Casual Factors for General Aviation Accidents/Incidents · Casual Factors for General Aviation Accidents/Incidents ... Landing Gear Strut/Axle/Truck: ... Precursor criteria determination

Casual Factors forGeneral AviationAccidents/Incidents

January 1984 – October 2004

HQ

-042

306

i

Table of Contents

Page

Introduction ii - vii Graphic Charts ATA Code Comparison Data 1 - 3 Causal Factor Comparison Data 4 - 8 FAR Part 91 Data Charts 9 - 29 FAR Part 135 Data Charts 30 - 40 Appendix FAR Part 91 Data Tables 1 - 7 FAR Part 135 Data Tables 8 - 12

ii

Introduction 1.0 Executive Summary The Small Airplane Directorate reviewed accident and incident data for a 20-year time period (January 1984 through October 2004) to determine the major causes of general aviation accidents. The Aviation Safety/Accident Prevention (ASAP) database provided accident and incident records for this report. The intent of the study is to provide an initial review of accident and incident data to determine the top 10 leading major causal factors of general aviation accidents for various categories of aircraft. The data consists of the following two major categories:

• Aircraft operating under Part 91 General Operating and Flight Rules; and • Aircraft operating under Part 135 Operating rules for Commuter and On Demand Operations.

We reviewed a total of 62,037 records. Part 91 operations accounted for 57,117 records (92%) and Part 135 operations accounted for 4,920 records (8%). Causal factors that were Air Transport Association of America (ATA) code related were considered as mechanical related and consisted of 26% of all accident/incident reports. We separated the data by categories of aircraft type, such as single-engine, multiple-engine, and glider. Additional category groupings are by the following leading three manufacturers of general aviation products, which are Cessna, Piper, and Beechcraft. These three manufacturers account for most general aviation products in service over the 20-year period. The report focuses on leading accident or incident causal factors to help target resources for determining possible mitigation of accidents or incidents. Within the FAA, the areas of design and operation will benefit from focusing on these leading accident or incident causal factors.

iii

2.0 Analysis Method 2.1 Methodology The ASAP system in Ft. Worth, Texas, provided data for the analysis in this report. The dataset consists of all part 23 accidents/incidents where the aircraft was operating under either Federal Aviation Regulation (FAR) part 91 operations or part 135 operations. The time period for the dataset is January 1984 to October 2004. The data is in Microsoft ® Access format. We used ®Access query commands to perform all data searches and queries. We divided the data into FAR part 91 operations and FAR part 135 operations. We further divided part 91 operations and part 135 operations data into single-engine, multiple-engine, and glider groups for each of the major three manufacturers: Cessna, Piper, and Beechcraft. We divided this data into fatal and non-fatal events. We listed the top ten causal factors for each group. We intend for this report to graphically display the top ten causal factors for the various general aviation classes and operations. We used ATA codes to determine if mechanical failure attributed to an accident or incident. 2.2 Data Sources We gathered all the data for the analysis in this report from the Accidents/Incidents section of the ASAP database. The data in the ASAP database is downloaded from the Oklahoma City national database weekly. 2.3 Assumptions This report does not verify the accuracy of the individual record coding of the causal factors. Some causal factor codes may overlap. For this report, we used the causal factor code defined from each record as the database indicated. Again, we did not conduct a review of the accuracy or relevance of each record’s causal code.

iv

2.4 Definitions The Accident/Incident causal factor coding system is somewhat cryptic in nature. The following causal factor definitions clarify some of the incident or accident codes addressed in this report: Improper Operation of Brake/Flight Control on Ground: Loss of directional ground control due to improper operation of brake or flight controls. Typical examples are: losing directional control during landing, improper use of brake system, and losing directional control during take-off. Selected Unsuitable Terrain: Landing on unimproved areas, landing on unknown terrain condition, and veering off runway onto unimproved areas. Unsafe Acts by Third Party: Unauthorized ground vehicles colliding with aircraft, aircraft to aircraft collision during ground operation, maintenance induced problems, and unauthorized personnel present during ground operations. Inadequate Preflight Inspection of Aircraft: Failure to remove aircraft tie downs, door not latched on take-off, improper setting of seat stops prior to take-off, fuel cap not properly installed, failure to remove control locks prior to take-off, and improper setting of control trim prior to take-off. Failure to Avoid Objects or Obstructions: During ground or air operations such as striking towers, other aircraft on ground, power lines, ground support equipment, trees, and wild life, such as deer, on the ground. Poor Preflight Plan/Aircraft Performance: Exceeded ability of aircraft to climb during towing flight, operation in excessive wind or gust components, operation off of improper runway surface for aircraft type, and exceeded density altitude limit of aircraft type. Inadvertently Retracting Landing Gear: Pilot accidentally retracted gear, selected gear up instead of flaps up. Landing Gear Actuator: Failure of the landing gear actuator system including failure of down lock system, and failure of actuator motor/transmission. Landing Gear Strut/Axle/Truck: Failure of the strut assembly, trunnion area including bearings, torque link system, and landing gear attachment brackets/hardware. Exceed Load Design: Loss of aircraft integrity caused by exceeding design loads due to over speed, over weight, acrobatic flight in non-rated aircraft, and down/up drafts. Miscellaneous Pilot Unsafe Acts: Pilot distraction induced accident/incident such landing on wrong runway or taxiway, take off without Air Traffic Control (ATC) clearance, flying too low and striking trees, other aircraft, etc., and not securing gas or oil caps resulting in loss of fuel/oil.

