Flight Safety Detectives – Details, episodes & analysis

In March, a Mooney airplane door opened in flight, causing a loss of control and two fatalities. Todd and John examine this incident and three other Mooney events. Instead of a fault with Mooney aircraft, they find a pattern of very experienced pilots having issues and crashing when a passenger or baggage door opens in flight.

Doors open in flight often. The outcome depends on pilot action.

The pilot in the most recent crash had commercial and instrument ratings and nearly 800 hours of experience. Besides the door opening in flight, the NTSB found no other issues with the aircraft. The door alone should not have caused the plane crash.

In the earlier cases they discuss, all the pilots had at least a hundred hours of flight experience and there were no issues with the aircraft other than the doors opening in flight. One of those accidents had an instructor pilot on board, and between the student and instructor, they had over 9,000 hours of flight experience. 

Todd shares an early similar flight experience when an oil access door came open during the takeoff roll. He aborted the takeoff. His current process during his flight training focuses on flying the aircraft and assessing the situation before taking any other action.

Related documents are available at the Flight Safety Detectives website.

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Get the highlights of the Experimental Aircraft Association's AirVenture 2024 in Oshkosh, Wisconsin! 

Hundreds of thousands of attendees attended the multi-day event. All sectors of aviation were represented, from the military to general aviation, from exotic and experimental aircraft to flight demonstrations by military and civilian aircraft. 

John Goglia attended once again this year and chatted with pilots, mechanics, elected officials, and aviation enthusiasts of every age. He met several people who regularly listen to the podcast, including some who offered ideas for future shows. 

AirVenture is a unique airshow experience, but there are opportunities to visit other airshows around the country. Many local airports also offer opportunities for the general public, to see airplanes up close and speak to local pilots, flight schools, and others involved in aviation.

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As Boeing continues to be the subject of investigations and congressional hearings the concept of criminalization has come to the forefront. This could have a devastating impact on aviation safety in the U.S. Special guest and aviation attorney Mark Dombroff focuses on efforts to criminalize the investigation of aviation accidents and incidents. 

The effort to use criminal prosecutions to address aviation safety issues in the U.S. would dramatically impact the process of getting to the facts, including making witnesses more reluctant to come forward with details. Criminalizing will make the safety investigation process more difficult and less effective.

While some in the legal community favor criminalization, it is not the approach used in most of the world. Aviation accident investigation focuses on understanding what happened and how to prevent similar events in the future. A criminal investigation would shift the goals to assigning blame and handing out punishment. 

Several notable past investigations came up during the discussion, including a fatal 2006 midair collision in Brazil involving a 737 and a corporate jet. The corporate jet pilots were detained in Brazil for several months and threatened with prosecution for almost 18 years. When TWA Flight 800 crashed, there was tension over whether the FBI or the NTSB would conduct the investigation. 

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Episode 137

The investigation of an issue involving a RJ100 in Sweden is relevant to everyone who flies sophisticated aircraft. Specifically, this investigation revealed issues related to the high angle of attack stall sensor that is commonly used in the aviation industry.

The Swedish authority that investigated the issue deployed a multi-person team. They were able to identify the maintenance errors that led to a false stall warning in flight.

John notes that the stick shake stall warning is the same event that started both 737 Max crashes, as well as an Air France A340 crash. These are just part of a long history of airplane stalls resulting in loss of aircraft and lives. In this case, the plane landed safely.

The final accident report has detail that can help prevent these types of accidents. John and Todd highlight the key findings for pilots and maintenance personnel.

Related documents are available at the Flight Safety Detectives website.

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Episode 136

Was the fatal crash of a Piper PA46-500TP airplane the result of a plane with unresolved maintenance issues or a pilot with insufficient skills? The Flight Safety Detectives find that the NTSB report of this accident has no educational value or safety benefit.

Calling the single engine turbo-prop plane “not your father’s 172,” Greg brings to light the complexities of the aircraft involved. “When things go bad, they go bad very quickly.”

Todd adds his research on social media that indicates the pilot was uncomfortable with the plane. He notes that the pilot needed an unusually high number of hours to earn his instrument rating.

John covers the maintenance records. He wonders if the “no action taken” conclusion of the last work order was because the pilot declined repairs or if the root cause was believed to be the pilot’s inability to fly the aircraft.

The Flight Safety Detectives look at the NTSB report and available information to offer safety insights. They point to poor pilot skills and aeronautical decision making as important factors.

