Small Operator Accidents How can a small operator cope with an Accident? John M. Cox Safety Operating Systems
Two Business Jet Accidents Participation Preparedness Effectiveness Results
Hawker Accident November 10, 2015
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 13,976.92 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
APU
No Operator Representative
Operator Representative 4 months
No Operator Representative
NTSB Operations Repot page 41
NTSB Operations Report page 48
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
May 21, 2014
No Operator Representative
IS-BAO Stage II
Operator Participation Not a Party Submission ineffective SMS met IS-BAO standards Was it effective?
It Can t Happen To Us
1.6 Accident Rate per 100,000 hours 1.4 1.46 1.2 1.08 1 0.99 0.89 0.91 0.9 Bus jets Part 91 Corp jets Part 91 0.8 Fractional Jets 0.75 Part 135 Jets 0.6 0.47 0.6 0.51 0.56 0.58 0.64 0.63 Sched Air Carrier Non-Sched Air Carrier 0.4 0.2 0 0.32 0.39 0.36 0.33 0.34 0.33 0.31 0.32 0.31 0.28 0.28 0.29 0.27 0.26 0.27 0.27 0.27 0.25 0.22 0.18 0.17 0.18 0.15 0.15 0.16 0.15 0.14 0.14 0.15 0.16 0.16 0.15 0.16 0.13 0.13 0.12 0.11 0.11 0.1 0.14 0.06 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
US Business Jets - All Operations 70 Total Accidents 188 60 50 46 47 45 60 46 52 59 45 58 48 Total Accidents And Incidents 719 40 39 US BUSINESS JETS - ALL OPERATIONS Accidents 34 Fatal Acc. 30 24 28 25 23 26 Fatalities Incidents 20 10 0 19 18 18 17 17 15 14 14 14 13 12 12 10 10 8 8 6 6 5 5 4 4 3 3 2 2 2 1 1 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Average Robert E Breiling & Assoc
Accident and Incidents 2005 2015 531 Operators experienced incidents 188 Operators experienced accidents 132 Fatalities Not one of the operators expected to have an accident or incident
40 Corporate Executive US Business Jet 37 35 30 31 28 25 25 26 23 CORPORATE/EXECUTIVE 20 15 17 18 17 16 16 21 19 Accidents Fatal Acc. Fatalities Incidents 10 5 0 8 8 7 7 7 6 6 6 5 5 5 5 5 5 4 4 3 3 2 2 1 1 1 1 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
Corporate Operators 2005 2015 60 Operators experienced accidents 252 Operators experienced incidents
12 Fractional US Business Jet 10 10 9 8 8 8 7 7 FRACTIONAL OPERATIONS 6 6 6 Accidents Fatal Acc. 5 Fatalities Incidents 4 3 3 2 2 2 2 2 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
Fractionals 2005 2015 60 Operators experienced accidents 252 Operators experienced accidents
18 Commercial/Air Taxi US Business Jet 17 16 16 14 14 13 12 12 12 12 11 11 10 10 10 9 10 9 9 10 COMMERCIAL/AIR TAXI Accidents Fatal Acc. 8 8 Fatalities 6 7 6 7 Incidents 5 5 4 4 4 3 3 3 3 3 3 2 2 2 1 2 2 2 1 1 2 1 1 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
Commercial and Air Taxi 2005 2015 72 Operators experienced accidents 113 Operators experienced incidents
16 Private/Business US Business Jet 14 14 12 10 10 10 10 9 9 PRIVATE/BUSINESS 8 8 Accidents Fatal Acc. 7 7 Fatalities Incidents 6 6 6 5 5 5 4 4 4 4 4 3 3 3 2 2 2 2 2 2 1 1 1 1 0 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
Private and Business 2005 2015 35 Operators experienced accidents 88 Operators experienced incidents
