What You Can Learn From an NTSB Report

The answer is simple: If we can identify the causal factors in these accidents, we can take steps to mitigate them. 

One of my favorite ways to refresh my knowledge on this topic is to review the accident investigation reports published by the National Transportation Safety Board (NTSB) and the Aircraft Owners and Pilts Association's McSpadden Report, formerly known as the Nall Report. The latter aggregates accidents on an annual basis and identifies causal factors looking for trends. 

The 34th report was issued last week, although the information is updated on a 30-day cycle. Before it went digital, the annual release was done in hard copy, and for some CFIs (raises hand) it was like the Sears’ toy catalog. I looked forward to it all year. 

The report helped to show where aviation safety had improved, along with identifying factors leading to accidents. I found it was best used by looking for trends I could address and mitigate at the instructor level. For example, I taught my primary learners how to read a weather forecast and determine aircraft performance from day one, so they don’t have to rely on their CFI as a crutch.

Last year AOPA renamed the report in honor of Richard McSpadden, former senior vice president of the organization's Safety Institute who was killed in an airplane crash on October 1, 2023. McSpadden was a highly skilled and experienced pilot, and his résumé included experience as a member of the U.S. Air Force Thunderbirds.

The day of the accident, McSpadden and former NFL tight end-turned-pilot and FBO owner Russ Francis were flying out of Lake Placid Airport (KLKP) in New York for a photo mission for AOPA. Per company procedure, Francis would do the takeoff and then McSpadden would take over for the formation flight for the photo shoot.

The photo platform aircraft, a Beechcraft A36, was already in the air when a Cessna Cardinal RG took off. Witnesses on the ground told the NTSB that the Cardinal engine sounded as if it was surging. McSpadden radioed that they were returning because of a problem. The Cardinal came down short of the runway, striking the berm and coming to rest nose down in the ravine. There was no fire, but fuel spilled when the wing tanks were compromised.

Both men survived the crash but died shortly thereafter. The NTSB has not yet released a final report as to the cause of the accident.

The latest McSpadden report noted that the number of accidents increased from 1,120 in 2021 to 1,152 in 2022. To put it into perspective, flight activity is significantly up, and a great many of the accidents happened in the training environment with a CFI on board.

The combination of an increase in flight hours and fairly inexperienced pilots (both the students and the instructors who often have less than two years of experience as teachers of flight) is being discussed as a factor in the increase in accidents among the CFI associations.

The accidents are categorized into phases of flight. NTSB accident causes are listed under each phase, such as weather, mechanical failure, fuel exhaustion, and pilot error.

It often takes 10 days or more for the NTSB to compile the preliminary report on an accident. Witnesses are often interviewed by telephone and asked to fill out a narrative form to be submitted to the agency. Unless there is loss of life, the NTSB may not travel to an accident site.

It usually takes the NTSB at least a year to 18 months to determine the probable cause of an accident. The investigation involves creating a narrative of the chain of events that led to the accident. When you read them in hindsight, it can be easy to notice the faulty decision making.

It probably doesn't come as a surprise that human error is the No. 1 causal factor. This is often manifested as the pilot's failure to properly manage fuel,  lack of cockpit resource management, not managing distractions, and ultimately questionable decision making such as continuing VFR flight into IFR conditions.

A lack of situational awareness can creep up on any pilot, not just students. Recently someone shared a report with me from November 2022 that involved two commercially rated pilots who were also CFIs. They were flying a Pipistrel Virus in Florida to build time for an air carrier development program.

According to the NTSB report, one pilot had 1,100 hours total time with 70 in make and model, and the other had 1,240 hours and 40 in make and model.

The flight involved multiple legs on the same day. The aircraft was on the fourth leg of the day when both pilots notice the fuel level was low. When the engine quit, the pilot with more experience took control of the aircraft.

When it became clear the aircraft did not have sufficient altitude to glide to the runway, the pilot deployed the ballistic parachute. The aircraft was at approximately 600 feet agl. The report did not indicate what kind of terrain the aircraft was over. It stated there were no injuries to the pilots, but the aircraft came down hard enough to sustain substantial damage to the fuselage. 

According to the report, the postaccident inspection of the fuel system "showed no fuel visible in either wing tank and no fuel visible in the inline fuel filters."

The NTSB determined the probable cause(s) of the accident to be  “the pilots’ inadequate preflight fuel planning and improper in-flight fuel management, which resulted in a total loss of engine power due to fuel exhaustion and subsequent deployment of the ballistic parachute recovery system.”

The aircraft experienced substantial damage, which is why it was classified as an accident. Had it been a simple off-airport landing without parachute deployment, it would likely have been classified an incident.

According to federal regulations, an accident is defined as 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 and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage."

Substantial damage is defined as "damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component."

The regulation goes on to state that engine failure or "damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered ‘substantial damage’ for the purpose of this part."

This last part is very important because an unscheduled, off-airport landing caused by an uncommanded loss of engine power isn't necessarily a crash. If, however, you put the aircraft down in an empty lot or on a city street, and there is no damage to anything, not even the airplane, you better believe it will be reported as an "airplane crash" to 911 and on social media.

Another factor when reading the NTSB reports is that you can identify the decisions made by the pilot that led up to the accident. This is the so-called "Swiss cheese" model, meaning accidents usually don't have a single causal factor. There are usually several factors (the holes in the cheese) that line up, resulting in the unfortunate event.