Accident Information:
Date of accident: July 10, 2007
Type of aircraft: Cessna 310R
Aircraft registration: N501N
Owner of aircraft: National Association
Passengers on board: 0
Flight crew: 2
Fatalities: 5 (2 pilots and 3 people on the ground)
Survivors: 0
Flight Origin: Daytona Beach International Airport (DAB), Daytona Beach, Florida
Destination: Orlando Sanford International Airport, Orlando, Florida
Location of accident: The plane crashed into residential area when diverting to Orlando Sanford International Airport (SFB)
Cause of accident: Human error
Accident Summary:
On July 10, 2007, a Cessna 310R, N501N, operated by National Association for Stock Car Auto Racing (NASCAR) crashed into the residential area whilst performing an emergency landing to Orlando Sanford International Airport in Florida. Two pilots on board were killed, along with three people on the ground. The crash has flattened two houses and injured four people on the ground. The flight was operated under instrument flight rules (IFR) flight plan as a personal flight, it was reported that smoke was found in the cockpit during the time of the accident. The plane was destroyed by the impact of the crash and post-crash fire.
The NTSB determines the causes of the crash were due to the mislead by NASCAR’s management decisions and actions to allow the accident plane to be released, and the pilot’s decision to operate the flight knowing the existing problem of discrepancy, which caused the in-flight fire.
Investigation outline:
- Examine aircraft wreckage
(The discrepancy pages were recovered from the crash scene. Weather radar discrepancy was documented before the crash)
- Examine the two pilots’ profile
(One ATPL pilot and one CPL pilot on board)
- Examine the NASCAR Aviation Division Personnel
- Examine pre-accident maintenance, Airworthiness Responsibilities and procedures (The official standard operating procedures of NASCAR was not constantly updated.)
- Examine the circuit breaker system
- Examine the electrical system
Investigation operations:
- Studied the NASCAR company record and found weather radar system malfunction was reported by another pilot the day before the accident.
( No examination and action was taken to investigate the discrepancy. One of the pilots of the accident was notified about the weather radar discrepancy by NASCAR’s chief pilot and the maintenance technician, however he ignored the issue. )
- The cause of cash:
Was the exposure of smoke and fumes the reason the brought down the plane?
- The cause for the plane to lose control:
Examine whether the plane lost control was due to fire or heat.
- The pilots’ intention during the emergency landing:
Were the pilots intended to somewhere else when they acknowledged they would land at SFB?
- Pilot’s situational awareness:
Did the pilots lose their situational awareness when they were experiencing the in-flight fire?
- Examine the circuit breaker system
- Examine the electrical system
- Examine the company’s Safety Management System (SOP)
Conclusion and findings:
- The accident was caused by the actions and decisions made by NASCAR’s management and maintenance personnel to allow the accident plane be released with the identified unresolved discrepancy, which caused the in-flight fire.
- Both of the accident pilots had sufficient information about the unresolved discrepancy but they did not refuse the airplane.
- There was not adequate evidence to determine the origin of in-flight fire.
- The plane’s sudden manoeuvres away from Orlando Sanford International Airport could not be explained.
- The standard operation procedures of NASCAR do not provide enough information to determine whether an airplane was safe to fly. Therefore, this explains the reason that management and maintenance allowed the accident plane to be released.
- Safety management system could provide them a system to risk management, safety methods, and internal oversight programs that can improve safety.
Recommendations to FAA:
- Develop an alert to inform pilots and maintenance technician about the circuit breaker policy contained in Advisory Circular 120-80.
- Require aircraft manufacturers and those post-manufacture modifications to create and improve guidance regarding to resetting circuit breakers.
- Improve training for maintenance regarding to maintenance of electrical systems, circuit breakers, and aging wiring.
- Encourage all business operators to adopt Safety Management System
- programs that include sound risk management practices.
Changes made by NASCAR after accident:
- Using aircraft status board to show the details of maintenance activities.
- Include an aircraft status log into each plane’s maintenance discrepancy logbook.
- Checking the upcoming scheduled maintenance for each plane by using an improved maintenance checking tool that is available to pilots, maintenance and other NASCAR personnel.
- Developing new, serialized maintenance discrepancy forms that can include additional categories for better maintenance issues checking.
References
National Transportation Safety Board (January 28, 2009) Aircraft Accident Summary Report: In-flight Fire, Emergency Descent and Crash in a Residential Area. (NTSB/AAR-09/01/SUM. PB2009-910401)
Want to know more?
National Transportation Safety Board (January 28, 2009) Aircraft Accident Summary Report: In-flight Fire, Emergency Descent and Crash in a Residential Area. (NTSB/AAR-09/01/SUM. PB2009-910401)
For more information or pictures of the accident, please refer to the crash report above.
