The National Transportation Safety Board is recommending that The Air Care Alliance require voluntary pilot organizations to verify pilot currency before every flight.
The NTSB is also recommending that voluntary pilot organizations inform passengers, when inquiring about a flight, that the charitable medical flight would not be conducted under the same standards that apply to a commercial flight. It also recommends that organizations develop written safety guidance, best practices, and training material for volunteer pilots that address, at a minimum, aeronautical decision-making; proper preflight planning; pilot qualification, training, and currency; and self-induced pressure.
The recommendations are the the result of the NTSB’s investigations of four accidents that killed eight people and seriously injured two between Sept. 26, 2007, and Aug. 12, 2008.
On Aug. 12, 2008, a Beech G35, operating an Angel Flight, crashed into a shopping plaza parking lot in South Easton, Massachusetts. The 65-year-old volunteer pilot and the two passengers, a cancer patient and his wife, were killed. Radar data and communications records show that the pilot failed to intercept the localizer on his initial approach to the airport and was receiving vectors from the controller to re-intercept the localizer when the flight was lost from radar. The instrument-rated pilot had not logged actual or simulated instrument flight time between Aug. 4, 2006, and Feb. 3, 2008, and there was no record that he had completed an instrument proficiency check. The NTSB determined that the probable cause of this accident was the pilot’s failure to maintain control of the airplane while attempting to execute an instrument approach in instrument meteorological conditions. Contributing to the accident was the pilot’s lack of instrument currency.
On July 17, 2008, a Beech A36 crashed after hitting an airport glideslope antenna during takeoff from Tampa Executive Airport in Florida. The 81-year-old volunteer private pilot, the cancer patient, and a family friend accompanying her were killed. The NTSB determined that the probable cause of this accident was the pilot’s improper decision to take off with a tailwind and his failure to maintain runway alignment during initial takeoff climb.
On June 3, 2008, a Socata TBM 700 crashed during initial climbout from Iowa City Municipal Airport in Iowa. The child who needed medical treatment died in the crash; the mother and the 57-year-old volunteer private pilot were seriously injured. The NTSB determined that the probable cause of this accident was the pilot’s improper decision to depart with a preexisting tailwind and failure to abort the takeoff.
On Sept. 26, 2007, a Piper PA-32R-301T crashed in Defiance, Ohio. The 57-year-old pilot, who was killed, was en route to pick up a patient to transport him to a medical facility. The NTSB determined that the probable cause of this accident was the pilot’s spatial disorientation when he encountered convective turbulence, which resulted in a loss of control.
In Part 91 operations, the pilot is solely responsible for evaluating his own level of proficiency, determining if the flight can be safely conducted, and ensuring he is operating an airworthy airplane; however, each of the four pilots in these accidents failed to fully accomplish these tasks, according to NTSB officials, who note that two pilots failed to properly evaluate the winds when selecting a departure runway and did not maintain directional control of the airplane; one pilot became spatially disoriented in convective turbulence; and the other pilot had difficulties performing an instrument approach and was not current for instrument flight.
In its recommendation, the NTSB notes: “In these accidents, the pilots demonstrated shortcomings in sound aeronautical decision-making by failing to adequately assess the weather and their inability to operate the airplane in those conditions. The NTSB is concerned that these pilots did not provide the passengers with the basic level of safety that passengers in these circumstances have a right to expect. Furthermore, the voluntary pilot organization arranging or fostering the flights made no attempt to verify the pilots’ currency. Because each of these flights was operated under Part 91, the passengers on board received only the level of safety that the individual pilot provided to them; no additional oversight, training, verification, or guidance was provided to these pilots beyond the basic Part 91 requirements imposed on the pilots themselves.”
“The typical patient seeking a charitable medical flight is not likely aware of the significant differences in pilot training, pilot qualifications, or FAA oversight for a charitable medical flight operated under Part 91 compared to commercial flights operated under 14 CFR Parts 121 or 135,” the recommendation continues. ” The NTSB is concerned that members of the public who accept charitable medical flights likely have no meaningful awareness of the resulting increased potential for exposure to the risks that may be associated with these flights. In most instances, passengers flying on such charitable medical flights are unaware of the pilot’s experience level or the airworthiness of the aircraft. The NTSB concludes that a more meaningful awareness of the less rigorous oversight provided for such Part 91 charitable medical flights would provide passengers with a basis for making an informed decision about the standards of safety that apply to these operations before accepting the flight.
NTSB officials acknowledge that “many of the volunteer pilots who provide charitable medical transportation are highly skilled, proficient in operating their aircraft, and prepared to execute an appropriate response to changing flight conditions or emergencies,” but note that “others may not be.”
“The NTSB is concerned that the pilots flying charitable medical flights receive no guidance, additional training, or oversight regarding aeronautical decision-making, proper preflight planning, or the risk of self-induced pressure,” the recommendation continues. “Since the failures in aeronautical decision-making and improper preflight planning were major factors in the accidents reviewed, it is evident that stronger guidance, training, or oversight that ensures pilot and aircraft safety is needed for the volunteer pilots who provide charitable medical flights.”
For more information: NTSB.gov To read the full recommendation, click here.