35 Non-US Business Jet 30 29 29 25 24 20 21 19 20 NON US CIVIL BUS JET ACC/INCIDENT Accidents Fatal Acc. 15 15 14 14 14 16 Fatalities Incidents 10 5 11 7 6 3 12 9 8 4 4 2 9 4 9 7 3 8 6 11 4 9 9 8 8 6 5 2 2 12 6 4 9 5 12 7 4 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Average Robert E Breiling & Assoc
9 Non-US Corporate/Executive 8 8 7 6 5 5 CORPORATE/EXECUTIVE Accidents Fatal Acc. 4 4 4 4 Fatalities Incidents 3 3 3 3 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
1.2 Non-US Fractional 1 1 1 1 0.8 0.6 FRACTIONAL OPERATIONS Accidents Fatal Acc. Fatalities Incidents 0.4 0.2 0 0 0 0 0 0 0 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
35 Non-US Commercial/Air Taxi 30 29 COMMERCIAL/AIR TAXI Accidents 25 Fatal Acc. 23 20 Fatalities 15 14 13 12 16 14 Incidents 15 12 10 10 9 9 10 9 5 0 7 7 7 7 6 6 6 6 5 5 5 4 3 3 3 3 3 2 2 2 2 2 2 1 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
4.5 Non-US Private Business 4 4 3.5 3 2.5 2 2 PRIVATE/BUSINESS Accidents Fatal Acc. Fatalities Incidents 1.5 1 1 1 1 1 0.5 0 0 0 0 0 0 0 0 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
60 Business Jet Sumary 2014 vs. 2015 50 51 40 Accidents 30 30 32 Fatal Acc. Non-Ftl.Acc. 20 19 22 21 Fatalities Incidents 13 10 11 9 0 2015 2014 Total Total Robert E Breiling & Assoc
1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 16 Accident Rate by Group Per 100,000 hours 14 13.9 13.2 12.9 12 12.1 10 8 6 4 2 0 0 9.9 9.9 9.5 10.9 10.7 10.3 9.6 9.5 9.2 8.7 9 9.1 8.5 8.2 8 7.9 7.9 7.7 7.2 7.4 7.2 6.5 6.6 6.8 6.7 6.7 6.5 6.9 6.9 7.1 7 6.6 6.4 6.5 6.7 6.3 6.3 6.1 5.9 5.9 5.6 5.4 5.1 5.1 5.1 4.8 4.6 4.7 4.7 4.8 4.5 4.3 4.4 4 4.2 4.4 4 3.9 3.7 3.5 3.5 3.6 3.80 3.1 3.1 2.9 2.9 3.2 3.5 3.7 3.9 3.6 3.8 3.7 3.79 3.5 3.2 3.1 2.7 3 3.25 3 2.8 2.7 2.5 2.2 2.1 2 2 2.3 2.6 2.4 2.1 2.26 2.33 2.56 2.41 2.2 2.2 2 2 2 1.7 1.78 1.68 1.781.72 1.8 1.7 1.4 1.4 1.4 1.4 1.5 1.7 1.5 1.2 1.3 1.1 1.1 1.27 1.6 1.9 1.7 1.6 1.1 1.3 1.63 1.2 1.32 1.2 0.95 0.99 0.720.74 0.88 0.730.76 0.72 0.56 0.79 1 1 1.3 1 1.1 0.87 0.910.85 0.960.93 1.070.99 1.3 1.5 1.1 0.57 0.73 0.52 0.530.560.270.29 0.68 0.610.36 0.52 0.66 0.390.370.350.340.21 0.37 0.5 0.54 0.22 0.32 0.17 0.210.21 0.31 0.260.230.190.220.140.180.15 0.210.230.210.240.180.25 0.270.24 0.420.47 0.14 0.23 0.290.270.290.290.220.21 0.09 0.180.130.110.120.030.090.080.140.110.080.070.070.060.14 0.31 0.63 0.69 0.130.180.130.130.110.150.160.160.150.1 0.040.030.06 0.160.14 ACCIDENT RATES MAJOR OPERATOR GROUPS-NTSB General Aviation Business Corporate On Demand Air Taxi Sched Air Carrier Sched Commuters Robert E Breiling & Assoc
90 Business Aviation 84 80 73 70 68 65 64 60 50 40 30 20 10 0 48 24 38 15 40 24 35 18 45 16 54 19 10 59 37 21 54 54 6.55 6.41 6.73 6.83 7.07 7.4 7.37 7.51 6.87 26 12 25 11 33 48 27 46 25 32 21 19 17 15 14 12 10 10 10 9 5.84 6.07 6.3 6.1 6.2 6.4 6.5 5 4 1.28 0.366 1.06 1.08 0.951 0.905 0.73 0.8 0.72 1.27 0.234 0.36 0.264 0.226 0.135 0.29 0.16 0.16 0.56 0.21 0.79 0.25 0.73 0.22 0.52 0.16 0.64 0.18 0.5 0.06 0.54 0.08 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 40 32 35 Accidents Ftl Acc Fatalities Hours Flown Acc. Rate Ftl. Acc.Rate Robert E Breiling & Assoc
