The NTSB has released the Probable Cause for George’s accident. It is short and to the point. It says that Sanil made a mistake and pulled the wrong lever when trying to slow down and “feathered the props” (reversed their angle, which pretty much kills the engines.) It also says a contributing factor George’s inadequate monitoring of Sanil’s performance. The feathering control is on the left side of the plane, on the pilot’s left side. Sonil is a large man. George was in the right seat and could never have reached across to move those levers. Every professional pilot I have talked to has said that once the props were feathered there was practically nothing George could have done to get control of the plane. Adding to the difficulty, a crucial piece of equipment, the unfeathering accumulators, were removed by Quest with only an entry in the maintenance records. There is a chance the props could have been corrected using this piece of equipment, but it wasn’t there. All that was left to do at that point was for George to try to land the plane. Speed was increasing as the plane dropped very rapidly. There was very little distance to the end of the runway. Sanil fought with George over control of the plane. The end result, a catastrophic crash.
This is a long entry, but for those who care to read it, it is very enlightening.
Here is the pertinent excerpt from the report:
The airplane was operating as a corporate flight transporting medical specimens on a night, visual approach in visual meteorological conditions when the accident occurred. The flight was scheduled to be a single-pilot operation conducted under the provisions of 14 Code of Federal Regulations Part 91, and the pilot-in-command (PIC) had been assigned to the flight. Although the second-in-command (SIC), 1) also a Quest Diagnostics pilot, was not assigned to the flight, he asked the PIC if he could accompany him on the flight to gain familiarization with operations into Teterboro Airport. Typically, the PIC flies the airplane from the left seat; however, the PIC on this flight allowed the SIC to occupy the left seat and fly the airplane. The investigation could not determine if the pilots had coordinated responsibilities for the flight before departure or if the PIC was providing additional training to the SIC during the flight.
Radar data indicated that, while on the base leg of the traffic pattern, the airplane had an airspeed of about 204 knots, which exceeded the maximum flap extension speed by more than 50 knots and the maximum landing gear extension speed by more than 80 knots. According to the SIC, during this critical portion of the approach to landing, the nonflying PIC remained focused on providing familiarization of the airport and city environment to the SIC, who was flying the airplane, and the PIC failed to monitor the airplane’s airspeed. 2) After the SIC recognized the airplane’s excessive approach speed close to the runway environment, he attempted to slow the airplane. However, he inadvertently retarded the propeller levers and feathered the propellers instead of retarding the throttle levers. Recognizing the resultant loss of thrust, the PIC challenged the SIC’s actions and stated that both engines had experienced power loss. 3) The airplane’s unfeathering accumulators had been removed; therefore, it was not possible for either pilot to quickly unfeather the propellers and reestablish engine power. Approaching the runway centerline at both low altitude and high airspeed and with the propellers feathered, the pilots were unable to slow the airplane and descend before overflying the runway. The airplane crossed the runway threshold at 300 feet and 186 knots (90 knots more than the approach speed of 96 knots), departed airport property, struck objects, and burst into flames.
Updated at Nov 16 2011 12:49PM
The National Transportation Safety Board determines the probable cause(s) of this accident as follows.
The complete loss of thrust due to the second-in-command’s (SIC) inadvertent feathering of both propellers during a high-speed,
low-altitude approach. Contributing to the accident was the pilot-in-command’s inadequate monitoring of the SIC’s performance.
4) Chairman Hersman and Member Rosekind did not approve this probable cause. Chairman Hersman filed a dissenting statement, which Member Rosekind joined. Member Rosekind filed a dissenting statement, which Chairman Hersman joined. 5) Member Sumwalt filed a concurring statement, which Vice Chairman Hart and Member Weener joined. The statements can be found in the public docket for this accident.
My thoughts on this report are as follows:
1) The SIC, Sanil Gopinath, was not a Quest Diagnostics pilot as stated in the report. He was a contract pilot. He had not undergone Quest’s required training for their pilots.
