Hidden defects linked to scores of small-aircraft crashes, a USA Today investigation shows
A tragedy in Iowa
The first flight of 8-year-old Caryn Stewart's life was supposed to be a quick sightseeing tour over eastern Iowa in her uncle's four-seat Piper Cherokee.
Nervous and excited, she sat quietly behind her mother and next to her sister as Andy Bryan, a cousin, drove the single-engine plane down Runway 17 at George L. Scott Municipal Airport.
The airplane elevated briefly and plunged into a field where it exploded into flames. Caryn suffered severe burns that scarred her torso, back, arms, legs and face. Her mother, cousin and 11-year-old sister were killed, part of a massive and growing death toll from small-aircraft crashes.
Manufacturing companies and federal investigators would say Bryan lost control of the Piper on that Easter Sunday in 2005. But company documents and government records pointed to a different cause: a faulty carburetor that the manufacturer later urged airplane owners to remove because it was causing engine failures.
Nearly 45,000 people have been killed over the past five decades in private planes and helicopters — almost nine times the number that have died in airline crashes — and federal investigators have cited pilots as causing or contributing to 86% of private crashes. But a USA TODAY investigation shows repeated instances in which crashes, deaths and injuries were caused by defective parts and dangerous designs, casting doubt on the government's official rulings and revealing the inner workings of an industry hit so hard by legal claims that it sought and won liability protection from Congress.
Wide-ranging defects have persisted for years as manufacturers covered up problems, lied to federal regulators and failed to remedy known malfunctions, USA TODAY found. Some defective parts remained in use for decades — and some are still in use — because manufacturers refused to acknowledge or recall the suspect parts or issued a limited recall that left dangerous components in hundreds of aircraft.
The manufacturers involved paid hundreds of millions of dollars in settlements that received little or no public attention until now and that need not be disclosed to federal regulators. In addition, civil-court judges and juries have found major manufacturers such as Cessna Aircraft, Robinson Helicopter, Mitsubishi Aircraft, Bell Helicopter and Lycoming Engines liable for deadly crashes, ordering them to pay hundreds of millions of dollars in compensatory and punitive damages.
The verdicts contradict findings of the National Transportation Safety Board, which conducts limited investigations into most crashes of private aircraft and asks manufacturers to look for defects in their parts, even if the manufacturers are being sued over a crash.
Judges and juries have spent weeks hearing cases that took years to prepare and unearthed evidence that NTSB investigations never discovered.
A Florida judge, finding that Cessna had known for "many years" of a potentially lethal defect in thousands of planes but hadn't fixed it, wrote in 2001 that the company could be guilty of "a reckless disregard for human life equivalent to manslaughter."
A USA TODAY review of tens of thousands of pages of internal company records, lawsuits and government documents found defects implicated in a series of fatal crashes of small planes and helicopters. The deadly defects include:
• Helicopter fuel tanks that easily rupture and ignite, causing scores of people to be burned alive after low-impact crashes that were otherwise survivable;
• Pilot seats that suddenly slide backward, making airplanes nose-dive when pilots lose grip of the controls.
• Ice-protection systems that fail to keep airplane wings clean during flight and fail to warn pilots of dangerous ice buildup that causes crashes.
• Helicopter blades that flap wildly in flight and separate from the mast or cut through the helicopter tail.
• Airplane exhaust systems that leak exhaust gas, causing engine fires.
• Carburetors such as the one in the Iowa crash that flood or starve engines and had been causing midair engine failures since at least 1963 when the federal government notified the manufacturer of "a serious problem" with its carburetor that had caused a recent fatal crash.
Manufacturers say crashes are caused by pilot errors, aircraft neglect or owners' failure to follow manufacturer bulletins urging part replacements.
After the Iowa crash, engine maker Lycoming and carburetor maker Precision Airmotive blamed the pilot in the face of a lawsuit by Caryn Stewart's father and uncle. In April 2013, after a judge rejected both companies' requests to throw out the case, the companies paid the two men a $19 million settlement, court records show.
Ruling against Lycoming and Precision, Philadelphia Judge Matthew Carrafiello found evidence both might be culpable. Precision received more than 100 warranty claims concerning carburetor defects, the judge said, and Lycoming continued to use the carburetors even though it "knew of ongoing problems" with the carburetors "and of numerous plane crashes resulting from such problems."
None of that information was included in the NTSB investigation, which was aided by Lycoming and Precision and blamed Andy Bryan, the pilot, for "failure to abort the takeoff" and "failure to maintain adequate airspeed during takeoff."
"It was just like a conviction when they said that," said Greg Bryan, Andy's father and the airplane owner. "That's your son's legacy — our family's legacy — that we did something to cause this terrible accident."
Death toll dwarfs commercial airlines
The danger of private airplanes and helicopters — known as "general aviation" — far exceeds that of airline flight. In 2013 alone, there were 1,199 general-aviation crashes — more than three per day on average — killing 347 people, injuring 571 and destroying 121 aircraft.
A domestic passenger airline hasn't crashed since Feb. 12, 2009, when 50 died on Colgan Air Flight 3407 near Buffalo.
While the airline crash rate has plummeted to near zero, the general-aviation rate is unchanged from 15 years ago — and roughly 40 times higher than for airlines.
"When you look at aviation, the place where people are getting killed is general aviation. Year after year, we are killing hundreds of people in general aviation," said former NTSB chairwoman Deborah Hersman, who left in April to become president of the National Safety Council.
The crashes have killed tens of thousands of amateur pilots in single-engine airplanes, police and medical workers in emergency helicopters, farmers in agricultural sprayers and business executives in corporate jets.
No other country experiences anything similar. The U.S. has more than twice as many general-aviation aircraft as every other nation combined and is home to leading manufacturers and a powerful lobby, which persuaded Congress in 1994 to bar injury and death claims involving aircraft and parts that are more than 18 years old. That is significant protection: Roughly three-quarters of the nation's 220,000 general-aviation aircraft are more than 18 years old.
The law was enacted after multimillion-dollar settlements and verdicts — including a $29 million verdict against Cessna for a crash that killed three and $22 million against Mitsubishi for a crash that killed five — that escalated insurance costs and forced some manufacturers into bankruptcy.
Judges have dismissed many lawsuits under the 1994 law. But major verdicts continue because the law allows claims concerning newer parts and against manufacturers that allegedly covered up defects.
USA TODAY found 80 lawsuits involving 215 general-aviation deaths since 1994 that resulted in a manufacturer paying a settlement or damages of at least $1 million. The verdicts include $70 million against General Electric for a helicopter crash that killed seven firefighters and two crewmembers; $48 million against parts maker Doncasters for a crash that killed five skydivers and a pilot; and $26 million against Lycoming for a crash that killed three, including a 10-year-old girl and her mother.
