Crash rulings often pin blame on pilot

BY RONNIE GREENE

rgreene@MiamiHerald.com

In the sky over Idaho in icy weather, the Cessna 208B's wings began to flutter, and pilot Fred Villanueva, a Vietnam War veteran, could not hold them. The wings moved ''side to side," a witness said, and then the nose dropped -- classic signs of icing.

With a giant boom, the Cessna crashed into a plowed field. Villanueva and his Salmon Air co-worker, Raymond Ingram, were killed that morning, Dec. 6, 2004.

Nine months later, when the National Transportation Safety Board assessed blame for the air cargo crash, it cited the pilot for failing to keep control.

The case is not unique: In eight of every 10 fatal U.S. cargo crashes since 2000, the NTSB has blamed the person in the cockpit as the primary reason for the disaster, a Miami Herald investigation found.

The "probable cause'' findings, typically winnowed to a few sentences, are often the final word on why a plane went down.

Yet a Miami Herald review of probable cause reports on every fatal U.S. cargo crash since 2000 shows other contributing factors were ignored or downplayed, raising doubts about whether dozens of the crashes should have been blamed on the pilot.

Consider:

. The plane Villanueva flew, the Cessna 208B, has been involved in 10 fatal U.S. cargo crashes since 2000,more than any other plane, and government files are rife with concern over the aircraft's problems in icing conditions.

The NTSB itself questioned the Cessna 208B's handling in icing, including one detailed report just nine days after the Idaho crash. The concerns became so urgent that the safety board in January pressed the Federal Aviation Administration to ban the planes from flying into "conditions determined to be more than light icing."

Despite these well-documented concerns, not once did the NTSB cite the Cessna as the primary or contributing factor in the crashes.

. Another turboprop, the Mitsubishi MU-2, has been involved in seven fatal cargo crashes in the states this decade, second only to the Cessna 208B. In rapid fire, five have come since March 2004 alone, killing six.

The spate of accidents triggered congressional concern and prompted the FAA recently to issue a report concluding the plane has a high crash rate that warrants enhanced pilot training.

Not once has the NTSB cited the MU-2 as a primary or contributing factor of cargo crashes since 2000.

. Investigators often come to conclusions without crucial evidence: cockpit recorders that capture talk between pilot and copilot, and sophisticated digital flight recorders that monitor all facets of a plane's travels.

Eight times since 2000, the NTSB was unable to determine the cause of a fatal cargo crash, leaving companies and families without closure. Other times, the safety board blamed the pilot, even without the so-called black boxes, which are required on passenger aircraft but not on small cargo planes. The devices typically cost about $20,000 apiece.

"They are far too quick just to blame the pilot and move on," said Mary F. Schiavo, former Inspector General of the U.S. Department of Transportation, now a private attorney. "I've noticed a real trend of blaming the pilots."

IGNORING THE OBVIOUS?

Cargo pilots die nearly once a month on average flying in an industry known for old planes, tight deadlines and overnight flying -- factors that help make it the deadliest form of commercial flight in the United States, a Miami Herald review found.

By nearly always pointing to the pilot, the government has ignored more systemic problems in an industry dogged by safety failings, the newspaper found.

The NTSB is an independent government agency that investigates fatal crashes, concluding a probable cause in each case and suggesting broader reforms to the FAA.

"In every investigation we look at all factors -- theaircraft's history, the pilot's history, the environment -- before determining a probable cause," Acting Chairman Mark V. Rosenker said in a statement to The Miami Herald.

The safety board declined to discuss individual cases, but it defended its overall pattern of citing pilots.

"Who is the last person who could have prevented the accident?" asked Tom Haueter, a pilot and Deputy Director of the NTSB's Office of Aviation Safety. "The vast majority of the time, it's pilot action or inaction that results in the accident."

Schiavo, the former top regulator and one-time aviation professor, draws a different conclusion. "They get blamed unfairly for a lot of things," she said.

The Salmon Air crash is one example.

