Thursday, January 29, 2009

NTSB Blames NASCAR Aviation Dept. and Pilots for 2007 Plane Crash

NTSB logoIn July of 2007, a Cessna 310 crashed into a residential area near Orlando, FL. The crash and ensuing fire killed both pilots and three people on the ground, and injured a number of others. The aircraft and several houses were destroyed. It wasn't a commercial flight, but you may remember it just the same. The aircraft belonged to the National Association for Stock Car Auto Racing (NASCAR), so the accident got a lot of media coverage.

A report released yesterday by the U.S. National Transportation Safety Board determined that the probable causes for the accident were "the actions and decisions by National Association for Stock Car Auto Racing’s corporate aviation division’s management and maintenance personnel to allow the accident airplane to be released for flight with a known and unresolved discrepancy, and the accident pilots’ decision to operate the airplane with that known discrepancy, a discrepancy that likely resulted in an in-flight fire."

According to the NTSB, another NASCAR pilot flew the accident aircraft the day before the accident, and reported a "burning smell" while in flight. The pilot turned off the weather radar and manually pulled the associated circuit breaker, after which the odor dissipated. He recorded this event in the aircraft's maintenance discrepancy binder and reported it to senior staff in the NASCAR corporate flight department.

Despite being aware of this unresolved issue involving the aircraft's electrical system, the flight department released the aircraft for flight, and the two pilots, one of whom was employed by NASCAR and was aware of the unresolved electrical problem, accepted the aircraft for their planned flight from Daytona Beach to Lakeland, FL.

At some point prior to or during the accident flight, says the NTSB report, it is likely that one of the pilots reset the circuit breaker that had been pulled on the previous flight, re-energizing related components in the electrical system, which likely led to the inflight fire.

While performing an emergency diversion to the Orlando Sanford International Airport after reporting an in-flight fire, the Cessna 310R, (N501N), part of the fleet operated by NASCAR's corporate aviation division, crashed into a residential area, destroying two homes, killing five people (including the two pilots), and injuring several others on the ground. The accident happened on the morning of July 10, 2007.

"This accident is especially tragic not only because lives were lost and people were grievously injured, but because it could have been so easily avoided," said NTSB Acting Chairman Mark V. Rosenker.

"From the time the plane landed the night before the accident with a known maintenance issue to the time it was airborne the next morning, there were numerous opportunities that should have been taken to stop the chain of events that led to this terrible loss," Rosenker continued.
Additionally, in its findings that the NASCAR flight department had inadequate policies and procedures to prevent an aircraft with a known maintenance issue to be released for flight, the Board determined that had a Safety Management System (SMS) been in place, which would have provided a formal system of risk management and internal oversight, the accident might have been avoided.
Rosenker remarked that "given how effective SMS would likely have been in this accident, those corporate flight departments without one should study the lessons of this accident and ask themselves how they can justify operating without the substantial safety improvements such a program provides."

The Board noted that because the accident flight was released for flight and operated with a known maintenance issue unaddressed, the aircraft was not in compliance with Federal regulations. In reference to a missing maintenance document, Rosenker said, "that the NASCAR flight department had no record of the maintenance form on which the electrical problem was reported by the pilot on the previous flight, is frankly, alarming."

As a result of the investigation, the Board issued five recommendations to the Federal Aviation Administration (FAA). Here is the link to the synopsis of the NTSB report, including the probable cause and recommendations