2) The report states that Sanil noticed he was going too fast as they approached the runway. But he told me right after the crash that George told him to slow the plane down and that was when he unfeathered the props.
3) The unfeathering accumulators had been removed. Quest states this was done to standardize the fleet. But obviously, this piece of equipment was crucial.
4) The Chairman of the NTSB, Deborah Hersman DID NOT approve this as the probable cause, and was joined by another member of the board. They both filed dissenting statements.
5) The other three members of the board did agree with the report, but filed a statement criticizing Quest’s safety practices strongly. To see them in the docket, follow the previous link, go to page 3 and look at the opinions on the bottom of the list of documents. I am including the statements in this post, too.
Here is Chairman Hersman’s Dissenting Opinion. The red highlights are mine.
Notation 8316B Chairman Hersman, Dissenting:
I understand that the accident flight was operated under the provisions of 14 CFR Part 91, which generally sets forth the requirements for small non?commercial flights. However, I am troubled by other facts revealed during the course of this accident investigation about the owner/operator of this flight, Quest Diagnostics, Inc. (“Quest”).
As noted in the accident report, at the time of the accident, Quest owned 30 aircraft, serving 63 cities per night, with 131 legs, and over 28,000 flight hours per year. All of this flight activity is transporting medical specimens. Unlike most other corporate flight departments, Quest used its aircraft for executive transport only 400 hours per year – making this operation more like a Part 135 cargo operation than a traditional corporate flight department. During an interview with an NTSB investigator, Quest’s director of flight logistics commented that “[w]e’ve grown so much that at the level we are now, we are an airline. We are the largest part 91 operator in what we do.”1
In light of this statement and Quest’s high level of activity for a commercial purpose, I question whether the Part 91 regulations provide a sufficient level of safety and oversight for an operator that is essentially in the aviation business, rather than in business aviation.
In contrast, Quest has obtained commercial operating authority from the U.S. Department of Transportation for the ground operations it conducts in different states. Although our investigation did not examine the ground transportation logistics of Quest, given what we know about their air operations, I doubt that the truck transportation is for anything other than Quest’s medical specimens. Yet, in the ground transportation business Quest is required to apply for commercial operating authority which elevates the level of accountability, recordkeeping and oversight for its vehicle operations.2
The Federal Aviation Regulations (FARs) have evolved to create different safety regimes for various types of private aircraft operations. Specifically, in 2005, the Federal Aviation Administration (FAA) created Part 91K because fractional management companies had far outgrown the limited operations envisioned in FAR 91.501, which were intended to authorize turbojet flight operations of a relatively limited scope. Together with industry stakeholders, the FAA developed new regulations at Part 91K that require fractional managers to maintain Part 135?like procedures and documentation. Similarly, since 1981, the FAA has required large aircraft configured for 6,000 lbs or more of payload capacity and with seating for 20 or more passengers to operate under Part 125. In doing so, the FAA moved these types of operators out of Part 91 in order to elevate the level of safety.3
1 eADMS Brief Report, Accident Number ERA09LA469, History of Flight discussion, p. 5. 2 A review of information available from the FMCSA website shows Quest Diagnostics has at least three different DOT numbers for operations in different states: DOT 499823 (Baltimore, MD); DOT 857280 (Lenexa, KS); and, DOT 1994603 (Auburn, MI). 3 Part 125 operators cannot hold themselves out to the general public to furnish transportation “for hire” or common carriage.Given the large number of flights operated by Quest, why should there not be a higher standard of safety for its flight operations beyond those in Part 91? It is particularly troubling that when questioned by an NTSB investigator about the regulatory oversight of large Part 91 operations, the FAA responded that “there are no specific oversight requirements for non?certificated Title 14 CFR part 91 operators contained in the FAA Order 1800.56J, National Flight Standards Work Program Guidelines.” Further, the FAA states that there is no number of aircraft in a Part 91 operation that would trigger a higher level of oversight.4 At what point is further scrutiny appropriate? When they operate in 100 cities per night? When they have 50 aircraft? Or after they have another accident?
