flap; the inboard flap was otherwise intact. The inboard end of the right outboard flap exhibited fire damage, including a section of the attached flap track, as well as a section of the inboard edge that was missing and presumed destroyed in the fire.
The Crew
The captain held an ATP certificate with airplane multiengine land, instrument, commercial pilot and airplane single-engine land ratings His second-class physical had a limitation that he must wear corrective lenses. According to Fresh Air’s pilot records, the captain flew a Convair CV-440 for Miami Air Lease in 2005 and then received basic indoctrination training at Fresh Air on Aug. 29, 2005, after purchasing the company. He was one of two full-time captains for Fresh Air, served as the company’s director of operations, and was its only check airman.
The captain had accumulated 22,586 hr. of total pilot flying time, 21,925 hr. of which were as PIC. He had flown about 9,000 hr. in the Convair CV-340/440 and he had 34 and 104 hr. of total flying time in the 30 and 90 days before the accident, respectively.
Former Fresh Air pilots — a captain and a first officer — both told investigators that the accident captain typically flew the heavy-loaded legs out of SJU and that the first officer would fly the empty return legs. Another captain also stated that while he was a first officer, the accident captain would usually fly the heavy legs, while he (the first officer) flew the lighter empty legs. The former first officer said that the accident captain would let him fly the heavy legs to get a feel for the airplane as the first officer was getting close to becoming a Convair captain.
The accident captain’s initial type rating in the Convair CV-340 was on Sept. 19, 1977. On June 24, 2010, the captain received an FAR Part 125 competency check (valid until June 30, 2011) in the Convair CV-440 from a Tiger Contract Cargo Inc. check airman. The Fresh Air general manager —the captain’s son, whose duties included maintenance of pilot records — was unable to verify that the captain had received a competency check or instrument proficiency check in the 12 months before the accident. He said his father received his check airman observation in “September or October” of the previous year. He further stated he believed that session was both a proficiency check and a check airman observation with the FAA.
According to the FAA air safety inspector at SJU who conducted the observation, the captain had a check airman observation on Sept. 23, 2010, but this was not a competency check. Other Part 125 operators of the Convair indicated that none had provided a competency check on the accident captain in the 12 months before the accident.
The 44-year-old first officer held a second-in-command (SIC) rating on the Convair CV-440 and a second-class medical certificate. He was originally hired by Fresh Air as a Convair first officer in 2007 before leaving on Feb. 18, 2008, to work as a mechanic for Seaborne Airlines. He was rehired by Fresh Air and received basic indoctrination training on Feb. 24, 2012. He also received an SIC proficiency check on the Convair CV-440 from the accident captain on Feb. 24, 2012.
The first officer had 2,716 hr. of total pilot flying time, 200 hr. of which were as PIC (none in the Convair CV-440) and 700 hr. of which were as SIC of the Convair CV-340/440. He had 16 hr. of total flying time in the last year, all within the 30 days before the accident.
According to the FAA, the first officer received both his private and commercial airplane single-engine land and instrument airplane certificates in 1996 and his commercial airplane single-engine and multiengine land and instrument airplane certificate in 2001. However, between 1996 and 2008, he received five notices of disapproval in the following areas: performing chandelles and lazy 8s, proper holding pattern entry and basic VOR interception tracking, preflight preparation, cross-country flight planning and poor performance maneuvers.
While at Seaborne Airlines, the first officer expressed interest in joining the flight operations department as a pilot, and in early 2009 he started ground school. After completing ground school, he began a five-day simulator training course. Seaborne’s director of operations told investigators that the first officer was not “up to par” during simulator training, that his piloting skills were below average and that he had trouble keeping up with the pace required to get through simulator training. Conversely, he did fine in ground school and passed the written tests. Specifically, the operations director recalled that the first officer struggled trying to “manage the platform while flying.” He added that the first officer was not a good pilot in general, rather than having specific areas of trouble in training.
Post-accident examination of the accident site revealed the handheld radio and cord wrapped around the captain’s left forearm. The first officer’s autopsy revealed fractures to both radii and both ulnas and a fracture of the left femur. Those injuries are consistent with the first officer acting as the pilot flying at impact. Toxicology reports for the captain and the first officer indicated no evidence of significant preexisting medical pathology.
