4.4 Mod 4 Improving Aviation Safety Eisenman Ronald

IMPROVING AVIATION SAFETY 1
Improving Aviation Safety
ASCI 202
Embry-Riddle Aeronautical University
Ronald Eisenman
On August 1, 2008, in N. Myrtle Beach, South Carolina, a pilot (age 22, male) with zero
passengers, aboard a Piper PA-12 single, reciprocating engine aircraft operated by Barnstormer Flite
Signs, Inc., had taken off at 1300 EDT and flown for 45 minutes on full tanks of fuel and descended and
landed. There was no precipitation, clear skies, calm winds, and a temperature of 32 degrees Celsius
during the time of this evolution. Upon his next flight, he was strongly advised by an operator to refuel
the airplane before departing. The pilot had disregarded the suggestion and took off with no flight plan
on a banner-tow flight without refueling the aircraft. The pilot stated that he would monitor his fuel
levels while in the air. At 1545 EDT, the fuel levels had depleted to ¼ and 1/3 capacity and that is when
issues stated to arise with the engine. The engine had sputtered once and then completely lost power.
Upon noticing he lost power, he notified air traffic control, released the banner, and realized that he
would not be able to make it to the airport and decided to eject himself from the aircraft. The plane
plummeted into the Atlantic Ocean near Grand Strand Airport (CRE), South Carolina. The accident had
sustained minor injuries to the pilot, but substantial damage to the plane itself. The National
Transportation Safety Board has determined that fuel depletion and poor judgment by the pilot was the
cause of engine power failure. The examination of the PIPER PA-12 by the NTSB, revealed insufficient
fuel in the carburetor and fuel tanks. Additionally, there was an unknown amount of fuel discovered in
the gascolator of the super cruiser.
Safety Management Systems (SMS) are becoming the standard throughout the industry of
aviation all around the world. This system integrates modern safety risk management and safety
assurance ideas into standardized and proactive measures. FAA (2016) states that SMSs emphasize
safety management as a fundamental business process to be considered in the same manner as other
aspects of business management (FAA, 2016). Pilot’s should be fully aware of their aircraft’s basic
requirements in order to sustain airtime. They go through training in order to improve skills in decision
making, management capability, increased confidence in risk controls, knowledge sharing, and show
support to the safety culture. This particular pilot naively ignored an operators advise and went into
flight without the required amount of fuel to accomplish the flight operation. The pilot is responsible for
his crew and passengers. One bad decision could lead to the ultimate death of all the lives of those on
that aircraft.
The National Transportation Safety Board (NTSB) gives recommendations to transportation
manufacturers and providers along with federal and state agencies regarding safety. They are also
responsible for conducting investigations of transportation accidents and implementing safety studies
for transportation. These companies may or may not take these recommendations into consideration
and implement them into their practices. EveryCRSReport.com (2016) wrote that Federal Aviation
Administration (FAA) regulations to address airline pilot fatigue; state laws addressing distracted driving;
federal safety standards for helicopter air ambulances; and crashworthiness standards for helicopter
fuel systems, which are required under new federal law (EveryCRSReport.com, 2016). With this
accident, the NTSB had determined that the potential cause for the total loss of engine power was due
to fuel exhaustion because of the pilot’s inadequate fuel planning. In order for future generations to
avoid this issue, they should ensure they follow all protocols and preoperational inspections before
making the decision to take off.
In order to prevent this mishap from happening again, there are measures that need to be
taken. Safety Management Systems should be implemented in order to ensure safety. Proper decision
making is essential for pilots to prevent accidents from happening. Pilots should complete minimum
requirements necessary in order to be compliant with federal flight operations. Preoperational flight
inspections should be conducted to prevent mechanical failures that could cause catastrophic damage
to aircraft and crew. Pilot fatigue needs to be a factor in the decision to perform any flight operation at
any point of the day. Inexperienced pilots should proceed with caution when attempting to take on
multiple flights in one session. Something as simple as refueling at an airport is not something someone
should avoid when making multiple long flights and the pilot involved in this accident should be
reprimanded for not making the logical decision.

References:
Monville, T. (2009, March 23) National Transportation Safety Board Aviation Accident Final Report.
Accident Number: MIA08LA158 Retrieved from:
https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?
EventID=20080825X01297&AKey=1&RType=Final&IType=LA
Federal Aviation Administration. (2016, July 14) Safety Management System. Retrieved from:
https://www.faa.gov/about/initiatives/sms/explained/basis/
EveryCRSReport.com (2016, August 10) NTSB Background and Possible Issues for Reauthorization and
Oversight. Retrieved from: https://www.everycrsreport.com/reports/R44587.html

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IMPROVING AVIATION SAFETY 1

Improving Aviation Safety

Embry-Riddle Aeronautical University

the gascolator of the super cruiser.

The National Transportation Safety Board (NTSB) gives recommendations to transportation

making the decision to take off.

reprimanded for not making the logical decision.

Accident Number: MIA08LA158 Retrieved from:

Oversight. Retrieved from: https://www.everycrsreport.com/reports/R44587.html

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