v

3.0 Results 3.1 Overview Our analysis provides a high-level look at what is causing general aviation aircraft involvement in both accidents and incidents. We accomplished this by analyzing a large amount of accident and incident data, dividing it into specific groups, and applying simple filter tools that determine a ranking of the data. This report does not focus on commuter aircraft operations. The Small Airplane Directorate produced a “Small Airplane Commuter Service Issues Study” in June of 2002. That study is specifically dedicated to the commuter fleet of aircraft. That report is available from the Small Airplane Directorate Continued Operational Safety Branch. 3.2 Observations We reviewed 62,037 accident/incident records during our analysis. Of this total, 57,117 records were on aircraft operating under part 91 rules. The remaining 4,920 records were of aircraft operating under part 135 rules. Landing gear issues were a primary cause for accidents of both part 91 single and multiple engine accidents. Failure of the retraction/extension system along with failure to extend the gear accounted for 12% of all part 91 accidents. Improper operation of brakes/flight control on ground also was a leading causal factor of part 91 accidents. 6,108 events (11%) of part 91 accidents were due to improper operation of brake/flight control during ground operations. The leading causal factor for both Cessna and Piper aircraft was improper operation of brake/flight control during ground operations. The leading causal factor for Beechcraft was failure to extend the landing gear. Part 135 operations proved to be similar in that landing gear retraction/extension system failure was the leading factor. 16,213 accidents/incidents (26%) are classified with an ATA code as the causal factor. An ATA code indicates a mechanical malfunction of the aircraft’s systems. The remaining accidents/incidents were attributable to non-mechanical factors, including pilot error, human factor related problems, and improper procedures.

vi

The top ATA system codes indicating mechanical issues are as follows:

ATA Code Count % ATA Title

32 7824 48.3% Landing Gear 85 1790 11.0% Reciprocating Engine 24 1240 7.6% Electrical Power 28 1058 6.5% Fuel 73 511 3.2% Engine Fuel and Controls

The leading ATA system code was landing gear. Through out this analysis, landing gear was a leading factor in general aviation accidents/incidents. The ATA component codes are a four-digit code that focuses on the specific component or section of a system. The top 10 ATA component codes indicating mechanical issues are as follows:

ATA Code Count % ATA Title

3230 3788 23.4% Landing Gear Retraction/Extension System 8500 905 5.6% Engine (Reciprocating) 3233 526 3.2% Landing Gear Actuator 3213 511 3.2% Main Landing Gear Strut/Axle 3242 452 2.8% Brake 2400 421 2.6% Electrical Power system 8530 399 2.5% Reciprocating Engine Cylinder section 2800 370 2.3% Fuel 2434 337 2.1% DC Generator-Alternator 8520 331 2.0% Reciprocating Engine Power section

Landing gear retraction/extension system problems were, by a large percentage, the leading mechanical problem with general aviation aircraft.

vii

The following is a review of the leading manufacturers involved in accidents or incidents with ATA code as a causal factor. Percentages below the top three manufacturers decrease rapidly; therefore, many of the manufacturers have been grouped under “Other”.

Manufacturer Count % Cessna 5753 35.5% Piper 4260 26.3% Beech 2575 15.9% Mooney 627 3.9% Swearingen 490 3.0% Bellanca/American Champion 467 2.9% Gulfstream 414 2.6% Other (35+ other manufacturers) 1627 10.0%

3.3 Continued Activity The Small Airplane Directorate conducted the analysis for this report to support the Continued Operational Safety program. The program targets the general aviation fleet of 250,000+ aircraft to determine how to make them safer. With the growing age of the general aviation fleet, Continued Operational Safety concerns will become more varied within the different fleets of aircraft models. The Small Airplane Directorate will continue to explore problems with the general aviation fleet. Precursor criteria determination is an ongoing project. This report will help determine what investigative tools safety engineers should use to identify electrical and electronic problems within fleets of aircraft. Precursor identification can aid in preventing accidents before they happen.