As damages have mounted, manufacturers have stonewalled plaintiffs' attorneys and federal officials in recent major cases. Judges have sanctioned and scolded companies for withholding information in at least a dozen lawsuits, USA TODAY found.
The $26 million verdict against Lycoming came in a carburetor-defect lawsuit after a judge found that the company repeatedly refused to turn over documents to plaintiffs. In February 2013, Washington state Judge Monica Benton found that Lycoming "has been in continuing contempt of court" since 2011 and decided to hold it liable for the 2008 crash. A jury later awarded the survivors $26 million, which includes $6 million in punitive damages. The award is being appealed.
In a lawsuit blaming a crash on a failure of a computerized cockpit display, federal magistrate Judge Janice Stewart of Oregon rebuked display manufacturer Avidyne Corp. in a 2010 hearing for its "failure to produce" documents, calling it, "at best, grossly negligent."
The government was stonewalled, too. Two years earlier, when the NTSB investigated failures of the cockpit displays, Avidyne refused to give the board information about displays that had malfunctioned. Avidyne called the request "overly broad, not relevant and onerous," according to NTSB records.
Sikorsky Aircraft withheld from the NTSB and plaintiffs an analysis it did in 2009 after seven oil workers and a pilot were killed when one of its helicopters crashed en route to a Gulf of Mexico oil rig. Sikorsky did not release the analysis, which showed problems with its helicopter model that crashed, until nearly 1½ years after it was written — three months after the NTSB cleared the company.
Federal magistrate Judge Karen Wells Roby wrote that "the only plausible reason" for Sikorsky's delay is because the analysis was "adverse to Sikorsky's interests." Roby ordered Sikorsky to pay $577,000 in legal penalties.
If it's cheaper to let you die than to fix it, you're going to die
One of the most gruesome and long-standing problems has caused scores of people to be burned alive or asphyxiated in fires that erupt after helicopter crashes. Such deaths are notorious because they can occur after minor crashes, hard landings and rollovers that themselves don't kill or even injure helicopter occupants. The impact can rupture helicopter fuel tanks, sending fuel gushing out, where it ignites into a lethal inferno.
Using autopsy reports and crash records, USA TODAY identified 79 people killed and 28 injured since 1992 by helicopter fires following low-impact crashes. In 36 non-fatal crashes, fire destroyed or substantially damaged helicopters after minor incidents such as rollovers, crash reports show.
Although crash-resistant fuel tanks have been available since the early 1970s, when the Army installed them and dramatically reduced soldiers' deaths, many manufacturers have not bothered, one safety expert said, because of the added cost, which the FAA has estimated at several thousand dollars per tank.
"If it's cheaper to let you die than to fix it, you're going to die," said Harry Robertson, who invented the crash-resistant "Robbie tanks" for the Army and is in the National Aviation Hall of Fame.
Robinson Helicopter Co. of Torrance, Calif., came up with a solution in 2006 that cost the company nothing. It issued Safety Notice SN-40, advising pilots and passengers to wear fire-retardant Nomex fiber suits to protect themselves in a fire.
Company President Kurt Robinson said in an interview that the notice was issued because of a crash three months earlier in Fredericksburg, Texas. A Robinson R-44 clipped a power line, fell to the ground and erupted in flames. Alec Beck died of burns and smoke inhalation, with "no evidence of blunt force trauma," and Gayla Leonard died of smoke inhalation and did not break a bone, according to their autopsy reports. Pilot Craig Nemec lived for 14 months with burns over half his body, had both arms amputated, lost his vision and underwent roughly 20 surgeries, his wife, Ellen Nemec said. In June 2007, he died.
Robinson's Nomex-suit advisory appears to have had little effect. There were 320 Robinson helicopter crashes in the U.S. after it was issued; not a single occupant was wearing a Nomex suit, NTSB reports show. "It was ignored by a large group of people," Robinson said.
Nemec called the advisory "absurd" and began pushing Robinson to make safer fuel tanks.
Safety experts and officials have recently warned about the fuel tank in the R-44, one of the world's best-selling helicopters. Its two aluminum fuel tanks are packed on either side of a 3-inch-thick steel mast that controls the rotor, said Bill Waldock, a crash expert at Embry-Riddle Aeronautical University in Arizona, who has been an expert witness in lawsuits against Robinson. If the helicopter rolls onto its side, the mast can rupture a tank, sending jets of fuel spurting forward into the cockpit to be ignited by a spark, he said.
"I've looked at about 14 of these, and you see essentially the same pattern in each one," Waldock said.
Problems became apparent less than a year after the R-44 went on the market when a 1993 crash killed three people near Los Angeles. Pilot Benjamin Venti Jr. and passenger Nicholas Lovoy both died from "inhalation of products of combustion and thermal burns," the Los Angeles County Coroner found. A total of 14 people have been killed and seven injured in the U.S. from post-crash fires of the R-44 and the Robinson R-22, an earlier model, crash records and autopsy reports show.
But it wasn't until roughly 2006 that Robinson began developing fuel-tank bladders to be installed in its R-44s and R-22s. The company started selling the bladders in late 2009, for $6,800, and installing them on its new helicopters. Kurt Robinson said the bladders "significantly enhance safety" and defended the helicopters' safety record, noting that they complied with FAA regulations. Robinson became company president in 2010 and said he can't speak to crashes before then.
In March 2013, the Australian Civil Aviation Authority ordered all R-44 owners to install fuel bladders within a month or be barred from flight. Three "low-energy" R-44 crashes in Australia since 2011 had caused fires and killed eight people, the authority said.
The NTSB in January asked the FAA to issue a similar order, citing lethal R-44 fires in the U.S. The FAA said in reply that the R-44 "does not appear significantly different" from similar helicopters in terms of fire risk and is studying the matter.
Nemec's husband, Craig, died in 2007 following a helicopter crash the previous year. USA TODAY
After her husband's death, Ellen Nemec learned about earlier R-44 crashes that sparked deadly fires and grew angry. "Had it not been for this really insufficient fuel tank that Robinson knew about," she said, "this would have been just a bad landing."
Still a "safety issue" after decades of scrutiny
Some problems have persisted for decades as manufacturers have minimized dangers and struggled to develop solutions.
As early as the 1960s, pilots and NTSB investigators were reporting that Cessna pilot seats were sliding backward on the rails designed to grip them. Airplanes crashed when pins that held seats in rail holes popped out, letting seats slide so far back that pilots could not reach the controls.
"Pilot's seat slid to full rear position on bounced landing," the NTSB wrote of a Cessna 172 hard landing on Aug. 18, 1966, in New Jersey.
Similar NTSB reports followed: "Pilot's seat slid back. Unable to reach controls" (April 11, 1969, Alaska). "Pilot's seat unlatched and moved rearward during takeoff roll" (Aug. 30, 1969, Milwaukee). "Pilot seat not locked before takeoff, seat slid back" (Aug. 8, 1971, Pennsylvania).