Safety Board specialists examined the activities of the pilots for the 72 hr. prior to the accident. While there are some gaps in the record, the Safety Board determined that the captain was likely suffering fatigue due to sleep deprivation.
On Jan. 17, 2011, the captain witnessed an inflight fire aft of the left engine on a Tiger Contract Cargo Convair CV-440 as it departed from St. Thomas. Fresh Air’s general manager said that the captain was overflying that flight in another airplane, saw the fire and radioed the pilots to tell them that they had a fire and needed to turn around. The Tiger Convair made it back “by the skin of their teeth,” said the general manager.
The NTSB’s Analysis
The weather on the morning of the accident was not a factor. ATC services provided to the accident flight, including after the flight crew declared an emergency, were sufficient and were not a factor in the accident, either. Additionally, the airport’s response to the crash was both adequate and timely, according to the Safety Board.
The Convair CV-440 AFM states that the anti-detonation injection (ADI) system was required to be operative for all takeoffs at the maximum allowable takeoff weight. The Convair CV-440 also had an autofeather system that automatically feathers the propeller in the event of an engine failure. “It is critical,” said the Safety Board, “that the ADI and auto–feather systems are operative for each takeoff for airplanes such as the Convair CV-440. Use of these systems can ensure that the engines are optimized for maximum performance in the event of an engine failure or inflight shut down.”
Fresh Air pilots who flew with the captain told Safety Board investigators that he generally did not use either the ADI or the autofeather systems. One pilot stated that the autofeather system on the accident airplane was not operative because the circuit breaker had been pulled. The Fresh Air general manager told investigators the captain would likely have selected the autofeather OFF during the accident flight. (See “Water Injection and Autofeather — Accident Factors” sidebar.)
As noted earlier, Safety Board investigators estimated that the ramp weight of the airplane for the accident flight was 47,710 lb. and that the takeoff weight was 47,510 lb. The Convair CV-440 AFM allows a maximum takeoff weight of 48,000 lb. with the ADI system armed, but only 40,900 lb. with the ADI system unarmed. The maximum allowable operating weight for a takeoff with the autofeather system inoperative was 43,500 lb. Thus, the takeoff weight of 47,510 lb. would have required that both the ADI system be armed and the autofeather system be ON and ARMED for takeoff. However, the auto-feather switch was in the UNARMED position.
The Safety Board concluded that the flight crew probably did not use the ADI and autofeather systems during the takeoff, and, as a result, the accident airplane exceeded the maximum allowable takeoff weight of 40,900 lb.
Return to Airport
The airplane lifted off normally; however, within 2 min. the first officer declared an emergency, and the captain requested a left turn back to the airport.
Pilots flying multiengine aircraft are generally trained to shut down the engine experiencing a problem and to feather its propeller; thus, the flight crew likely intended to shut down the right engine by bringing the mixture control lever to the IDLE CUTOFF position and feathering the right propeller as called out in the Engine Fire in Flight checklist. The pilots then would have had the operative left engine to return to the airport. However, post-accident examinations revealed that the left propeller was found feathered at impact, with the left-engine settings consistent with the engine at takeoff or climb setting.
The right-engine settings were generally consistent with the engine being shut down; however, the right propeller’s pitch was consistent with a high rotation/takeoff power setting. Although the investigation was not able to determine why the crew chose to shut down the engine, they likely suspected an engine fire due to the smoke. Had the autofeather system been ARMED, the right propeller would have automatically started the feathering process and, simultaneously, a blocking relay would have been energized, preventing the left propeller from feathering.
One of the pilots had to feather the right-side propeller manually because the autofeather system was not activated. It is likely a pilot manually selected the left propeller to FEATHER at some point before impact with the water.
The accident airplane was not equipped with flight data or voice recorders (nor was it required to be so equipped). Therefore, the investigation was unable to determine at what point in the accident sequence the flight crew shut down the right engine and at what point they feathered the left propeller, or why they would have done so.