1

Leading ATA Codes

51% (8,173)

23% (3,788)

6% (905)3% (526)

3% (511)

3% (452)

3% (421`)

2% (399)

2% (370)

2% (337)

2% (331)

3230 - Landing Gear Retraction/Extension System 8500 - Engine (Reciprocating)3233 - Landing Gear Actuator 3213 - Main Landing Gear Strut/Axle3242 - Brake 2400 - Electrical Power system8530 - Reciprocating Engine Cylinder section 2800 - Fuel2434 - DC Generator-Alternator 8520 - Reciprocating Engine Power sectionAll Others

2

Leading ATA Systems

48% (7,824)

11% (1,790)

8% (1,240)

7% (1,058)

3% (511)

23% (3,790)

32 - Landing Gear 85 - Reciprocating Engine

24 - Electrical Power 28 - Fuel

73 - Engine Fuel and Controls Remaining ATAs

3

Leading Manufacturers(ATA Codes By Manufacturer)

22% (3,625)

16% (2,575)

26% (4,260)

36% (5,753)

Cessna

Piper

Beechcraft

Other

4

All Accidents FAR 91 and FAR 135(62,037)

8% (4,920)

92% (57,117)

FAR 135

FAR 91

5

FAR 91 - All Accidents(57,117)

21% (11,831)

12% (6,745)

25% (14,565)

42% (23,976)

Cessna

Beechcraft

Other

Piper

6

FAR 91 - Fatal Accidents(4,579)

22% (997)

13% (585)

28% (1,264)

37% (1,733)Cessna

Piper

Beechcraft

Other

7

FAR 135 - All Accidents(4,920)

26% (1,2267)

18% (895)

21% (1,016)

35% (1,742)

Cessna

PiperBeechcraft

Other

8

FAR 135 - Fatal Accidents(291)

19% (54)

14% (42)

23% (68)

44% (127)