After urging owners of its military models in 1975 to replace worn parts, Cessna waited until 1983 to notify civilian owners — 17 years after the NTSB first noted a problem.
Cessna's civilian notice was a low-priority "service information letter," which said nothing about the danger of a seat sliding backwards. Its title: "Seat rail inspection guidelines."
But when the FAA proposed in 1987 issuing a mandate for Cessna owners to inspect seat rails and replace worn parts, the company grew worried.
Mandatory seat-rail inspection "would result in a significant number of seat rails that required replacement," Cessna said in an Aug. 7, 1987, letter to the FAA.
The problem, Cessna added, is that "with present production capabilities, we would be unable to supply massive quantities of rails." That could ground thousands of airplanes if their seat rails were found to be worn and replacements weren't available.
The FAA tried to accommodate, according to a Sept. 4, 1987, agency memo, and encouraged Cessna to develop "an inexpensive interim modification for defective seat rails that would prevent aircraft groundings."
Cessna developed and began selling the inexpensive modification, but it was difficult to install and involved "awkward operation," Cessna noted in an internal memo. Cessna owners, who could choose whether or not to buy the modification, were so reluctant that the company estimated replacing every seat rail would take 600 years.
On Aug. 14, 1989, James Cassoutt, his wife, Cindy Cassoutt, and a friend, Judy Kealey, suffered extensive fractures, burns and organ injuries when Cassoutt crashed his Cessna A-185E, which did not have the new part. After a Florida judge found that Cessna's responses to the seat problems "were neither timely nor adequate," a Florida jury awarded the three $480 million, including $400 million in punitive damages. The 2001 case settled for $41 million, court records show.
Cessna insisted that the crashes were caused by pilots who didn't maintain the seats or assure they were secured before takeoff. The company said in a statement to USA TODAY that its aircraft are safe "when they are used and maintained as required by published guidance."
Cessna developed a safety device in 2007 to stop a pilot's seat from sliding if the rail pins came loose, but since then there have been at least five Cessna crashes involving seat sliding, federal records show.
The crashes killed one, injured three and substantially damaged all five airplanes. It's unclear how many pilots installed the devices because the FAA never mandated their installation, despite a plea by Cessna.
In 2011, the FAA required Cessna owners to conduct more thorough seat inspections than it ordered in 1987 because "inadvertent seat movement continues to be a safety issue."
But a federal judge warned that inspections and warnings do not compensate for a defective design.
"Even if the pilot takes all of the precautions urged by Cessna," Judge David Herndon of Illinois wrote in 2005, "the pilot may be left with a false sense of security because he or she believes the seat is properly locked, when it is not."
Tiny part was "primary cause of engine failure"
Other manufacturers have moved quickly to replace defective parts but with recalls that are limited and leave potentially defective parts in many aircraft.
Lycoming Engines faced a choice when it discovered in 1998 that two helicopters lost engine power in flight because a bolt fractured in each of their Lycoming engines.
No one was hurt. But Lycoming had to decide what to do about thousands of similar bolts in its stockroom and inside various helicopter and airplane models.
The company recalled about 160 bolts from helicopters and removed 4,250 bolts from its stockroom "as a purely precautionary measure," according to a statement Lycoming gave the NTSB.
Lycoming issued no recall or warning for the roughly 1,100 similar bolts still in airplanes. Bolt fractures were "limited to helicopter applications," the company believed. The FAA agreed.
By early 2001, bolt fractures had caused engine failure in three Lycoming-powered planes, including two Royal Jordanian Falcons, a rare model of aerobatic aircraft, and the popular Piper Saratoga II. There were no injuries.
Facing another decision, Lycoming again took limited action. It replaced bolts in all Falcons, which was easy and cheap because there were only five of the airplanes. The hundreds of Piper Saratoga II owners got no recall or warning.
Bolt fractures "were not thought to extend beyond helicopter and aerobatic applications," Lycoming told the NTSB. The FAA agreed again.
On June 7, 2002, Mississippi dentist Mark Williams was flying his Lycoming-powered Piper Saratoga II near home when the engine suddenly stopped. Williams crashed and suffered severe fractures and internal bleeding, for which Lycoming later paid him $2.85 million, according to court papers. A Lycoming metallurgist wrote that the "primary cause of engine failure" was a fractured engine bolt.
Lycoming took no immediate action. The company declined to comment on the bolt fractures.
On Sept. 8, 2002, a Piper Saratoga II flying out of New Jersey lost engine power and crashed. Two boys, ages 8 and 5, were severely burned but survived. Their parents, Michael and Sandy Kirkley, were killed. The FAA quickly pinpointed the cause as bolt fracture, prompting Lycoming to recall bolts on roughly 1,000 engines in dozens of types of airplanes, including the Piper Saratoga II.
Williams received the recall notice around his 40th birthday and remembers thinking, "I would have loved to be one of the people in the recall opposed to the one who is the reason why there is a recall."
The Kirkley boys sued Lycoming, saying the company had known about the bolt problems since 1998 "but failed to take any precautionary action." The lawsuit settled for undisclosed terms.
Awards $6.7 million to the widow of a crash victim
The defects blamed for the crash that killed Caryn Stewart's mother and sister also generated allegations that a manufacturer tried to avoid a costly recall. The problems involve a small component called a "float," which controls the fuel level in a carburetor the same way a toilet-bowl float controls water in a bowl cabinet. The floats were causing engines to fail by saturating the carburetor with fuel, although one manufacturer was caught lying.
In the 1970s, carburetor maker Borg-Warner found that the floats' composition was causing the problems, company memos show. Faced with a potentially costly recall of a defective part, Borg-Warner told the FAA something different: Pilots caused the problems by using automotive gas instead of aviation fuel.
"This statement to the FAA is in fact false," an Alaska judge wrote in 1990, awarding $6.7 million to the widow of a man killed in a 1986 crash in Alaska. Borg-Warner likely would have paid for a $23 million recall "if a manufacturing defect was acknowledged," Superior Court Judge Jay Hodges wrote. The company's "failure to disclose" the actual cause "is outrageous conduct."
Hodges' verdict included $5 million in punitive damages — but it didn't stop the problems.
After Precision Airmotive bought the carburetor line in the 1990s, it began making plastic floats to replace metal floats that "malfunction when a leak develops," according to a patent for the plastic float. Yet Precision said nothing about malfunctions when it announced in 1998 that plastic floats were available, saying only that they would "improve service life and resistance to damage."
In 2010, a jury awarded $89 million, including $64 million in punitive damages, to survivors of a 1999 crash of a Piper Cherokee equipped with a metal float. Four people were killed and a teenage boy was seriously injured. The case settled for $20 million, according to court records.
The judge in the case involving Caryn Stewart also was critical, noting that Precision "did not mention that the new float resolved problems" and "did not notify the FAA that it had identified and resolved a defect."
