Light business aircraft make up a sizable portion of the business aviation fleet. These aircraft offer unmatched capabilities and economics for their owners but are routinely operated single pilot. Compared to multi-pilot operations, having just one pilot at the controls creates some challenges. At the top of that list is managing risk.
The NBAA Safety Committee has identified improving the single-pilot accident rate as a top safety focus area, saying, “Single-pilot operations have enhanced risks when compared to multi-pilot operations, demonstrated by the fact that single-pilot aircraft are 30 percent more likely to be involved in an accident than aircraft with dual-pilot crews. Single-pilot operations are more susceptible to task saturation; when task saturation increases, so too does the number of errors.”
NBAA’s “Risk Management Guide for Single-Pilot Light Business Aircraft” suggests that the true root cause of an accident is not available from conventional data. As an example, loss of control in flight (LOC-I) is cited as the top cause of general aviation and light business aircraft accidents, “yet loss of control is typically the last event in the accident chain.” It answers the how, but not the why—the accident chain often begins with poor risk management.
This guide on risk management for single-pilot ops is a great primer on risk-management fundamentals such as identifying, assessing, and mitigating risk and provides an easy-to-use flight risk assessment tool (FRAT). The guide demonstrates that the principals of a safety management system (SMS) are scalable to fit the needs of a small operator.
In addition to identifying, assessing, and mitigating risk, the guide provides additional counsel regarding principals of risk management such as “take no unnecessary risk” and “accept risks consciously.” All are good advice.
A concern with any risk-assessment exercise within an SMS is that it often comes from a “position of go.” From the start, an operator will take sometimes-heroic measures to mitigate the risk to the lowest acceptable level to complete the mission, rather than discontinue the operation.
But a more appropriate response might be to adopt a “position of no.” Once a risk other than “low” is identified, implement a “safety timeout” and seek out other resources to find the safest solution—that could include delaying, canceling, modifying, or finding an alternative to the flight.
A mindset of “go/no-go” may be more acceptable to the single pilot than attempting to mitigate the risk to an acceptable level. This is especially true when multiple risks are identified for a single flight.
The NBAA FRAT is based on identifying and assessing risk in the following categories: pilot (qualifications, currency, proficiency, and aeromedical/HF); aircraft (equipage, fuel, etc.); environment (weather, ATC, and terrain); and external factors (pressures, work, etc.).
Using the NBAA FRAT, as a pilot or operator, how would you mitigate the issues “identified” during this recent accident flight?
On Dec. 29, 2016, a Cessna Citation CJ4 was destroyed when it crashed into Lake Erie following a late-night departure from Burke Lakefront Airport (KBKL) in Cleveland, Ohio. The pilot and five passengers were killed. The aircraft was owned by a Columbus, Ohio-based beer distributorship, with the company’s CEO as the sole pilot at the controls during the accident flight.
Earlier in the day, the pilot and passengers departed the Ohio State University Airport (KOSU) in Columbus for a short 30-minute flight to KBKL to attend a professional basketball game. The aircraft landed at KBKL at around 18:00 local. Following the basketball game, the pilot and passengers returned to the airport at about 22:30 local. The plan was to fly back to KOSU. At this point, the pilot had been awake for 17 hours and was likely fatigued.
The accident pilot had 1,205 hours total flight time; a Cessna 525 single-pilot type rating was added to his private pilot certificate three weeks prior to the accident flight. He had logged a total of 56.5 hours in the CJ4, with less than nine hours as a PIC. Before purchasing the accident aircraft, the pilot owned a Citation Mustang for two years and had logged approximately 400 hours in that aircraft.
At the time of the accident, weather at KBKL indicated marginal VMC with lower scattered clouds, a broken ceiling at 1,300 feet agl, and eight miles of visibility and light snow. The winds were out of the west at 22 knots, with gusts up to 31 knots. Before the accident, weather observations reported intermittent snow showers at the airport.
According to the NTSB accident final report, at approximately 23:00 local, ATC cleared the aircraft to take off from KBKL’s Runway 24R and instructed the pilot to turn right to a 330-degree heading and maintain 2,000 feet (about 1,400 feet agl). Shortly after takeoff, while in the right turn, the aircraft entered IMC conditions over Lake Erie.
The initial climb rate exceeded 6,000 fpm and the aircraft passed through its assigned altitude of 2,000 feet. An aircraft altitude alerting system provided aural “altitude” alerts as the aircraft approached its assigned altitude and passed through it. After the second “altitude” alert, the pilot reduced the thrust.
Then, the aircraft reached a maximum altitude of 2,900 feet and at that point indicated a 62-degree right bank and a pitch attitude decreasing to 15-degrees nose low. During the subsequent descent, the bank angle decreased to about 25-degrees, but at this point the airspeed increased to 300 knots with a 6,000-fpm descent rate until it crashed into Lake Erie. During the accident sequence, TAWS provided “bank angle” and “sink rate” alerts followed by seven “pull up” warnings to the pilot.
During the accident analysis, NTSB investigators suggested, “It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged.” Investigators contribute this error to the pilot failing to confirm autopilot engagement on the primary flight display (PFD).
There may have been autopilot mode confusion based on a difference between the avionics on the accident aircraft and the airplane flown previously by the pilot. This belief that the autopilot was engaged—combined with fatigue—might have also contributed to a lack of attention to the aircraft flight path, instrument scan, and subsequent spatial disorientation.
The NTSB determined that the probable cause of this accident was “controlled flight into terrain (CFIT) due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot’s previous flight experience.”
From this description, is it accurate for the NTSB to suggest that the primary cause of the accident flight was CFIT due to pilot spatial disorientation? Are the contributing factors pilot fatigue, mode confusion, and a negative learning experience from the pilot’s previous flight experience?
Understandably, the NTSB is mandated to identify a singular “primary” cause of an accident. From the description, above, the accident could also be classified as a LOC-I accident—the pilot was not in “control”—but what action initiated the chain of events leading to this crash?
Here, we have the latitude to identify a root cause; a lack of risk management is apparent. Using a FRAT, several risks are identified, including the pilot’s low total flight time, proficiency in a new aircraft type, and fitness for flight due to fatigue. Environmental risk factors include the weather (MVFR and high winds) and time of day.
As the PIC or director of flight ops, would you delay, cancel, modify, or find an alternative to this flight?
Fatigue is a big deal; studies show that 17 hours of continuous wakefulness reduce a pilot’s reaction time by 122 percent—the equivalent of a blood alcohol content of 0.05 percent. It may have been helpful to delay the departure until the next morning after a restful night in a hotel.
Canceling a flight and finding an alternative form of transportation is always an option—no trip is worth accepting unreasonable risk. In this case, a 30-minute flight could have been replaced with a two-hour car ride on I-71 between Cleveland and Columbus.
Likewise, hiring a more seasoned second pilot with experience in the CJ4 would have mitigated the risk of a pilot with less than 10 hours of PIC time in type operating in marginal weather conditions.
Within business aviation there is a difficult conundrum: why do astute individuals, with an acumen for managing risk in a business environment, make such horrible decisions in the cockpit of an aircraft?
To counter this issue, formal training in risk management—as a part of a single-pilot resource management course—is necessary for any pilot operating a complex light business aircraft. Likewise, using simple tools such as the NBAA FRAT or other equivalents provide a practical approach to identify, assess, and mitigate risk.
For the single pilot, developing a go/no-go mindset, starting from a position of “no,” will go a long way to ensuring that a flight can either be completed safely or to produce an alternative safer plan.