Many Part 91 corporate flight departments have training, equipment, and operations on par with Part 121, and their record is quite good. It would behoove the industry to take advantage of the information learned from this accident and study this issue further to determine whether revisions to the regulatory scheme are merited to provide a higher level of safety and oversight for these type of corporate operations.
Here is Member Rosekind’s Dissenting Opinion:
Notation 8316B Member Rosekind, Dissenting:
By definition, this brief report is limited. However, fatigue was likely present at the time of the accident and fatigue-degraded performance likely contributed to the accident’s occurrence. Despite substantial indications of fatigue effects, the present accident report fails to acknowledge fatigue’s role in the accident.
First, the accident occurred at 3:05 a.m., during the window of circadian low that is scientifically well established as a period of reduced alertness and performance, and increased errors, incidents and accidents. The recent NTSB report on the Lubbock, TX aviation accident addresses these issues in greater detail.1 The same physiological fatigue risk factors identified as contributory in the Lubbock, TX aviation accident are present in this accident and similar fatigue-degraded performance was manifested.
Second, the accident occurred on the captain’s fourth and the copilot’s third consecutive night on duty. Night work requires the need for day sleep which typically results in acute sleep loss and cumulative sleep debt. As discussed in the Lubbock, TX aviation accident, NASA and other data show that individuals do not naturally adjust physiologically to night work. Also, at the time of the accident, the copilot had been on duty for more than 11 hours. Therefore, fatigue (as a result of acute sleep loss, a cumulative sleep debt, and circadian low) was likely present and affecting both pilots’ performance at the time of the accident.
Third, fatigue degraded performance that was likely contributory or causal in the accident included reduced attention or vigilance (i.e. like the captain’s failure to monitor airspeed) and incorrect decisions/actions (i.e. retarding propeller levers or feathering the propellers).
Finally, Quest Diagnostics has a history of pilots operating aircraft for extended periods of time. Specifically, fatigue was identified as a contributing factor to the Blain, PA accident on September 3, 1994. The Flight Safety Foundation also made a specific finding in their safety audit stating that Quest pilots operate excessive flight hours.
The present report neglects to acknowledge and analyze the above fatigue factors and therefore fails to acknowledge the role of fatigue in this accident. Based on the factors identified above, fatigue was a likely contributory cause to the accident.
If you are wondering if George was generally tired, just watch the slide show and notice how many of the pictures show him sleeping. At our house we talked a lot about “sleep debt.” George was in bed for 12 hours the day before the accident. We considered that a good day of rest. I noticed that it took George a lot of time to get enough sleep because his daytime sleep was often interrupted. There is no way to keep a house completely quiet during the day. We had a 7 year old daughter at the time. The phone rang (often Quest calling to alert George to changes in the schedule, with no regard for waking him up during his off hours when sleep was so critical.) George had a different schedule most nights, and often flew different plane types from one night to the next. Sanil was not trained for the plane up to Quest’s standards, and had been working 11 hours at the time of the accident. George had submitted a great deal of research about the consequences of sleep deprivation to Quest’s Safety Officer, asking him to please consider the issue of fatigue and try to intervene in scheduling to minimize exhaustion. Nothing was ever done with the information he submitted, and nothing changed regarding Quest’s scheduling style.
Here is the opinion by Member Sumwalt:
I believe this accident brief and probable cause statement accurately describes the circumstances of this accident, and I therefore support the product. However, in carefully reviewing the entire docket for this accident, I discovered things that — although perhaps not directly relevant to the cause of this accident — are of great concern to me.
Although safety was stated as a top priority for Quest Diagnostics, their practices seem to indicate otherwise. Specifically, throughout the interview summaries, whether with current or former employees, there was a persistent theme of “get the job done at all costs” and pushing to complete the mission.
One pilot was reportedly chastised for not being able to land at Washington Dulles International Airport due to low weather. The safety officer for Quest acknowledged that the Director of National Air Logistics would call out pilots for missing approaches, and pressured pilots to “take a look” to see if they could land.