The crash itself was horrifying. Caryn Stewart recalled her cousin yelling at everyone to get out, and her sister Sarah screaming a "blood-curdling scream." Caryn suffered burns over 75% of her body.
Brian Stewart lives a mile from the airport where the plane crashed and still struggles with his loss. "Some days it's hard, some days you just go by it," Stewart said. "It's never out of your mind."
Not pilot error
Two weeks after crashing his Piper Saratoga plane, Mark Williams left the hospital in a wheelchair and met with federal crash investigators for an interview that felt like an interrogation.
"They kept on berating me, 'How much fuel was in (the plane)? What was your fuel burn that day?' Their questions seemed so accusatory," recalled Williams, an amateur pilot and a dentist from Meridian, Miss.
Williams tried to describe how his six-seater had lost power 1,100 feet in the air. But the investigators had their own ideas. Because there was no fire after the crash, they suspected Williams had burned up his fuel and pressured him to take the blame.
Williams, who suffered a broken pelvis, broken shoulder and a severed ear, insisted there was no fire because the fuel drained out when a tree limb sheared off a wing.
A short time later, Williams' statement was confirmed by a third federal investigator, who found that a failed engine component — not pilot error — caused the June 7, 2002, crash, Williams said. Federal investigators would blame the same component for a New Jersey crash three months later that killed a Canadian couple and critically injured their two sons, ages 8 and 5.
Williams wonders to this day what investigators would have concluded had he not been alive to speak to them.
"Had I not survived, this accident would have been wrapped up as pilot error, fuel exhaustion, and nobody ever would know the difference," Williams said.
Federal accident investigators repeatedly overlooked defects and other dangers of private aviation as they blamed individual pilots for the overwhelming number of crashes of small airplanes and helicopters, a USA TODAY investigation has found. The failure of crash investigators to find defective parts, dangerous aircraft designs, inadequate safety features and weak government oversight helped allow hidden hazards to persist for decades, killing or injuring thousands of pilots and passengers, the investigation found.
The National Transportation Safety Board, which investigates accidents and urges safety improvements, has an international reputation for exhaustive investigations of commercial jet crashes. But its probes of "general aviation," which covers private planes and helicopters, are much more brief, often done by telephone and frequently reliant on manufacturers to find problems with their own aircraft parts.
Williams suffered a broken pelvis, broken shoulder and a severed ear from a June 2002 plane crash. USA TODAY
NTSB investigators visited a crash scene or did "a significant amount of investigative work" in only 15% of the 64,000 general-aviation crashes from 1982 through 2013, according to a USA TODAY analysis.
They did significant investigations of 32% of airline accidents, which often involve damage on a tarmac or injuries caused by turbulence. In the Williams case, the NTSB had Federal Aviation Administration safety inspectors conduct the initial interview with Williams.
"The NTSB could do more" to investigate general-aviation crashes, former NTSB chairwoman Deborah Hersman said in a recent interview, "but I think it's a question of asking what does the public want and what are they willing to pay for." The NTSB has given top priority to commercial airline crashes, which it has helped to virtually eliminate. There hasn't been a major airline crash since early 2009.
But the shortcomings in general-aviation investigations have compounded a death toll of nearly 45,000 since 1964 — roughly nine times more than were killed in passenger airlines.
An in-depth review of federal records shows:
Nearly 1,200 people have been killed since 1985 in lightweight, home-built aircraft — an average of 40 a year — and their crash rate has been as much as four times the rate for other private aircraft. Yet the NTSB blamed 72% of the crashes on pilots and didn't discover until a 2012 special study — after 1,124 deaths — that many of the crashes resulted from engine failure, inadequate flight testing that did not uncover design problems and malfunctions, and flight manuals that failed to sufficiently explain the aircraft.
A series of civil lawsuits contradicted NTSB findings of pilot error and found manufacturers liable after juries or judges spent weeks reviewing records the NTSB didn't have. USA TODAY found 21 verdicts totaling nearly $1 billion against manufacturers that the NTSB exonerated. Several juries ordered companies to pay punitive damages after finding they failed to fix long-standing known defects in small planes or helicopters.
At least 214 air-ambulance helicopters have crashed since 1982, killing 272 patients, pilots and medical personnel and injuring 175. The NTSB blamed 72% of the crashes on pilots, but a 2006 board study found that many of the crashes were caused by flight dispatchers failing to tell pilots about dangerous weather and hazardous landing conditions, or could have been prevented by safety systems that warn when an aircraft is too close to terrain.
Crashes of skydiving airplanes have killed 306 people since 1964, including 10 crashes that killed 10 or more people. The NTSB blamed 62% of the crashes on pilots and didn't discover other problems until a 2008 study: Many skydiving airplanes were poorly maintained, pilots were ill-trained for the nuances of skydiving flights, and the FAA was failing to adequately oversee skydiving operators.
Isolated, minor incidents also showed the danger of shallow investigations. After a Cessna Skyhawk landed at Pilot Country Airport near Tampa in 1998 and plowed into a dirt mound at the end of the runway, the NTSB blamed the pilot and said nothing about the mound being so close to the runway.
A year and a half later, another pilot landed his Cessna at the same airport, collided with the same dirt mound, but his airplane flipped over leaving passenger George Gill a quadriplegic.
After Gill's lawyers presented evidence that the mound was closer to the runway than federal regulations allowed, airport operator Red Baron Aviation paid Gill $10 million, court records show. The company removed the mound.
"It's very easy to just plain blame the pilot and say 90% of crashes are caused by pilot error, so we don't really need to worry about other things," said Sue Baker, a public health professor at Johns Hopkins University who specializes in transportation injuries. "Pilot error is going to be part of almost any crash. But the reasons for pilot error may not be things under the pilot's control."
The NTSB says it has found pilots causing or contributing to 86% of general-aviation crashes. The board makes its determinations in one- or two-sentence probable-cause findings, which often cite a pilot's "failure" to do something.
John DeLisi, director of the NTSB's Office of Aviation Safety, said probable cause "is only the tip of the pyramid. To look at an investigation as a whole, there is so much more."
Ignoring "why" people die in crashes
NTSB investigations have missed other general-aviation dangers by focusing on the cause of the crash and disregarding the cause of death or injury and whether people could have survived with better aircraft safety features.
The NTSB seeks little information about the cause of injuries or deaths in general-aviation crashes. Its nine-page aviation accident form asks pilots or aircraft operators to simply check a box indicating each occupants' degree of injury. NTSB reports almost never say anything about a cause of injury or death.
By ignoring "crashworthiness" — how well an aircraft protects occupants in a crash — NTSB investigations have overlooked lethal components such as helicopter fuel tanks that repeatedly ruptured after minor crashes and ignited fires that burned people to death.
