In Flight Fire, Emergency Descent and Crash in a Residential Area

       September 20, 2016

Table of Contents

Introduction        3

Findings        4

Causes        6

Recommendations        8

Summary        9

References        10

In-flight Fire N501

Introduction

        According to the NTSB report, on July 10, 2007, an accident occurred involving a Cessna 310R, N501N that was operated by the National Association for Stock Car Auto Racing (NASCAR) corporate aviation division as a personal flight. The aircraft experienced an in-flight fire and crashed while performing an emergency diversion to Orlando Sanford International Airport in Orlando Florida (SFB). According the investigation team, the aircraft was released for flight while there was an unresolved maintenance discrepancy. This report outlines some safety issues about resetting circuit breakers, inspection and maintenance of electrical systems in general aviation aircraft, and establishing a safety management system for corporate operations in general aviation. (NTSB, 2009)  

        NASCAR, the owner of the accident aircraft operated nine airplanes mostly for corporate personnel transport. The accident aircraft was NASCARs only piston-engine powered airplane operated by the corporate aviation division and used primarily to transport parts, goods, and documents for NASCAR. The accident aircraft had two pilots on board; one Commercial Pilot and an Air Transport Pilot (ATP). The Commercial Pilot was 53 year old, a medical doctor, pilot in charge, occupied left seat during accident, held a commercial pilot certificate, single-engine, multi-engine, and instrument rating. He held a 3rd class medical certificate dated December 2005 with no limitations and accumulated 276 total flight hours, 106 were multiengine airplanes and 26 hours were Cessna 310. According to the investigation, he flew 11 and 6 hours respectively in the last 90 and 30 days before accident. The morning before the accident the Commercial Pilot saw patients and did not have scheduled or emergency surgeries or was he on call. (NTSB, 2009) Based on this information, there’s no reason to believe that the Commercial Pilot was fatigued, stressed or distracted by work related issues the day of the accident.

        The ATP pilot was 56 years old, flew the right seat, held a multi-engine ATP certificate and type ratings in several business jet airplane makes and models. He also held a first class FAA airmen medical certificate, dated June 2007 with limitations “must wear corrective lenses”. ATP had 10,580 flight hours, 67 were in a Cessna 310 airplane. He had flown 50 and 17 hours respectively in the last 90 and 30 days before the accident. According to the report, this was the ATPs 3rd duty day in the last 9 days. He was not on duty the day before the accident and on the day of the accident, his duty day began about 0700 about 1.5 hours before the accident aircrafts departure. Based on the information from the report, there’s no reason to believe that the ATP was fatigued, stressed or distracted by work related issues the day of the accident.

        According to the NTSB report, both pilots had completed Cessna 310 proficiency training on Jan 25, 2007. The investigation team performed interviews after the accident with the pilot’s instructors. The Commercial Pilot’s instructor required him to have additional simulator and classroom instruction and was not confident in his ability to ever fly without another pilot on board. The ATPs instructor stated that the ATP was highly qualified, required little or no academic instruction and showed exceptional proficiency during two simulator sessions. ATP completed the training in less than the programmed syllabus time. The Maintenance technician for the accident airplane had an FAA certified A&P license with inspection authorization and had been employed as a mechanic with NASCAR since 1995.

Findings

        NASCAR had standard operating procedures (SOP) in place for flight and maintenance personnel however was not consistently updated or followed and not easily accessible for personnel to access and utilize. The SOP was not detailed, had requirements for scheduling and maintenance records to be retrievable but no specific procedures on how to meet the requirement. Additionally, the SOP had requirements for the Director of Maintenance (DOM) to ensure NASCAR airplanes were maintained in an airworthy condition at all times and for releasing airplanes for flight after maintenance. Similar to the scheduling and maintenance records process, there was not a documented means for the DOM to communicate the status. It was apparent that in the event an aircraft needed to be removed from the flight schedule, there was no system in place to reference. The process they were using was a face to face meeting between the aviation director, chief pilot, and DOM. The day before the accident, the DOM, Chief Pilot and aviation director discussed the weather radar write up but no one took actions to ensure the discrepancy was resolved before allowing it to fly. The Chief Pilot indicated the DOM told him the discrepancy will be ok and ensure the ATP does not turn it on. (NTSB, 2009)

        The Day before the accident occurred, another company pilot had to turn off the weather radar and manually pull the circuit breaker because of a burning smell. The smell went away according to the pilot’s entry in the airplane’s maintenance discrepancy binder and the pilot flew for more than an hour without incident. Research of similar airplanes indicate the location around the radar wiring to be the densest concentration of wiring in the Cessna 310 and fuel lines to run through this area. The circuit breaker was pulled for the weather radar system and stopped the burning smell however it did not address the root cause of the problem. (NTSB, 2009)

        The NTSB Findings were the weather radar anomaly that happened the day before the accident could have developed into a significant in-flight smoke and fire event but was temporarily alleviated when the pilot pulled the related circuit breaker. In the air force and the commercial airlines world, the system would have been removed and a placard installed in the cockpit or the pilot or mechanic should troubleshoot the inoperative equipment and determine the airworthiness before the next flight.