In October 2009, an aircraft engine manufacturer discovered a critical safety-of-flight issue with some engines operated by Quest. In a highly unusual move, the engine manufacturer’s guidance was to “ground all affected airplanes immediately.” Instead of requiring one of those airplanes to land immediately, Quest’s Director of National Air Logistics instructed the pilot to continue for an additional two hours so that the aircraft could land at a Quest maintenance facility. According to the interview summary of Quest’s Director of National Air Logistics, he thought that continuing the flight would be an acceptable risk. His justification was shocking: in the worst case, if the affected engine should blow up, the pilot could continue on the good engine.
One measure of an organization’s safety culture is whether or not employees are willing to report to management safety concerns, events, near-misses, and errors. According to the interview summary of Quest’s safety officer, Quest pilots did not perceive a constructive attitude within management regarding such reporting, and thus, would not submit safety reports. Further, in Quest’s submission to NTSB, it attempted to show its commitment to safety by having an independent safety “hot line.” It stated, “Over the past three years, there have been no calls to the hot line related in any respect to aviation safety.” I find it highly incredible that an aviation operation that conducts 28,000 flights per year could operate for three years without encountering any reportable safety events. Yet, sadly, Quest seems to believe that this lack of reports is a positive indication of safety. To the contrary – what it likely indicates is a serious lack of trust from employees. Instead of Quest demonstrating its commitment to safety, I believe this lack of reporting vividly illustrates it is missing a vital component of a safety culture.
My belief is further bolstered by one Quest pilot indicating that an open door policy exists on paper, but once someone expresses safety concerns, they are targeted for harassment. Another interview was summarized as saying that most Quest pilots are afraid to say anything or speak up, and they are in constant fear for their jobs. Further, an NTSB interview with the assistant chief pilot for Quest discussed a flight where he was flying and reportedly on duty for 35 hours with only 3.5 hours of sleep between duty periods. Asked why he did not contest such a fatiguing schedule, he replied: “Why would I do that? I have a mortgage payment. I have a job, and if I don’t do this, I don’t have a job anymore.”
In their submission to NTSB, Quest dismissed these comments as statements from disgruntled former employees. Perhaps some of that may be the case, but the opinion I have formed is on the basis of reading all interviews – including that of the company’s assistant chief pilot and safety officer.
Denial is the enemy of change.
It is my hope that this statement will send a powerful message to the senior management of Quest Diagnostics: instead of denying these issues, the aviation department needs significant change or more accidents will occur.
Yes, Mr. Sumwalt agrees with the report as published. As I noted, there is a significant mistake in the report regarding Sanil being a Quest employee. He was not. But regardless, Sumwalt wisely questions Quest’s operation’s safety and their veracity regarding what is going on in the flight department. The CEO of Quest is leaving the company. Perhaps his successor will see the importance of making changes at Quest’s Flight Department before there are more tragedies like the one that has affected our family. I believe that Sanil was tired, untrained and confused when the feathered the propellers of the plane, and that George had only a few seconds to fix the problem. The unfeathering accumulators were removed. In the original statement to the NTSB, Sanil describes fighting with George for control of the plane. As captain, George should have immediately been given control of the plane to correct the issue.
My opinion: because of Sanil’s lack of experience and the lack of an accident protocol that would have required him to hand over control of the plane, they never had a chance.
All of the above statements can be found on the NTSB’s webpage.
We had a fairy birthday party for Lily, and that made all of us happy. Some of the girls deemed it “the best party ever,” and while I ran around serving the guests I heard one little girl say to the other, “This is the life!” and I felt happy that they were enjoying themselves. I was touched by Lily, so proud to be ten, to be the host. Of course, that made me miss George, and mom, and I fell back into being sad for a moment. Two and a half years, its getting to be a long time by other people’s estimation. I’m starting to feel self conscious about my grief. I want to be like I was before, but of course that’s not going to happen, we’re all very different. 