Other Convair pilots told investigators the Convair 440 could not climb on one engine when heavily loaded but, at best, just hold altitude. The accident airplane was above the maximum allowable takeoff weight, making it even more difficult for the flight crew to maintain altitude or airspeed when operating with one engine.
Radar data indicate that the airplane continued to climb at greater than the single-engine climb speed until the tower controller cleared the flight to land after the flight crew declared an emergency, indicating that the right engine was not shut down until the airplane was cleared to land. The radar data then indicate a relatively steady decline in altitude until the final right turn to align with Runway 28.
The calculated airspeed on the accident flight was around 140 kt. when the airplane began to bank to the right to line up with Runway 28 but then decreased during the right turn. The Safety Board concluded that the flight crew feathered the left propeller late in the accident sequence because the flight profile indicates that at least one engine was generating thrust until near the end of the flight.
According to the Convair CV-440 AFM, at an altitude just above sea level and for the maximum gross weight of the accident airplane, Vmc is 87 kt. Vmc referenced in the AFM is determined using no greater than 5 deg. of bank angle into the operating engine.
Radar data show that as the airplane was heading south at an altitude of about 520 ft., it began a descending turn to the right to line up with Runway 28. As the airplane reached a calculated bank angle of 30-deg. right-wing-down, the calculated airspeed remained between 120 and 140 kt. The bank angle then reduced and the airplane leveled off near 200 ft. The CAS continually dropped as the airplane reduced its bank angle to stop the turn and align with the runway. At the end of the recorded radar data, the airplane was close to both aerodynamic stall and the controllability limit for one-engine-inoperative flight.
Radar contact was lost with the airplane at 100 ft. as it continued the right turn. Shortly thereafter, the airplane crashed. The Safety Board concluded that the airspeed slowed to a point at which the airplane either experienced an aerodynamic stall or it dropped below the minimum control speed during the right turn to align with Runway 28.
All of the fire and thermal damage was located aft of the right engine and its fire detection/warning system. Additionally, the condition of the paint on the upper right-wing skin within the nacelle area was consistent with long-term exposure to high heat exceeding normal operation. The paint discoloration and lack of oil residue on the right augmentors when compared to the left augmentors and with augmentors from an exemplar airplane indicated that the right side was exposed to much higher temperatures than the left side.
While the investigation could not determine the exact location of the ignition source, it appears to have been aft of the engine in the vicinity of the junction between the augmentor assemblies and exhaust muffler assembly. Statements from mechanics familiar with this type of airplane indicate exhaust fires do occur in the augmentors. Under normal conditions, the fire is exhausted out the muffler assembly, resulting in little or no damage to the aircraft. A fire leaking out of the augmentor assembly at the junction with the muffler assembly would have produced the damage that was found on the accident aircraft.
The Safety Board concluded that the thermal damage to the airplane resulted from the ignition of a flammable liquid in one of the right augmentors, and a leak in the vicinity of the augmentor/muffler junction allowed the fire to exit the junction and damage portions of the right wing.
In addition, the Safety Board took special note of the fact that the captain witnessed the Tiger Contract Cargo Convair engine fire and “may have recalled the severity of that event when he experienced this engine fire.” That recollection could have affected his decision-making, the Board said. “While post-accident examination of the airplane from the San Juan accident indicated that the engine fire appeared to be less severe than the previous event,” the Board wrote, “the flight crew [of the Fresh Air airplane] would not have been aware of its severity during the flight.”
The investigation attempted to determine who was the pilot flying (PF) and who was the pilot monitoring (PM) on the accident flight. Fresh Air’s general manager stated that the first officer made the initial transmission to ATC declaring an emergency, indicating that the captain was initially the PF and the first officer was handling communications. However, after the emergency declaration, the captain made all further communications with ATC, and the injuries incurred by the flight crew at impact were consistent with the first officer flying and the captain handling radio communications.
The investigation was therefore unable to determine why the captain allowed the first officer to fly the airplane when faced with an emergency. However, the captain, as the PIC, was ultimately responsible for the operation of the airplane.
