November 1994 Volume 37 / Number 11
Management by objective
Poor business management in a flight operation can be just as lethal as pilot impropriety. The NTSB regularly lambastes air carriers and corporate flight departments for not spotting the warning signs that invariably precede an accident or incident. As consumers using rental aircraft or purchasing flight instruction, we should also be on the lookout for a lackadaisical approach to safety.
Accident postmortems generally fall into two categories. There is the uncommon one where everyone is truly perplexed about something that happened to a meticulous pilot or flight operation. The more frequent scenario, however, is when we are amazed that a problem didn't occur sooner. To an ardent observer, the warning signs are usually there with few real surprises. And while aviation is said to be unforgiving, catastrophe doesn't usually strike the first time a transgression occurs. In fact, poor management or cockpit decisions may be a way of life until an accident occurs.
Here is the saga of an FBO, supplier of training, renter of aircraft, and provider of maintenance. The problems that developed were not part of a deliberate plot to cheat the flying public, only an attempt to run a small business in a difficult environment. But good intentions seldom overcome the laws of gravity.
Item number 1: The days are short in November, and the new student pilot wasn't getting enough flight time on the weekends to progress rapidly. As a professional he worked long days, and to solo before the really bad weather set in, he needed additional hours during the week. The new flight instructor was only too willing to accommodate. He had just earned his CFI certificate and, with only 65 hours of dual instruction given, was anxious to exercise his new skills.
The trouble was that by the time the student drove out to the airport and the preflight was done, dusk had come. Most of the flight was conducted in the dark.
This was the student pilot's sixth lesson and only the instructor's second hour of night instruction. The Cessna 152 collided with terrain under unknown circumstances, and both pilots died. The preliminary examination of the wreckage showed no mechanical malfunctions and there were no distress calls. The weather was clear. My speculation is that they were performing stalls and the aircraft got away from them. On a dark night with few ground lights, it's easy to lose orientation in an unusual attitude.
A pre-solo student doesn't need much exposure to night operations. That comes later. There is a measurable increase in risk after dark, so it makes sense to wait until the student can handle the basics and has developed a feel for the aircraft.
Management must keep an eye out for the overenthusiasm that plagues all new pilots and instructors. The elixir of flying on a beautiful, clear night can be overpowering. The flying clubs and FBOs that I have been associated with took a keen interest in new CFI activities. This related to wind, weather, and time of day. Was this a judgment call that could have been decided either way? Absolutely. It's easy to second guess after the fact, but I suspect that many flight schools would have encouraged the instructor and student to stick to daylight until well into advanced training.
Item number 2: Take an elderly single-engine aircraft maintained by the same shop for years. The owner, a highly experienced pilot and a perfectionist regarding maintenance, insisted on a most conservative approach. Just the implication that an item was slightly flawed resulted in a work order to replace the part. The aircraft had an impeccable record.
On an evening currency flight, the Insight Graphic Engine Monitor read normally for the first 20 minutes. After the second takeoff, on downwind leg, the engine gave just the slightest shudder. A quick glance at the GEM showed the number five cylinder to be stone-cold dead. There was no temperature reading. The best place to have an engine problem, other than on the ground, is on the downwind leg — where most pilots practice engine failures — and the aircraft was landed without incident.
Inspection revealed that the fuel injection line had broken just above where it enters the cylinder. It had apparently slipped out of a retainer bracket, where it vibrated and flexed enough to fail. The idea of raw fuel pouring onto a hot engine is not comforting, but the mixture that night was not right for combustion.
The owner ordered a complete set of new fuel lines. He figured that total replacement would ensure safety, even though it appeared that vibration caused the failure, not old age. The shop had the airplane for a week and, after it was all put back together, did a ground test. The owner decided to make a test hop anyway. Runup was normal, and so was the early part of the takeoff. Just after becoming airborne, the engine started to run rough and lose power. There is always a moment's hesitation while deciding whether to continue or reject the takeoff. The owner very wisely landed on the remaining runway, steered his way around the localizer antenna, and rolled gracefully to a stop in a muddy field. There was no damage to the aircraft.
It's a shop's nightmare when an engine fails on the very first takeoff after maintenance. There are many questions asked and probably even more left unsaid. Here, the nut holding the main fuel line going into the fuel distribution unit, or spider, had come loose. This resulted in fuel starvation, and the engine was hosed down again with raw avgas. Twice the luck held and there was no fire.
It's a tough call to make when a shop with a good reputation makes an error like this. Those of us without fault may cast the first stone. The owner elected to change shops.
Item number 3: Another pilot decided to rent an old twin for the annual pilgrimage to Oshkosh. Since he had not flown twins recently, he rented the airplane a day early for some airwork and pattern exercises to refamiliarize himself. The starters were quite balky, and the FBO agreed to fix them. Oshkosh bound, at the fuel stop, a starter refused to engage. A call to the FBO was greeted with a casual reply. Pull the cowling off, pry against the starter bendix to engage it, and the problem is solved. An hour later, the pilot-turned mechanic was on his way.
The manager of the FBO was going to Oshkosh himself and decided to check on the airplane while it was there. Apparently he didn't do much, because at the fuel stop on the return flight, the cowling removal and bendix positioning drill was repeated. The airplane sort of got into the spirit of decay on the last leg as the attitude indicator went south. The distance measuring equipment never did work and made no exception on this flight. As the pilot observed, the FBO probably couldn't afford to keep the old twin up at the prices they charged. This airplane needed new starters, as well as some other maintenance.
The epilogue to the story occurred a week or so later when the twin was out on a training flight. During a single-engine demonstration, the idling engine stopped or was shut down, and the starter decided to take the rest of the day off. An actual single-engine landing was made without incident. Now you might say that's what training is all about. Another view is that this was an actual emergency, self-inflicted, with a happy ending. A misjudged approach or another aircraft entering the runway at the wrong time could have changed the outcome significantly.
As a renter, aircraft owner, or potential flight school customer, what would your opinion be of this FBO's management approach? If you were the NTSB, would you blame the pilots, the FBO, or both? Would the fact that all these incidents occurred in less than one year affect your decision?
Our industry is built on integrity and trust. Old airplanes need careful maintenance, and new pilots need careful guidance. We have to look out for each other. How should the aviation industry look upon the well-intentioned small business that only wants to provide a service but is perhaps lacking in management oversight that could prevent an accident?
See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.