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Special Investigation Report on the Safety of Agricultural Aircraft Operations

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Special Investigation Report on the Safety of Agricultural Aircraft Operations Special Investigation Report on the Safety of Agricultural Aircraft Operations Special Investigation Report NTSB/SIR-14/01 National PB2014-105983 Transportation Safety Board NTSB/SIR-14/01 PB2014-105983 Notation 8582 Adopted May 7, 2014 Special Investigation Report Special Investigation Report on the Safety of Agricultural Aircraft Operations National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2014. Special Investigation Report on the Safety of Agricultural Aircraft Operations. Special Investigation Report NTSB/SIR-14/01. Washington, DC. Abstract: This special investigation report describes the results of a National Transportation Safety Board (NTSB) review of 78 accidents that occurred during calendar year 2013 and involved some aspect of agricultural (ag) operations, pilot training, or other crop protection activities. The report identifies the following recurring safety issues: lack of ag operations-specific fatigue management guidance, lack of ag operations-specific risk management guidance, inadequate aircraft maintenance, and lack of guidance for pilot knowledge and skills tests. Safety recommendations to the Federal Aviation Administration and to the National Agricultural Aviation Research & Education Foundation are included. The Appendix at the end of the report contains a full listing by NTSB case number of the accidents reviewed for the special investigation. The National Transportation Safety Board is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 Copies of NTSB publications may be purchased from the National Technical Information Service. To purchase this publication, order report number PB2014-105983 from: National Technical Information Service 5301 Shawnee Road 22161 Alexandria, VA 22312 (800) 553-6847 or (703) 605-6000 http://www.ntis.gov The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. NTSB Special Investigation Report Contents Figures ............................................................................................................................................ ii Acronyms and Abbreviations ..................................................................................................... iii 1. Introduction ..............................................................................................................................1 2. Fatigue .........................................................................................................................................5 3. Attention Demands and Risk Management Practices ..........................................................10 3.1 Attention Demands ..................................................................................................................10 3.2 Risk Management ....................................................................................................................12 4. Aircraft Maintenance ..............................................................................................................15 5. Pilot Knowledge and Skills Test Guidance ............................................................................17 6. Previous NTSB Safety Action .................................................................................................20 6.1 Safety Recommendations to the FAA......................................................................................20 6.2 Safety Recommendations to the AWEA..................................................................................21 6.3 Safety Recommendation to the DOI, USDA, and DOD ..........................................................21 6.4 Safety Recommendation to 46 States, 5 Territories, and the District of Columbia .................22 6.5 Other Previous NTSB Safety Action .......................................................................................22 7. Conclusions ...............................................................................................................................23 8. New Safety Recommendations ................................................................................................24 9. Appendix ...................................................................................................................................26 10. References ...............................................................................................................................30 i NTSB Special Investigation Report Figures 1 Figure 1. Hazards, constraints, and pilot attention demands common to ag operations. ....2 2 Figure 2. Wreckage of an Arrow Falcon Exporters OH-58+ helicopter. ............................6 3 Figure 3. Wreckage of a Weatherly 602B airplane. ............................................................7 4 Figure 4. GPS swath guidance system installed in a two-seat training aircraft. ...............11 5 Figure 5. Wreckage of a Bell 206B that struck power lines (left) and the 6 severed lines (right)............................................................................................................13 7 Figure 6. Damaged rudder pedal of a Cessna 188B airplane. ...........................................16 ii NTSB Special Investigation Report Acronyms and Abbreviations AC advisory circular AWEA American Wind Energy Association CFR Code of Federal Regulations DOD Department of Defense DOI Department of the Interior FAA Federal Aviation Administration FAASTeam FAA Safety Team GA general aviation MET meteorological evaluation tower NAAA National Agricultural Aviation Association NAAREF National Agricultural Aviation Research & Education Foundation NTSB National Transportation Safety Board PAASS Professional Aerial Applicators’ Support System SAFO safety alert for operators SB service bulletin SIL service information letter TBO time between overhaul USDA US Department of Agriculture iii NTSB Special Investigation Report 1. Introduction Agricultural aircraft operations (commonly referred to as “ag operations”) involve the use of airplanes and helicopters for dispensing activities—including the aerial application of fertilizers, seeds, and crop protection products such as those used to control pests, weeds, and harmful fungi—that directly affect agriculture, horticulture, or forest preservation.1 Ag operations are conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 137, which provides operation-specific requirements and certain exceptions from the 14 CFR Part 91 operating rules.2 A review of historical accident data and the findings of several ag aircraft accident investigations prompted the National Transportation Safety Board (NTSB) to initiate this special investigation to identify safety issues in this unique general aviation (GA) sector and to suggest action to address these issues.3 According to the National Agricultural Aviation Association (NAAA), an industry group representing about 1,800 members nationwide, about 1,350 aerial application businesses employ about 2,700 ag pilots in the United States (NAAA 2012, 28). The mission priorities of ag operations present pilots with unique hazards, challenges, and constraints, some of which cannot be completely eliminated. For example, ag pilots must maneuver their aircraft at very low altitude over terrain and must therefore accept an elevated risk of terrain and obstacle collisions, as well as having limited time to safely respond to an aircraft mechanical anomaly or recover from an inadvertent aerodynamic stall. Also, as a typically single-pilot operation, ag flying places high demands on pilots’ attention. In addition to flying their aircraft, ag pilots must operate their dispensing equipment and adjust their swath runs (often while monitoring in-cockpit resources such as GPS-aided precision aerial swathing equipment) to manage product drift and ensure quality coverage. They also must monitor the outside environment for a variety of considerations, such as weather phenomena (that can affect visibility or product drift), work area boundaries, obstacles, and areas to be avoided due to populations, noise abatement, livestock, or other safety considerations. Finally, seasonal crop schedules, weather conditions, the potential for crop damage if a job is not completed, competition for contracts, and other factors can influence pilots’ or operators’ scheduling practices, creating demanding work schedules that
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