14 Corporate/Executive 13 12 12 11 11 10 10 8 6 8 6.38 8 7 6.51 8 6.89 6 7.13 7.56 7 7.98 8 6 8.54 9 8.71 7.97 6 7.17 7.42 7.7 7.8 7.8 6 8 7 8.2 Accidents Ftl Acc Fatalities Hours Flown Acc. Rate Ftl. Acc. Rate 5 5 5 5 5 5 4 4 4 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 0 0.125 0.063 0.108 0.031 0.116 0.029 0.028 0.014 0.093 0.013 0.076 0.013 0.14 0.011 0.11 0.057 0.08 0.057 0.07 0.01 0.07 0 0.06 0 0.14 0.03 0.07 0.05 0.03 0.01 0.06 0.01 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
Air Taxi 80 70 72 73 69 66 66 64 60 60 60 61 58 54 50 40 30 20 10 0 50 47 Accidents 44 43 Ftl Acc 42 41 Fatalities 38 Hours Flown 36 35 35 Acc. Rate Ftl. Acc. Rate 30 27 25 23 20 20 18 18 18 18 17 17 16 16 16 14 12 10 10 8 8 7 6 2.99 2.91 2.93 3.24 3.81 3.74 4.03 3.41 3.06 3.47 3.08 3.5 3.4 3.4 3.5 2.4 2.06 2.49 2.04 1.7 1.39 1.51 1.7 1.53 2 0.96 1.62 0.6 0.62 0.61 0.71 1.02 1.3 0.29 0.27 0.35 0.59 1.02 1.09 0.07 0.19 0.52 0.23 0.3 0.23 0.21 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Robert E Breiling & Assoc
10,000 Corp/Exec 91 Pro Flown 10 9,000 8,000 9 8 8,005 8,113 8,341 8,605 8,898 9 8 7,000 7 7 7,070 7 6,000 5,000 4,869 5,231 5,550 5,616 5,813 6,014 6,313 6,459 6,426 6,615 5 5 5 6 6 5 Fleet Accidents 4,000 3,000 4 4 3 4 3 4 3 Total Accidents 74 2,000 2 2 2 1,000 1 0 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 Robert E Breiling & Assoc
Part 135 4,000 18 3,500 3,480 3,531 3,710 3,639 3,628 16 3,801 3,700 16 3,314 3,000 2,855 2,953 13 3,158 12 2,708 2,741 2,821 2,910 3,10914 12 2,500 11 10 2,000 9 9 9 9 8 Fleet Accidents 1,500 1,000 4 5 7 4 6 4 Total Accidents 119 3 3 3 500 2 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 Robert E Breiling & Assoc
The Absence Of An Accident Is Not An Indication Of Safety Prior to this takeoff Concorde was accident free
Risk Management Risk is part of life
Are Some Risks Acceptable?
How Much Risk Is Acceptable?
Manage the Risk
Do Not Introduce More Risk Than You Mitigate
Real World Sometime They Get It Wrong NASCAR Accident July 10, 2007 Cessna 310 Takeoff from SFB
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.
Circuit Breaker reset? Can you tell?
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!
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
Do You Know Where The Risks Are?
Unexpected Events Occur
How Ready Are You? ERP current? Phone numbers checked? Drilled Do you know the proper protocol?
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.)
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.
ICAO Annex 13
ICAO Annex 13 5.1 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.
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
ICAO Annex 13 5.24.1 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.
ICAO Annex 13 6.3 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.
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
Limited Assets Party Coordinator The focal point with the investigator Company Employee Go Team Special training needed Operations, Systems, Structure, Maintenance Special Training Needed
Limited Assets Outsource If expertise is not in house find it outside Get help early Sooner is better Pre-arrange experts
Limited Assets Media Special training is needed Pre-plan Who is the face of the operator? Families
Small Operators CAN Survive an Accident John Cox j.cox@safeopsys.com 727 515 1061