The NTSB concluded that flight crew injuries were consistent with the first officer flying the airplane at the time of impact. “However, considering the first officer’s limited recent experience in the Convair CV-440 and the performance deficiencies identified in his training and certification history, he was likely not capable of handling the emergency without help from the captain,” it said.
Fatigue Factors
Although an inflight fire is an emergency situation, a flight crew applying effective crew resource management, adhering to their PF and PM duties, and properly using a checklist to handle the emergency should have been able to maintain positive control of the accident airplane.
Flight crews encountering emergency situations, such as on this flight, are frequently faced with high levels of stress due to workload and time pressures, among other factors, and may make errors or face performance limitations directly linked to human cognitive limitations. Although moderate stress can improve performance, errors and performance degradations occur when a pilot experiences high stress and becomes overloaded.
Research indicates that a pilot may focus on a narrow piece of information that is perceived to be most threatening or salient and exclude other important information. For example, stress can lead to a phenomenon known as “tunnel vision,” or the narrowing of attention, in which basic information like airspeed can be overlooked, as the scan of all environmental cues may be restricted.
The Safety Board believes that the captain was likely suffering from acute sleep loss at the time of the accident, which would have negatively affected his ability to guide the first officer in properly handling the emergency.
Because of the limited information available on the first officer and his relative inexperience in the accident airplane, the investigation was unable to determine the extent to which fatigue may have played a role in the first officer’s performance at the time of the accident.
The FAA
FAA’s Certificate Management Office (CMO) for Fresh Air was located in Miramar, Florida. At the time of the accident, the principal operations, maintenance and avionics inspectors (POI, PMI and PAI) for the Fresh Air certificate were all located in Orlando, Florida. The FAA requires three operational inspections on a Part 125 certificate holder each year: a main base inspection, a manual procedures inspection and a ramp inspection.
Fresh Air’s POI conducted all required main base and manual procedures inspections (including a review of pilot records and the operations manuals) at Fresh Air’s Davie, Florida, office, with the most recent inspections occurring on Jan. 6, 2012. The San Juan FSDO performed the last ramp inspection before the accident on Feb. 18, 2011.
A review of the captain’s duty time records found numerous discrepancies, inaccuracies and missing information. In addition, Fresh Air was unable to verify that the captain had successfully completed his annual competency check in the 12 months before the accident, as required by 14 CFR 125.401.
Fresh Air’s general manager incorrectly assumed that one check ride covered both scenarios because he believed that competency checks and check airmen observations could be combined. A competency check requires the pilot to physically manipulate the controls of the airplane and may include any of the maneuvers and procedures currently required for the original issuance of the particular pilot certificate or rating required for the operations authorized and appropriate to the category, class and type of airplane involved. (See “NTSB to FAA: Take Another Look at Part 125 Effectiveness” sidebar.)
A check airman evaluation flight, required every two years in the specific type of airplane in which the pilot plans to conduct evaluations, is considered to be a practical test of the check airman’s ability to test other airmen, not his flying ability. The POI failed to discover the anomaly. The investigation did not find any documentation showing that the accident captain was current to operate as PIC under the provisions of Part 125.
Despite the FAA’s recent aircraft records inspection and Fresh Air’s cooperation, the investigation was unable to locate current documentation related to the accident airplane’s status, including AD and SB compliance, engine and propeller records, applicable supplemental type certificates, major airplane repairs and alterations, the status of time-limited components, service difficulty reports, minimum equipment lists or continuous airworthiness maintenance program information. Additionally, Fresh Air was unable to provide current mechanic training records.
The Safety Board noted that the certificate holder (Fresh Air) has the responsibility to maintain current records of its flight crewmembers and aircraft. However, the FAA’s required annual inspections of each certificated operator include a review of pilot records and currency and of aircraft maintenance records.
“During the last documented main base inspection before the accident, the POI should have discovered the recordkeeping discrepancies and instructed the operator to verify the captain’s currency,” said the Safety Board. “Likewise, the PMI should have discovered Fresh Air’s critically deficient recordkeeping during the last documented aircraft records inspection, conducted seven days before the accident, or during any of the six inspections that the PMI and PAI conducted in the year before the accident. Thus, the NTSB concludes that Fresh Air failed to keep accurate and complete records, and the FAA did not address Fresh Air’s deficient recordkeeping; thus, the FAA’s oversight of Fresh Air’s recordkeeping was inadequate.”