Accident details:

• NTSB Accident Number: DFW08FA057
• Public Docket: https://data.ntsb.gov/Docket?ProjectID=67401
• NTSB Final Report (PDF available at flightsafetydetectives.com)
• NTSB Witness Statement (PDF available at flightsafetydetectives.com)

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Episode 135

The investigation into a June 2022 Cessna 182G crash in Texas is ongoing. The Flight Safety Detectives share initial facts and offer safety insights.

“A mechanical malfunction is high on my list to look at. Anything out of place, even a simple cotter pin, could have led to problems,” says John.

The detectives share the indications that there was loss of flight controls in the final stages of the flight. They share facts they have uncovered. Listen as they apply their experience to ask questions that the investigation should explore.

Weather conditions, possible mechanical issues, pilot experience, and more factors are explored. Hear what should be done to get beyond a superficial probable cause conclusion in this fatal air crash.

Accident details:

• NTSB Accident Number: CEN22FA232
• Preliminary Kathryn’s Report (PDF available at https://flightsafetydetectives.com/wp-content/uploads/2022/10/kathrynsreport.pdf)

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Episode 134

Poor decision-making by the pilot is showcased in the examination of a Piper PA-24 crash in Angel Fire, New Mexico. The Flight Safety Detectives find that the NTSB report of this air crash provides helpful information and findings that every pilot can learn from.

Greg, John and Todd review the facts, conditions and circumstances of the accident to amplify the role of the pilot’s decisions before and during the flight. A lack of preparation led to this crash and two fatalities.

The pilot was not prepared for the gusty winds present at takeoff. He was also not familiar with the high-density altitude conditions common during hot weather at this airport. Todd estimates the pilot had about 45 seconds between realizing something was wrong and hitting the ground.

For links related to this episode, visit flightsafetydetectives.com

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Episode 133

An accident involving a Hughes 269C helicopter demonstrates the lack of depth in accidents attributed to maintenance errors. Once again, there is no analysis on the human factors involved among maintenance personnel.

The NTSB probable cause for this air crash points to an improperly installed mounting bracket on the engine. The supporting details and aviation insights are lacking.

“My frustration is that they go no further than to say this is a maintenance issue,” John Goglia says. “No human factors are explored although that is as important in maintenance as it is in the cockpit.”

John, Greg and Todd find many questions unanswered. They discuss the value in going deeper than “maintenance screwed up.”

They explore the many questions not investigated that could lead to information that people can learn from. They talk about why even the most benign accidents can result in aviation safety benefits. This accident report is among many that are a disservice to the aviation community because it is superficial.

Also in this episode, Greg retracts a Episode 131 statement that 50% of NTSB probably causes are wrong. He does not have sufficient documentation to support the statement. However, he stands by his statement that he is confident that at least half of NTSB reports are incomplete.

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Episode 132

FAA Advisory Circular 60-22 just may save your life. The document looks at aeronautical decision making and five hazardous attitudes.

In the cockpit, on the hangar floor and in life, the Flight Safety Detectives say this information provides critical insight for everyone in aviation.

Greg, John and Todd use a Cirrus SR 22 air crash in Midland, Texas to illustrate how poor decision-making puts pilots and passengers at risk. Hear as they make the case for everyone in aviation to apply this insight to their work and life.

Pilots who don’t recognize their own limitations and rationalize poor decisions cause accidents. This free document can save your life.

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Episode 131

Continuing the discussion started in Episode 128, the deficiencies of the NTSB report of a plane crash in Palo Alto are laid out. John, Greg, and Todd conclude that the report actually contributes to the problem of inaccurate data leading to time and money being spent on the wrong aviation safety issues.

Estimates are that more than 50 percent of NTSB reports are inaccurate, incorrect or outright wrong. This report is highlighted as a case in point.

Greg outlines several questions not answered – or incorrectly addressed – in the report. Here are just a few:

• The departure clearance provided calls to turn right after takeoff, but the pilot turned left. Why?
• Both engines were working. Why was the aircraft so low following takeoff?
• Why did the NTSB spend so much time looking at the engines and no time looking at instrumentation?

“There are many issues with open questions that are not answered,” Greg says. “This is not a beneficial report to understand the cause or contributing factors.”

Todd adds that the media coverage of the air crash characterized the pilot as experienced and dedicated to safe operations. Yet, the NTSB did not look into what would lead him to make the errors apparent that day.

Listen to find out why the Flight Safety Detectives think this report does a disservice to the pilot, other victims and aviation safety overall.

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