While the safety board was investigating the crash and ultimately blaming the pilot, records show, it was completing a separate inquiry of the Cessna itself.

Icing on wings is a major potential hazard for cargo pilots flying small planes. In mere moments, icing can accumulate to the point that pilots lose control: If the ice adds too much weight, a plane may not be able to maintain altitude. Just as important, the flaps that control the plane can freeze up.

With these hazards, ice detection systems are vital.

NTSB QUESTIONS

Yet the NTSB review completed just after the Idaho crash raised questions about the Cessna's icing safeguards. Among the concerns: The plane's boot de-icing system, which is not a "turn on and leave on'' system, forces pilots to constantly monitor accumulation.

Another problem: The plane's high wing makes it nearly impossible for a pilot to see whether ice is forming on the upper wing.

The plane's handbook tells pilots to wait until ¼- to ¾-inch of ice has accumulated before activating the de-ice boots. But that presents problems. Because of the extra workload during approach and landing, "the pilot may not be able to adequately monitor and evaluate the ice accumulation," said the Dec. 15, 2004, NTSB report to the FAA.

The safety board also questioned FAA oversight, saying its "surveillance practices may not be adequate'' to ensure operators avoid icing crashes.

Salmon Air's own safety manual warned, "The Cessna Caravan's weak point known throughout the industry is its ground icing and/or in-flight icing scenarios," files show.

Cessna said the planes are safe -- as long as pilots and carriers abide by procedures spelled out by the company.

"A lot of them are carriers who, because of their business, they are required to move freight and people at night with weather," said Dick Ziegler, a spokesman for Cessna Aircraft Company.

"If the operators of the airplane operate within the parameters of that pilot's operating handbook, the airworthiness directives that call for physical inspections . and basically don't fly your airplane in ice, that would go a long way toward reducing a number of accidents," he said.

But the NTSB had problems with the manufacturer's safety awareness caveats, saying the program "might not place sufficient emphasis on recognizing unacceptable ice accumulations." It concluded pilots may be unprepared for icing conditions.

After the string of fatal crashes and numerous warnings, the NTSB urged the FAA to ''expeditiously'' require more pilot training, develop strategies to avoid icing crashes, mandate more thorough checks of the plane's wings by pilots and operators for icing before flight -- and reexamine its own monitoring of the plane.

Then, in January, the NTSB went one step further: It issued an "urgent'' safety recommendation to the FAA to ban all operators of Cessna 208 series planes from flying in conditions "determined to be more than light icing."

CESSNA TRACK RECORD

In light of the recent actions, The Miami Herald asked the safety board whether it was reconsidering any of its probable cause findings in Cessna's crashes. The NTSB did not respond.

An investigation into a May 2001 crash raises questions about the plane's safety and the NTSB's conclusions.

A Cessna 208B owned by FedEx Corp. and operated by Corporate Air of Billings, Mont., crashed into mountains about three miles south of Steamboat Springs, Colo., killing the 44-year-old pilot.

The NTSB said an "inadvertent stall'' caused the plane to lose control, that the pilot contributed to the crash because his attention was diverted as ice formed on the airframe, and that he lacked experience in knowing how to deal with such situations.

In the end, the plane encountered icing, and the pilot's attention was diverted -- again, a classic scenario of Cessnas in icing. Yet in its probable cause report, the safety board questioned not the plane -- but the pilot.

It did so even though the plane lacked a cockpit voice recorder and flight data recorder, tools mandated on commercial jets that help solve why planes fall.

In other cases, the safety board pointed to pilots when cargo operators and family members contend other issues were at play.

"I feel they gave up because it was a bunch of packages in the back," said Todd DeSimone, general manager of Planemasters Ltd., which lost a pilot in Illinois in December 2002. "If you would have had people in the back they would have continued the research until the very end."

That Cessna 208B crashed on approach to the runway at Greater Rockford Airport on a freezing, overcast, gusty evening -- the air traffic controllers losing contact with the pilot moments before.

"The tower personnel advised the dispatcher that they were missing an airplane," NTSB records show.

