The National Transportation Safety Board has determined that an aircraft accident in Sanford, Florida, in July 2007, which killed two in the plane and three on the ground, was caused by a series of poor decisions, both by corporate flight department management and by the pilots that flew the accident aircraft.
On July 10, 2007, at about 8:35 in the morning, a Cessna 310R, (N501N), part of the fleet operated by NASCAR's corporate aviation division, crashed into a residential area, destroying two homes, while performing an emergency diversion to the Orlando Sanford International Airport in Florida after reporting an in-flight fire. The two pilots on board the airplane and three people on the ground were killed, four others were seriously injured.
In its final report, the Board said that the accident was due to (1) the NASCAR corporate aviation division's decision to allow the accident airplane to be released for flight with a known and unresolved electrical system problem, and (2) the accident pilots' decision to operate the airplane with full knowledge of the maintenance discrepancy.
"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.
The day before the accident, another NASCAR pilot flew the accident aircraft 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 between the Florida cities of Daytona Beach and Lakeland. At some point prior to or during the accident flight, 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.
"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 said.
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). The NTSB called on the FAA to advise general aviation pilots and maintenance personnel of how resetting a circuit breaker inflight without knowledge of what caused the circuit to be tripped, could create a "potentially hazardous situation," and to require that information to be included in their initial and biennial training. The Board further recommended that initial and recurrent training of maintenance personnel working on general aviation aircraft include "best practices" regarding the inspection and maintenance of electrical systems, circuit breakers and wiring.
The Board also recommended that both aircraft manufacturers and those responsible for postmanufacture modifications improve guidance or create new guidelines regarding which circuit breakers pilots should and should not attempt to reset before or during flight, and that this information be disseminated to airplane pilots, mechanics and owners.
Finally, the Board recommended that the FAA develop a safety alert to encourage all 14 CFR Part 91 business operators to adopt a Safety Management System that includes sound risk management practices.
A synopsis of the Board's report, including the probable cause and recommendations, is available on the NTSB website. The Board's full report will be available on the website in several weeks.