Additionally, although Fresh Air operated cargo flights, the investigation found no evidence that its cargo loading procedures were inspected during any Fresh Air ramp inspection, either by the POI or any FSDO air safety inspector in SJU to whom the POI assigned ramp inspections.
Apparently unknown to the FAA, Fresh Air would reweigh pallets that arrived at the airport after being unloaded from the Holsum truck and before being loaded on the airplane, even though the pallets were weighed on a certified and regularly calibrated scale at the bread distributor.
“While this procedure to reweigh the pallets could be helpful when a pallet had to be broken down, Fresh Air reweighed all pallets, and the weight was given to the captain as the actual weight of the cargo,” the Safety Board noted. “The investigation did not reveal any documentation ensuring the Fresh Air scale was calibrated and accurate. Thus, the pilots may not have been using appropriate weight information when calculating the airplane’s weight and balance, further reducing their margin of safety.”
The POI was unaware of this Fresh Air procedure. Although the Safety Board said Fresh Air’s cargo loading procedures did not contribute to the accident, the FAA failed to detect and address discrepancies between Fresh Air’s approved procedures and operational reality, including cargo loading, pilot currency, company recordkeeping and pilot evaluation.
And the Board went on to make this observation:
“Effective oversight of Part 125 operations also relies on complete and thorough inspections of an operator’s recordkeeping and compliance with its own and FAA procedures. Multiple FAA inspectors visited the operation but failed to detect or address a litany of issues, including deficient pilot and maintenance recordkeeping and unapproved cargo loading procedures. During the investigation, the NTSB found evidence suggesting that oversight of Part 125 operations was not seen as a priority.
“For example, Fresh Air’s POI told investigators that Part 125 was generally ‘a GA [general aviation] operation,’ not an air carrier operation. While most of its flights were relatively close to San Juan, Fresh Air’s OpsSpecs authorized it to operate commercially over the 48 contiguous states, meriting far more scrutiny than ‘a GA operation.’ Another former Part 125 POI told investigators that Part 125 ‘has always been a loose regulation’ because they are normally cargo operations and ‘not a big threat to the public.’ Combined with the basic gaps in oversight by multiple FAA inspectors related to Fresh Air’s cargo loading, pilot currency, company recordkeeping and pilot evaluation practices, such statements indicate an ineffective oversight regimen for Part 125 operations.
“As Fresh Air’s POI told investigators, ‘we need more oversight for these types of operators to promote a safety culture.’ The NTSB concludes that multiple FAA inspectors failed to perform effective oversight of Fresh Air, possibly due to a belief that Part 125 operations merit less scrutiny than Part 121 and 135 operations, despite the fact that the airplanes fly over populated areas within the national airspace system. Therefore, the NTSB recommends that the FAA evaluate the effectiveness of its Part 125 oversight program and ensure that Part 125 operations are conducted at the same level of safety as that of Parts 121 and 135.”
Probable Cause
The Safety Board determined that the probable cause of this accident “was the flight crew’s failure to maintain adequate airspeed after shutting down the right engine due to an inflight fire in one of the right augmentors. The failure to maintain airspeed resulted in either an aerodynamic stall or a loss of directional control.”
Recommendations
As a result of this investigation, the NTSB made the following recommendations to the FAA:
Evaluate the effectiveness of your Part 125 oversight program and ensure that Part 125 operations are conducted at the same level of safety as that of Parts 121 and 135.
Require all POIs of Part 125 certificate holders to conduct at least one en route inspection annually on each airplane type operated by the certificate holder.
Require check airmen who evaluate pilots under the Part 125 lateral moves provision to use the operations specifications of the certificate holder employing the pilot receiving the proficiency check to ensure a proper evaluation of the pilot’s knowledge of those specifications.
When all is said and done, this accident involved failures of federal oversight, company safety management, maintenance, operational procedures, CRM and individual airmanship —
a sad story abounding with lessons for all. B&CA