Small Operator Accidents

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1 Small Operator Accidents How can a small operator cope with an Accident? John M. Cox Safety Operating Systems

2 Two Business Jet Accidents Participation Preparedness Effectiveness Results

3 Hawker Accident November 10, 2015

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8 Documents retrieved from the accident site showed an amendment to the May 30, 2014 basic operating weight for N237WR, dated December 22, 2014, indicating that the Revised Basic Operating Weight for N237WR was 13, pounds. This weight included additional items such as pilot weights, galley service items and water, de-icing fluids, life vests, and passenger service items. The document also listed a weight reduction of 300 pounds for the removal of the Auxiliary power unit (APU). However, the NTSB recovered the APU at the accident site, indicating that it was installed onboard N237WR at the time of the accident. NTSB Operations Group Report page 35

9 APU

10 No Operator Representative

11 Operator Representative 4 months

12 No Operator Representative

13 NTSB Operations Repot page 41

14 NTSB Operations Report page 48

15 According to the Execuflight Chief Pilot, when asked if Execuflight had a Director of Safety, he replied no, and if there had ever been a Safety Director, or Director of Safety, he responded no. No, I don't believe so. NTSB Operations Report page 72

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17 May 21, 2014

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19 No Operator Representative

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21 IS-BAO Stage II

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23 Operator Participation Not a Party Submission ineffective SMS met IS-BAO standards Was it effective?

24 It Can t Happen To Us

25 1.6 Accident Rate per 100,000 hours Bus jets Part 91 Corp jets Part Fractional Jets 0.75 Part 135 Jets Sched Air Carrier Non-Sched Air Carrier Robert E Breiling & Assoc

26 US Business Jets - All Operations 70 Total Accidents Total Accidents And Incidents US BUSINESS JETS - ALL OPERATIONS Accidents 34 Fatal Acc Fatalities Incidents Average Robert E Breiling & Assoc

27 Accident and Incidents Operators experienced incidents 188 Operators experienced accidents 132 Fatalities Not one of the operators expected to have an accident or incident

28 40 Corporate Executive US Business Jet CORPORATE/EXECUTIVE Accidents Fatal Acc. Fatalities Incidents Robert E Breiling & Assoc

29 Corporate Operators Operators experienced accidents 252 Operators experienced incidents

30 12 Fractional US Business Jet FRACTIONAL OPERATIONS Accidents Fatal Acc. 5 Fatalities Incidents Robert E Breiling & Assoc

31 Fractionals Operators experienced accidents 252 Operators experienced accidents

32 18 Commercial/Air Taxi US Business Jet COMMERCIAL/AIR TAXI Accidents Fatal Acc. 8 8 Fatalities Incidents Robert E Breiling & Assoc

33 Commercial and Air Taxi Operators experienced accidents 113 Operators experienced incidents

34 16 Private/Business US Business Jet PRIVATE/BUSINESS 8 8 Accidents Fatal Acc. 7 7 Fatalities Incidents Robert E Breiling & Assoc

35 Private and Business Operators experienced accidents 88 Operators experienced incidents

36 35 Non-US Business Jet NON US CIVIL BUS JET ACC/INCIDENT Accidents Fatal Acc Fatalities Incidents Average Robert E Breiling & Assoc

37 9 Non-US Corporate/Executive CORPORATE/EXECUTIVE Accidents Fatal Acc Fatalities Incidents Robert E Breiling & Assoc

38 1.2 Non-US Fractional FRACTIONAL OPERATIONS Accidents Fatal Acc. Fatalities Incidents Robert E Breiling & Assoc

39 35 Non-US Commercial/Air Taxi COMMERCIAL/AIR TAXI Accidents 25 Fatal Acc Fatalities Incidents Robert E Breiling & Assoc

40 4.5 Non-US Private Business PRIVATE/BUSINESS Accidents Fatal Acc. Fatalities Incidents Robert E Breiling & Assoc

41 60 Business Jet Sumary 2014 vs Accidents Fatal Acc. Non-Ftl.Acc Fatalities Incidents Total Total Robert E Breiling & Assoc

42 Accident Rate by Group Per 100,000 hours ACCIDENT RATES MAJOR OPERATOR GROUPS-NTSB General Aviation Business Corporate On Demand Air Taxi Sched Air Carrier Sched Commuters Robert E Breiling & Assoc

43 90 Business Aviation Accidents Ftl Acc Fatalities Hours Flown Acc. Rate Ftl. Acc.Rate Robert E Breiling & Assoc

44 14 Corporate/Executive Accidents Ftl Acc Fatalities Hours Flown Acc. Rate Ftl. Acc. Rate Robert E Breiling & Assoc