A USA TODAY analysis of dozens of autopsy reports and crash records since 1982 found 58 helicopter crashes in which an occupant was unhurt by the impact only to be killed or injured by a post-crash fire. The 80 deaths and 33 injuries might have been prevented if the helicopters had sturdier fuel tanks, which were developed in the 1960s and installed in Army helicopters starting in 1970. The NTSB noted the dangers of such fires in 1980.
But it has since paid little attention to the issue. In 57 of the 58 crashes, NTSB investigators never noted the cause of death or a fuel-tank problem. They instead blamed pilots, maintenance workers or helicopter components for causing the crash. In January, the NTSB noted a problem with Robinson helicopters catching fire after crashes.
The NTSB's disregard of injury causes has alarmed safety experts and angered crash survivors such as Dave Wallace. He was burned over 45% of his body on May 28, 2005, when his Robinson R-44 helicopter erupted in flames after rolling onto its side during a landing in Southern California.
Dave Wallace was burned badly following a May 28, 2005, helicopter crash. USA TODAY
Released after 10 weeks in the burn unit at Arrowhead Regional Medical Center in Corona, Calif., Wallace got a call from NTSB investigator Patrick Jones. "He didn't ask me one thing about the fire," Wallace said, recalling instead accusatory questions about whether his helicopter was carrying too much weight and if Wallace had properly maintained his pilot's log book.
"I felt like I was under interrogation for murder," Wallace said.
Jones' final report notes that the R-44 had "impacted into a dry stream bed" where "the helicopter burst into flames" and that the three occupants "sustained burns while exiting the burning helicopter." But the report blames only Wallace — for "failure to maintain adequate main rotor rpm and directional control."
NTSB spokesman Peter Knudson said the report focused on the pilot, not the fire, because fires "are not at all unusual" and Wallace's R-44 hit the ground with a force that it is not designed to withstand.
In January, the NTSB noted seven R-44 crashes since 2008 in the U.S. and Australia in which 10 people were killed by fire and urged the FAA to require R-44 owners to install components that would help prevent post-crash fires. The FAA said in reply that the R-44 "does not appear significantly different" from similar helicopters in catching fire and will continue to study the helicopter.
Manufacturers play key role
Over the past 10 years, safety experts have pushed the NTSB to more precisely determine the causes of general-aviation crashes — and the causes of death — so that defective designs or faulty parts can be fixed.
In 2011, the U.S. Joint Helicopter Safety Analysis Team, an industry/government group seeking to reduce helicopter crashes, urged the NTSB to improve the "quality and depth" of its helicopter-crash investigations.
"Many accidents are not receiving in-depth onsite investigation by NTSB investigators," a team report said. "Investigations are being performed by telephone interview or by personnel whose primary function is not accident investigation." The personnel are FAA inspectors, who often conduct on-scene investigations for the NTSB.
NTSB investigators who miss a crash scene rely on reports from FAA personnel and local police, on weather data, flight logs, phone interviews — and on inspections of an aircraft and its components done by the manufacturers, even if a manufacturer is being sued for the crash.
"Many times what happens now is that when the accident occurs, the technical rep of the (manufacturing) company will call the NTSB and say we'll be party (to the investigation), we'll go out there and let you know what we see … the only people on scene would be perhaps an FAA guy and the field rep of the manufacturer," said Douglas Herlihy, a former NTSB investigator who now reconstructs crashes, often for plaintiffs in lawsuits against manufacturers.
"If you (the NTSB) are not there, you've got the representative from the company at the scene. His job is to skew the facts, to ignore the product difficulties and to remove the question of liability," Herlihy said.
Delisi of the NTSB said the board's five presidential appointees have the final say in determining the cause of a crash. The FAA, with 3,000 inspectors, can often get to a crash scene more quickly than one of the NTSB's 48 regional investigators, DeLisi said. Manufacturers "work very effectively in providing technical assistance," and their analytical work is overseen by an NTSB investigator.
"We have a very active role in managing the parties," DeLisi said.
The reliance on manufacturers to inspect their parts for malfunctions and defects has long raised concerns about a conflict of interest.
A 2000 report by the RAND Corp. research group said manufacturers are "essential" to aviation investigations and give the NTSB the "technical capability" to determine crash causes. The NTSB has 90 aviation investigators who handle roughly 1,500 crashes a year.
But manufacturers may "threaten the integrity" of investigations, the report added. Some manufacturers' representatives to the NTSB feel beholden to "corporate managers who are equally, if not more, concerned about the potential liability and corporate image problems associated with a major plane crash."
RAND recommended that the NTSB reduce its reliance on manufacturers and make greater use of people with no financial stake, such as government experts, consultants and scholars. That has not happened.
"There are cases where the investigation is less than stellar," said John Goglia, an NTSB board member from 1995 to 2004. "There are some particular problems with general aviation: The NTSB doesn't do all the investigations. Some of them the FAA does for the NTSB."
One consequence of limited investigations has been a series of verdicts in civil lawsuits that contradict NTSB findings. They include:
• $48 million against British parts maker Doncasters, including $28 million in punitive damages, for a 2006 crash that killed six in a deHavilland airplane. A jury blamed defective turbine blades that caused one of two engines to fail. The NTSB could not determine why the turbine blades broke and blamed the pilot for "failure to maintain airspeed" after the engine failure. Doncasters paid the $48 million.
• $89 million against Lycoming Engines and Precision Airmotive, including $65 million in punitive damages, for a 1999 crash that killed four flying in a Piper Cherokee. A jury blamed a defective carburetor that caused engine failure. The NTSB, whose investigative file covers just 40 pages, found no evidence of any malfunction and blamed "the pilot's loss of control." The case settled for $21 million.
• $480 million against Cessna Aircraft Co., including $400 million in punitive damages, for a 1989 crash that injured three. A jury concluded the crash was caused by a defective pilot's seat that slid backward unexpectedly, causing pilot James Cassoutt to lose control of the plane. Cassoutt had told the NTSB the seat slid back, but the NTSB concluded he "inadvertently stalled the aircraft." The case settled for $41 million.
• $26.1 million against Textron Lycoming, including $6 million in punitive damages, for a 2008 crash that killed three and which a judge found was caused by a defective carburetor that caused engine failure. The NTSB assigned Precision Airmotive to analyze the airplane's carburetor, which Precision manufactured. The company found that the carburetor was "completely filled with fuel" — a condition linked to engine failures in the past — but its three-page report to the NTSB says nothing about the history of the problem.
"Why would you not disclose that when the NTSB is relying on you and you know the (NTSB) field-office guy doesn't have a specialized knowledge of carburetors?" said Portland attorney Matthew Clarke, who filed the lawsuit.
The NTSB blamed the pilot's "improper decision" to fly into low-visibility conditions.
Pilots also were blamed — and later exonerated — in numerous cases involving air-traffic controllers.
Since 1997, the U.S. government has paid $60 million to settle 41 claims over crashes that the NTSB blamed on pilots but which claimants said were caused by air-traffic controllers, federal records show.