The probable cause report blamed the pilot, but a lawsuit filed by the victim's family alleges the plane and U.S. air traffic controllers were at fault. The defendants dispute that.

In Alabama, pilot Thomas J. Preziose, 54, was ferrying baseball caps and other cargo for Mid-Atlantic Freight on a familiar route when he radioed, "I needed to deviate, I needed to deviate, I needed to deviate, I needed ... ''

In a moment, the Cessna 208 dubbed Night Ship 282 was down in the swampy water of the Big Bateau Bay, and Preziose, a pilot so practiced that he taught others to fly, was dead.

More than three years later, the NTSB blamed the mysterious 2002 crash on "the pilot's spatial disorientation."

The finding was striking: An initial NTSB report said he "collided in-flight with an unknown object at 3,000 feet." But the final report contradicted that, finding no evidence of an in-flight collision.

MISSING PIECES

Preziose's sister, Moira Wade, herself a pilot from Mississippi, spent countless hours revisiting the crash site, pulling hundreds of pounds of the plane's wreckage scattered about -- pieces the NTSB had not collected.

"The first thing I thought of was: He was going to be blamed," Wade said. "When you have a little airplane crash, they're not going to put that much into it. They make mistakes. It's not an exact science."

She questions how the NTSB could cite "spatial disorientation'' when there was no black box. She thinks the government should consider requiring cockpit recorders in small planes with a history of crashes.

"The worst thing that can happen to somebody is to lose a family member and not know why," Wade said. "You wouldn't have the suffering and the pain the family goes through if you could determine the cause of accident pretty quickly."

She adds a sobering reality: "It would cost money, and a lot of people would be opposed to it. . And improvements in aviation are measured by deaths. How many deaths, and how much is it worth, to correct the problem?"

The NTSB said it supports the black box devices, including the retrofit of video recorders to "greatly assist us in our investigations."

In February 2005, the FAA pushed to require upgraded cockpit voice recorders and digital flight recorders for planes with at least 10 passenger seats. The anticipated price for operators to retrofit nearly 10,000 aircraft and install the devices in new planes: $256 million in current dollars, or $421 million over 20 years.

Yet the proposal, which could take effect next year, excluded those aircraft with fewer than 10 seats -- the type of small cargo operators whose planes continue to fall from the sky, and the planes that typically lack the black box devices.

Why not include small cargo planes?

"You're now talking about establishing a new requirement, and that sort of thing is much tougher to get through the rule-making process," said FAA spokesman Les Dorr. "You are talking about imposing a financial burden. I'm not saying one way or another that it is an improper financial burden, but you are talking about creating something new."

Without the black boxes, "frankly, it just seems easier sometimes to blame the dead guy," said aviation attorney Jerome L. Skinner, with the Chicago-based Nolan Law Group, which has filed lawsuits over Cessna crashes in icing. "He's not there to defend himself."

When the safety board is unable to determine probable cause, families are left with only questions.

In Alaska in August 2003, Shima Funakoshi, 30, and her mother, Yoshiko Funakoshi, 58, died in a cargo mail run. Visiting Alaska, the mother wanted to see her daughter at work for Hageland Aviation Services, but the twin-engine Reims Aviation 406 turboprop crashed into open waters 30 miles from Barrow.

Search teams reported seeing floating aircraft seats, cardboard boxes and small pieces of the aircraft's wreckage, but the plane was thought to have sunk in waters 50 to 70 feet deep.

NO CLOSURE

Nearly three years later, the bodies have not been recovered, and the NTSB could only say that the plane went down "while maneuvering for an undetermined reason." A safety board report noted that "a pilot who is familiar with geographical locations in the area reported that migrating whales are commonly sighted in the area where the radar depicted a descending right turn."

Family and friends remain frustrated by the lack of closure and believe the government should have done more.

"She was a good pilot," said Dora Wainwright, the pilot's former roommate.

Nami Funakoshi, the pilot's sister, said, "We don't have any answers ... and it makes us feel so bad."