45 Air Taxi Accidents Ftl Acc Fatalities 38 Hours Flown Acc. Rate Ftl. Acc. Rate Robert E Breiling & Assoc

46 10,000 Corp/Exec 91 Pro Flown 10 9,000 8, ,005 8,113 8,341 8,605 8, , , ,000 5,000 4,869 5,231 5,550 5,616 5,813 6,014 6,313 6,459 6,426 6, Fleet Accidents 4,000 3, Total Accidents 74 2, , Robert E Breiling & Assoc

47 Part 135 4, ,500 3,480 3,531 3,710 3,639 3, ,801 3, ,314 3,000 2,855 2, , ,708 2,741 2,821 2,910 3, , , Fleet Accidents 1,500 1, Total Accidents Robert E Breiling & Assoc

48 The Absence Of An Accident Is Not An Indication Of Safety Prior to this takeoff Concorde was accident free

49 Risk Management Risk is part of life

50 Are Some Risks Acceptable?

51 How Much Risk Is Acceptable?

52 Manage the Risk

53 Do Not Introduce More Risk Than You Mitigate

54

55 Real World Sometime They Get It Wrong NASCAR Accident July 10, 2007 Cessna 310 Takeoff from SFB

56

57 NTSB Findings It is likely that one of the pilots, consistent with routine and/or the Before Starting Engines checklist for the accident airplane, reset the weather radar circuit breaker, which restored electrical power to the weather radar system s wiring and resulted in the in-flight fire. There was insufficient evidence to conclusively determine the origin of the inflight fire.

58 Circuit Breaker reset? Can you tell?

59 SMS As A Finding Safety Management System programs would provide corporate flight departments a formal system of risk management, safety methods, and internal oversight programs that could improve safety. This is a Finding in the NTSB report!

60 Execuflight Execuflight did not have a Safety Management System (SMS) in place at the company. The previous Director of Operations drafted an SMS section (Section V SMS, V1) to be added to the Execuflight GOM for an unpublished Revision 54, and stated it was tough to get things accomplished out of the South Florida FSDO. You know, documents would be submitted, revisions would be submitted. And sometimes they'd get there, sometimes they didn't. Sometimes they got lost. 140 The Execuflight Chief Pilot stated the SMS is not yet mandated, but was tailored in on a future rewrite of the GOM.141 NTSB Operations Report page 72

61 Do You Know Where The Risks Are?

62 Unexpected Events Occur

63

64 How Ready Are You? ERP current? Phone numbers checked? Drilled Do you know the proper protocol?

65 What Is An Accident? NTSB Occurrence associated with the operation of an aircraft that takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. An incident is an occurrence other than an accident that affects or could affect the safety of operations. (See 49 CFR 830.)

66 What Is An Accident? ICAO Annex 13 An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: a) a person is fatally or seriously injured as a result of being in the aircraft, or direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or direct exposure to jet blast, except when the injuries are from natural causes, self inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew: or the aircraft sustains damage or structural failure which: adversely affects the structural strength, performance or flight characteristics of the aircraft, and would normally require major repair or replacement of the affected component, except for engine failure or damage. when the damage is limited to the engine, its cowlings or accessories: or for damage limited to propellers, wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the aircraft skin: or the aircraft is missing or is completely inaccessible. Note I.-- For statistical uniformity only, an injury resulting in death within thirty days of the date of the accident is classified as a fatal injury by ICAO. Note 2.-- An aircraft is considered to be missing when the official search has been terminated and the wreckage has not been located.

67 ICAO Annex 13

68 ICAO Annex The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State by mutual arrangement and consent. In any event the State of Occurrence shall use every means to facilitate the investigation.

69 ICAO Annex 13 PARTICIPATION IN THE INVESTIGATION PARTICIPATION OF THE STATE OF REGISTRY, THE STATE OF THE OPERATOR, THE STATE OF DESIGN AND THE STATE OF MANUFACTURE

70 ICAO Annex Advisers assisting accredited representatives shall be permitted, under the accredited representatives supervision, to participate in the investigation to the extent necessary to enable the accredited representatives to make their participation effective.

71 ICAO Annex The State conducting the investigation shall send a copy of the draft Final Report to the State that instituted the investigation and to all States that participated in the investigation, inviting their significant and substantiated comments on the report as soon as possible. The draft Final Report of the investigation shall be sent for comments to: a) the State of Registry; b) the State of the Operator; c) the State of Design; and d) the State of Manufacture.

72 Emergency Response Crisis We have to deal with it now Tactical We need to deal with it soon Strategic We will need it in the future

73 Limited Assets Party Coordinator The focal point with the investigator Company Employee Go Team Special training needed Operations, Systems, Structure, Maintenance Special Training Needed

74 Limited Assets Outsource If expertise is not in house find it outside Get help early Sooner is better Pre-arrange experts

75 Limited Assets Media Special training is needed Pre-plan Who is the face of the operator? Families

76 Small Operators CAN Survive an Accident John Cox

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