Former Marine Gavin Heyworth was blamed by the NTSB for a 2003 midair helicopter collision that killed two others because of his "failure to comply" with air-traffic-controller instructions. But after a week-long bench trial, a federal judge ruled that FAA controllers failed to keep the two helicopters apart and had acted "negligently and carelessly." The Justice Department settled claims against the FAA over the crash for $10.1 million.
The NTSB finding "was one of the worst things that ever happened to him," said Heyworth's attorney James Pocrass. "He felt responsible for the death of those two people. The vindication he had from the judge was bigger than winning the case."
The NTSB has become increasingly concerned about general aviation as crash and death rates have remained stagnant for 15 years while commercial crashes have practically ceased. In 2012, the NTSB elevated general-aviation safety to its annual list of "most wanted" improvements in transportation safety.
"That was a breakthrough," the NTSB's DeLisi said.
The NTSB, with a staff of 400, has focused since its creation in 1967 on hazards to the greatest number of people in aviation, rail transit, pipelines, waterways and roadways. The NTSB helps investigate 19 foreign airline crashes a year on average, including the recent disappearance of Malaysia Airlines Flight 370. Foreign investigations are "a particular challenge" because of the board's domestic obligations, the NTSB wrote in a recent annual report.
Former NTSB Chairwoman Deborah Hersman says that most people are dying in general aviation crashes annually. USA TODAY
In 2012, the NTSB said that in many general-aviation crashes "pilots did not have the adequate knowledge, skills or recurrent training to fly safely." At the opening of the 2012 forum, Hersman, then the NTSB chairwoman, said, "GA pilots are not learning from the deadly mistakes of their brethren."
The emphasis on pilots and pilot problems has steered the NTSB away from mechanical problems or ways to increase the chances of surviving a crash, some experts say.
"There is essentially no requirement that specific injury data be collected. They don't even collect impact data, like angle (of the crash) or velocity," said retired Army colonel Dennis Shanahan, former commander of the U.S. Army Aeromedical Research Laboratory who has consulted for the NTSB.
"This has severely impeded researchers' ability to find out what's going on from an injury basis," Shanahan added. "If you're interested in a particular aircraft and you want to know what the injuries are, it can't be done."
Harry Robertson, an aviation-safety pioneer who developed stronger helicopter fuel tanks in the 1960s and is in the National Aviation Hall of Fame, said general-aviation deaths cannot be substantially reduced until the NTSB understands their cause.
"The most important thing they can do first is improve the quality of their investigations as to what it was that caused the injury and the death," Robertson said.
And once causes are known, "engineers can step in and figure out the ways to assure an improvement in crashworthy capabilities. … Trying to improve crashworthiness is very hard if you don't know what broke."
The NTSB and its predecessor agencies have recognized for decades that general-aviation crashes are often mild enough for occupants to survive.
In 1980, the NTSB said, "General-aviation aircraft are unnecessarily lethal in crash situations which should be survivable."
To reduce automotive deaths, the National Highway Traffic Safety Administration gathers data on what kills or injures people in crashes. The findings have led NHTSA to mandate a wide range of safety equipment that has reduced the number of deaths in motor vehicles to 21,667 in 2012 from 35,025 in 1988, even as the amount of driving increased 50%.
A 2002 report written for the Department of Transportation by Sue Baker, the Johns Hopkins expert, urged the NTSB to follow NHTSA's approach and collect detailed information on a random sample of general-aviation crashes. That hasn't been done.
Shanahan said the NTSB was interested when he was consulting there in 1989, but money was not available.
The NTSB has instead conducted in-depth studies on specific general-aviation aircraft and flying conditions that are causing extensive crashes, such as home-built airplanes and medical helicopters. The studies have found causes and patterns that were not found during individual crash investigations and have led to safety recommendations and improvements.
But the NTSB safety recommendations come years or decades after a problem arises.
In May, an NTSB report noted "undue hazards and risks" of agricultural flights such as pilot fatigue and poor aircraft maintenance and urged safety improvements.
The report did not note that since 1982, 4,200 agricultural airplanes and helicopters had crashed, killing 394 people and injuring 1,224.
In two-thirds of the crashes, the NTSB blamed the pilot.
Death by bird strike
The Sikorsky helicopter that lifted off from the Louisiana coast on Jan. 4, 2009, should have been a model of safety for the two pilots and seven oil-rig workers on board. The $7 million aircraft was less than three years old and approved for flight by the world's premier aviation-safety agency, the Federal Aviation Administration.
But seven minutes after takeoff, the windshields shattered when the helicopter hit a red-tailed hawk. Equipment shifted in the cockpit, cutting engine power and plunging the 6-ton aircraft 850 feet into a marsh. Eight people were killed.
The helicopter seemed modern, but its windshields were made of acrylic and didn't have to meet strength standards the FAA established in 1996 to prevent catastrophe in a bird strike. The FAA allowed the acrylic windshields because the helicopter had only to meet federal safety standards from when it was designed — in 1978.
"It's absolutely crazy," said retired colonel Dennis Shanahan, an air-safety expert and former commander of the U.S. Army Aeromedical Research Laboratory. "This is essentially an abrogation of (the FAA's) responsibilities as a safety agency."
The FAA exempts tens of thousands of private airplanes and helicopters from its current safety standards, letting them operate without lifesaving protections such as passenger shoulder belts, anti-collision lights, crash-resistant fuel tanks, fire-resistant cargo compartments and bird-resistant windshields, a USA TODAY analysis shows.
The exemptions occur under a policy known as "grandfathering," which allows manufacturers to build brand-new aircraft under the safety standards that were in place when the aircraft was designed — often decades earlier. The most widely owned airplanes today — the Piper Cherokee and Cessna Skyhawk — need only meet federal safety standards from the 1960s and 1970s.
The FAA policy saves manufacturers money but also creates dangers, some safety experts say.
"Grandfathering means that you can keep making the same mistake over and over again and killing people the same way, even though you know better," said Sue Baker, a public health professor at Johns Hopkins University who specializes in transportation injuries. "If it were applied to cars, it would mean you could buy a Volkswagen Beetle made today without seat belts, and that's nonsense."
The FAA said in a statement that it has "not seen a negative safety effect" from grandfathering and that many aircraft have been upgraded with safety features that didn't exist when the aircraft was made. Agency officials declined repeated requests for an interview.
Safety deficiencies in private aircraft have contributed to thousands of deaths and injuries over the past five decades, according to a USA TODAY analysis and reports by the FAA itself. Crashes of private flights — a sector known as "general aviation" — have killed nearly 45,000 people since 1964, almost nine times the number killed in airliners.
USA TODAY's analysis shows:
The FAA vowed to substantially reduce the number of helicopter deaths through a 1994 standard requiring sturdy fuel tanks that would not rupture in low-impact crashes and rollovers. Ruptured tanks leak fuel, igniting infernos that kill people who survived a crash itself. The FAA in 1990 said the fires kill or injure roughly 27 people a year and called them "the number one rotorcraft crash hazard."
But the FAA required sturdy tanks only in helicopters designed after Nov. 2, 1994, letting manufacturers continue making thousands of new helicopters with rupture-prone tanks.
The FAA said in a statement that "the amended standards were appropriate only for new (helicopter) designs" and declined to elaborate.
Post-crash helicopter fires have killed at least 73 people and injured at least 25 since Nov. 2, 1994, according to a USA TODAY review of autopsy reports and crash records. Although crash reports do not describe helicopter fuel components, none of the 46 helicopters in the crashes was required to have the sturdier tanks, USA TODAY found. USA TODAY also found that fewer than a quarter of the roughly 4,850 active helicopters manufactured after 1994 are required to have sturdy tanks.
General aviation experts discuss the complexity of crash investigations and the resources required to find out what really happened. USA TODAY
As a 2002 FAA report concluded, "The post-crash fire problem still exists."
The FAA sought to reduce the number of midair collisions by requiring anti-collision lights on all general-aviation airplanes instead of just on those approved for night flying. The lights make airplanes more visible in daylight.
But the regulation applied only to airplanes designed after the March 11, 1996, effective date.
Manufacturers could continue to produce previously designed airplanes without those lights.
Since March 1996, 184 daytime midair collisions have killed 241 people, according to a USA TODAY review of federal records. In 130 of the crashes, investigators found the pilots didn't see each other.
The FAA rejected a 1992 suggestion by the National Transportation Safety Board to require crash-warning systems on all small general-aviation jets, saying the airplanes were safe without them. The systems help prevent a leading cause of general-aviation deaths — crashes by disoriented pilots — with alerts that sound if an airplane gets dangerously close to a mountain or other terrain.
When a 1994 Learjet crash killed 12, the FAA decided to study the suggestion it had spurned. The study of 44 crashes found warning systems could have prevented between 33 and 42 of them and saved 70 to 127 lives.
Swayed by the study and by improvements in the warning systems, the FAA ordered them installed in the 2000s on jets with six or more passenger seats. But it also created a loophole sought by manufacturers and small-plane operators: Airplane owners could ignore the requirement if they reduced passenger seating to fewer than six, which can be done by removing a single seat belt.
On Thanksgiving eve in 2011, Russel Hardy had no warning of the sheer cliff ahead of him as he flew a Rockwell Aero Commander in the darkness toward Arizona's Superstition Mountains. The airplane owner had removed one seat belt to avoid installing a warning system, investigators found, although the NTSB said the change had not been properly approved.
Six people were killed when the Aero Commander slammed into the mountain at 200 mph. The dead included Shawn Perry and his three children: Morgan, Logan and Luke, ages 9, 8 and 6.
A warning system "would have completely avoided the accident," said Karen Perry, the children's mother. "It's a requirement for a reason. But I can see why they might want to skirt around that regulation in an effort to not spend the money."
Figuring the value of a human life
The FAA's resistance to some safety features has compounded a major problem with the nation's roughly 220,000 general-aviation aircraft: Many are decades old.
The average single-engine airplane registered with the FAA was built 41 years ago, long before many safety features were invented. Roughly 50,000 of the aircraft were built more than a half-century ago, federal records show.
The average automobile in the U.S. is 11.4 years old, according to automotive research firm R.L. Polk.
"If you were to own a car built 40 years ago, you wouldn't want to drive it every day. It wouldn't have anti-lock brakes, air bags or energy-absorbing crumple zones," said Greg Bowles of the General Aviation Manufacturers Association. "That's the world of (general-aviation) airplanes as well."
Amateur pilots keep propeller-driven airplanes for decades because buying a new one is costly, and manufacturers have scaled back production of propeller airplanes, shifting to jets and turboprops.
An FAA advisory committee said last year that a majority of today's propeller airplanes were approved under safety standards from the 1960s and could not meet current standards "without significant additional costs."
With pilots flying old aircraft and not adding new protective features, "the safety level of general aviation does not improve," the 346-page report concluded.
Many amateur-flown aircraft lack rudimentary safety features such as shoulder belts, which the FAA and its predecessor delayed requiring in the 1960s, 1970s and 1980s, despite repeated studies showing they would prevent hundreds of deaths a year by keeping people from slamming into hard interior surfaces in a crash.
The NTSB found in 2008 that at least 13% of single-engine airplanes that crashed that year did not have shoulder belts. The finding suggests there were nearly 20,000 single-engine airplanes in the U.S. without the restraints.
The NTSB also found after studying 37,000 single-engine airplane crashes over the previous 25 years that people wearing shoulder belts and lap belts were nearly 50% less likely to be killed or seriously injured than people wearing only lap belts.
But when the NTSB urged the FAA to require airplane owners to install shoulder belts, the FAA said no. The "economic burden" would "outweigh any potential benefit," the FAA concluded.
The FAA often cites cost-benefit reasons for rejecting safety proposals — with the "cost" measured in dollars and the "benefit" measured in lives saved and property damage avoided. The Department of Transportation sets a $9.2 million value on each human life.
The FAA, like other federal agencies, must show that the likely benefit of a new safety feature would outweigh its cost. The FAA projects lives that will be saved based on deaths in the past — a position that safety advocates say begs for a major tragedy before aviation can be made safer.
"We actually are waiting for more people to be killed before we can do something that makes sense," said former NTSB chairwoman Deborah Hersman, who became president of the National Safety Council in May. "We don't kill enough people in aviation to merit regulatory changes." Hersman called this "the tyranny of small numbers."
One of the worst general-aviation crashes occurred on Aug. 5, 2008, in a Northern California forest when a firefighting helicopter crashed 18 minutes after takeoff. Seven firefighters and two crewmembers were killed by the impact and by a fire that ignited when the fuel tanks ruptured after the crash. The Sikorsky S-61, designed in 1959, was exempt from the 1994 fuel-tank standard.
When the NTSB urged the FAA to require the installation of sturdy fuel tanks on all S-61s, FAA's then-administrator Randolph Babbitt declined. "We lack adequate safety data to conclude there is an unsafe condition," Babbitt said.
In several instances, the FAA has put off safety proposals only to reverse itself years later.
• The FAA rejected requests starting in 1991 from Mitsubishi Heavy Industries America to require special licensing for people flying the company's MU-2 airplane. The MU-2 had crashed 136 times by 1991, killing 163. Australia, Canada and Germany all required special licensing for MU-2 pilots.
As the MU-2 death toll in the U.S. rose to 241 by 2005 and congressional pressure built, the FAA conducted a study that found pilots should get annual training for the MU-2. The training, which became mandatory in 2009, could have prevented 15 crashes between 1996 and 2005 that killed 21 people, the FAA said.
• The FAA hesitated when the NTSB in 2002 recommended more pilot training and safety equipment for helicopters flying over snow-covered terrain that makes distances and altitude difficult to discern.
A recent FAA study found that the training and equipment might have prevented 49 crashes between 1991 and 2010 that killed 63 people. The FAA mandated both items this year — 12 years after the NTSB proposal.
• After the 2009 helicopter crash near Louisiana that killed eight, the FAA rejected an NTSB proposal aimed at preventing similar crashes. The NTSB wanted the FAA to bar helicopter owners from replacing bird-resistant windshields with windshields that did not meet its bird standard.
The FAA said adopting such a policy would require revising a regulation, "which is not practical."
Court records show that helicopter operator PHI saved $15,750 on the $7 million Sikorsky because it had acrylic windshields instead of standard bird-resistant glass windshields. PHI had been using the weaker windshields on its Sikorskys since the 1980s, when the helicopter's glass windshields began causing problems, according to the NTSB.
The FAA still lets Sikorsky and others make new helicopters without bird-resistant windshields — provided the helicopters were designed before the bird standard took effect in 1996.
A "new" helicopter, designed in 1956
With grandfathering, the FAA differs sharply from its motor-vehicle counterpart, the National Highway Traffic Safety Administration, which requires new vehicles to meet the safety standards in place when cars and trucks roll off the assembly line.
Federally mandated protections such as air bags and anti-lock brakes are now widely used and have dramatically improved survival rates in automobile crashes. Occupants are 25% more likely to survive a crash now than in 1988, federal figures show. "Vehicles are much better at protecting people when crashes happen than they were 25 years ago," said Russ Rader of the Insurance Institute for Highway Safety.
The survival rate in general-aviation crashes has barely changed in that time, according to a USA TODAY analysis of federal records.
"We've stagnated," said Shanahan, the former Army research commander. General-aviation aircraft were safer than automobiles in the 1950s, Shanahan said, but "there's been a total reversal because so many aircraft are operating off of certificates that predate a lot of the safety regulations."
The FAA has acknowledged problems with grandfathering and with general-aviation safety.
The agency in 2011 called general aviation "one of the FAA's last unresolved safety challenges." It's looking at making it easier for manufacturers to develop new piston-engine airplanes and safety equipment.
An FAA goal to reduce the general-aviation fatal accident rate by 10% between 2009 and 2018 is failing thus far. The rate in 2012 — the most recent year for which figures are available — was higher than it was in 2009.
Some safety problems result from the FAA's system for regulating aircraft manufacturing. The FAA gets involved with manufacturers when they are designing a new aircraft and works with them for three to six years to ensure a design meets safety standards in place at the time.
FAA design approval lets manufacturers produce that aircraft for as long as they want — even for decades — under the safety standards in effect during the design review. Manufacturers can change an aircraft model — producing it with different engines, propellers or fuel tanks to increase speed, safety and range — without the FAA declaring the revised aircraft a "new" design.
Some aircraft have been revised a dozen times over a half-century without being considered a new design requiring FAA approval — or new safety features.
"Manufacturers get around the requirement by saying, 'This is not really a new helicopter, it's the same as it was in 1956,' and they end up with a B or C or D model," said Harry Robertson, an aviation-safety expert who has consulted for the FAA. "The FAA has been, in my judgment, very weak in resisting that claim."
The Sikorsky helicopter that crashed in Louisiana was a model that the FAA approved in 2005. But by presenting it to the FAA as an update to a helicopter designed in the late 1970s — not a new helicopter — Sikorsky avoided having to meet safety standards adopted since then, such as the windshield-strength regulation.
Sikorsky considered building the new-model helicopters to the latest safety standards, Sikorsky manager Eric Hansen said in a 2011 deposition. But, he said, "we determined that it would be cost-prohibitive to certify the aircraft to the latest amendment."
This grandfathering policy spares manufacturers from having to redesign their aircraft to meet every new FAA safety standard. For general-aviation manufacturers, which produce at most several hundred aircraft a year, redesign represents a much more substantial cost than for auto companies making millions of cars a year, said Rob Hackman, head of regulatory affairs for the Aircraft Owners and Pilots Association.
The FAA in 2000 acknowledged a problem, noting that while a single revision may be minor, a series of revisions could create an aircraft "with considerable differences from the original product." Many substantially revised aircraft "have not been required to demonstrate compliance with all the recent airworthiness standards," the FAA said. Since 2000, the FAA has been requiring components that manufacturers add to an aircraft model, such as modern navigation or communications systems, to meet current safety standards, but the requirement applies only to an individual part.
The FAA monitors aircraft for problems through the NTSB, its own investigations and safety reports from owners. The FAA can force aircraft improvements by ordering repairs or upgrades on specific models or by requiring active aircraft to meet a safety condition to be able to continue flying. But its monitoring system has limits.
Unlike commercial air carriers, which must report in-flight malfunctions and defects of major components, general-aviation operators have no reporting requirement.
And unlike automobile makers, which must tell the Department of Transportation about lawsuits and other defect allegations, aircraft manufacturers have no such reporting requirement.
The FAA took years to resolve problems with the Cessna Caravan, a rugged airplane designed in 1984 and used by many cargo haulers but which the agency found was crashing in icing conditions. In 1991, Caravan operators were reporting that the systems to remove ice from the wings were losing effectiveness during flight, according to an FAA bulletin.
Over the next decade, as ice-related crashes continued, the FAA issued directives to help Caravan pilots fly in icing conditions. It wasn't until years later that agency officials expressed concern about the FAA approval for the airplane to fly in icing conditions. A January 2004 agency memo noted that although approval was done properly, it was based on standards the FAA set in 1973 — not on a 1993 revision that required more flight testing. "Standards have changed dramatically since the (Caravan) was certificated," an FAA official wrote in the memo.
A series of warnings followed, telling pilots that the Caravan's stall-warning system "should not be relied upon in icing conditions" and that the pilots should not fly in the "moderate" icing conditions for which the Caravan was approved. By then, 57 people had died in 25 ice-related Caravan crashes, the FAA wrote in a memo.
Cessna said in a statement to USA TODAY that it provides "new information and improvements" to airplane owners to assure safe operation and disputes claims that its airplanes are unsafe "when they are used and maintained as required by published guidance."
In 2007, the FAA ordered the installation of a warning system that notifies Caravan pilots if they are flying at low speed in icing conditions.
Although the FAA had certified decades earlier that the airplane was safe, the agency said in 2007 that the new warning system "is necessary for the (Caravan) to operate safely."
Contributing: John Kelly, Kelly Jordan, Tim Loehrke, Shannon Green, Terry Byrne, Leigh Giangreco, Lauren Kirkwood, Mark Hannan, Morgan Fecto, Allison Wrabel, John Hillkirk
Interactives and presentation: Maureen Linke, Jerry Mosemak, Cooper Allen, Keith Carter, Mitchell Thorson