Cessna

Piper

Beechcraft

Other

9

FAR Part 91 - All Engines

6108

4215

3359 3284

20951891 1786

14241213 1212

0

1000

2000

3000

4000

5000

6000

7000

Improper Operation of B

rake/Flight Contro

l on Ground

Improper Landing Flare/Bouncing on Touchdown

Failure to Extend Landing Gear

Landing Gear Retraction/Extension System Failure

Failure to Avoid Objects or Obstru

ctions

Failure to Maintain Adequate Fly Speed

Poor Preflig

ht Planning - Fuel Q

uantity

Overrun End of R

unway During Landing

Selected Unsuitable Terrain

Full Fuel to

Fuel Low/Exhaust

10

FAR Part 91 - All Engines - Cessna

2737

2315

1137 11231027

918741 741 663

516

0

500

1000

1500

2000

2500

3000


rake/Flight Contro

l on Ground


Poor Preflig

ht Planning - Fuel Q

uantity




ctions


Full Fuel to

Fuel Low/Exhaust

Overrun End of R


Selected Unsuitable Terrain

11

FAR Part 91 - All Engines - Piper

1473

930 890810

593

453 424351 323 293

0

200

400

600

800

1000

1200

1400

1600

Impro

per Opera

tion of B

rake/F

light C

ontrol o

n Gro

und

Landing G

ear R

etrac

tion/Exte

nsion Sys

tem Fail

ure

Failure

to Extend Lan

ding Gea

r

Impro

per Lan

ding Flare/B

ouncing on Touch

down

Failure

to Avo

id Objec

ts or O

bstructi

ons

Failure

to Main

tain A

dequate

Fly Spee

d

Overru

n End of Runway

Durin

g Landing

Selecte

d Unsu

itable

Terrain

Poor Pref

light P

lanning - F

uel Quan

tity

Full Fuel

to Fuel Low/Exh

aust

12

FAR Part 91 - All Engines - Beechcraft

711 693

488451

258197

156 146 140 120

0

100

200

300

400

500

600

700

800

Failure to

Extend Landing Gear

Landing Gear Retra

ction/Extension System Failu

re

Inadvertently

Retractin

g Landing Gear

Improper L

anding Flare/Bouncing on Touchdown

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Failure to

Avoid Objects or Obstru

ctions

Improper M

anagement/Fuel T

ank Selector

Overrun End of R


Failure to

Maintain Adequate Fly Speed

Gear Indicated Down/Locked, G

ear Collapsed

13

FAR Part 91 - Multiple Engine

1553

809

327 327 291 278218 183 166 157

0

200

400

600

800

1000

1200

1400

1600

1800




Inadvertently Retracting Landing Gear


ctions


rake/Flight Contro

l on Ground

Overrun End of R


Landing Gear Actuator

Inadequate Preflight In

spection of Aircraft

Main Landing Gear Stru

t/Axle/Truck

14

FAR Part 91 - Multiple Engine - Fatal

80 79

7166

53

32

2421

18 18

0

10

20

30

40

50

60

70

80

90

Lost Contro

l in Adverse Weather

Insufficient Terra

in Clearance - Enroute


Failure Avoid Collision Ground or W

ater

Improper Instru

ment Procedure During Takeoff/Landing

Operation Below VMC

Pilot Incapacity - E

xcludes Alcohol

Failure to Avoid Aircraft/Both Airborne

Exceed Load Design

Poor Preflig

ht Planning - Weather

15

FAR Part 91 - Multiple Engine - Cessna

596

219

79 75 73 56 52 50 45 45

0

100

200

300

400

500

600

700





ctions


rake/Flight Contro

l on Ground

Overrun End of R




t/Axle/Truck

Brake



16

FAR Part 91 - Multiple Engine - Fatal - Cessna

30

27

23

20

17

12

98

6 6

0

5

10

15

20

25

30

35

Lost Contro

l in Adverse Weather

Insufficient Terra

in Clearance - Enroute

Failure to Avoid Collision with Ground or W

ater


Improper Instru

ment Procedure During Takeoff/Landing

Operation Below VMC

Continued VFR Flight Into Adverse Weather

Exceed Load Design

Failure to Avoid Aircraft/Both Airborne

Misc/Pilot Unsafe Acts

17

FAR Part 91 - Multiple Engine - Piper

507

351

150

95 92 84 83 7656 50

0

100

200

300

400

500

600




Improper Operation of Brake/Flight Control on Ground

Failure to Avoid Objects or Obstructions

Overrun End of Runway During Landing


Main Landing Gear Strut/Axle/Truck

Gear Indicated Down/Locked, Gear Collapsed



18

FAR Part 91 - Multiple Engine - Fatal - Piper

27

22

19 19

16

13

98

6 6

0

5

10

15

20

25

30

Insufficient T

errain Clearance - E

nroute

Lost Contro

l in Adverse W

eather

Failure Avoid Collis

ion Ground or Water

Failure to


Improper In

strument P

rocedure During Takeoff/L

anding

Pilot In

capacity - E

xcludes Alcohol

Operation Below VMC

Engine (Reciprocatin

g)

Poor Preflig

ht Planning - W

eather

Failure to

Avoid Aircraft/B

oth Airborne

19

FAR Part 91 - Multiple Engine - Beechcraft

364

192 183

10186 76 73 70

5334

0

50

100

150

200

250

300

350

400




Failure to Avoid Objects or Obstructions


Improper Operation of Brake/Flight Control on Ground


Overrun End of Runway During Landing

Inadequate Preflight Inspection of Aircraft

Electrical Power System

20

FAR Part 91 - Multiple Engine - Fatal - Beechcraft

23

20

18

1615

8 87 7

6 6

0

5

10

15

20

25


Insufficient T


nroute

Lost Contro

l in Adverse W

eather

Failure to Avoid Collis

ion with Ground or W

ater

Improper Instru

ment Procedure Durin

g Takeoff/Landing

Pilot Incapacity - E

xcludes Alcohol

Operation Below VMC

Failure to Follow Approved Instru

ment Procedure

Improper Operatio

n Flight Contro

l in Air

Improper Management/F

uel Tank Selector

Undetermined

21

FAR Part 91 - Single Engine - Fatal

557

403

320

198 192

143119 117 103 100

0

100

200

300

400

500

600


Insufficient T


nroute

Lost Contro

l in Adverse W

eather

Continued VFR Flight In

to Adverse Weather



ater

Failure to Avoid Objects or O

bstructio

ns

Failure to Avoid Airc

raft/Both Airb

orne

Aerobatics Below Safe Altitude


Poor Preflig

ht Planning - W

eather

22

FAR Part 91 - Single Engine - Cessna

2664

2236

1098

843 808715 696

607 527 496

0

500

1000

1500

2000

2500

3000

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Improper L


Poor Preflig

ht Planning - F

uel Quantity

Failure to


ctions

Failure to

Extend Landing Gear

Full Fuel to

Fuel Low/Exhaust

Failure to


Overrun End of R


Landing Gear Retra


re

Selected Unsuitable Terra

in

23


557

403

320

198 192

143119 117 103 100

0

100

200

300

400

500

600


Insufficient T


nroute

Lost Contro

l in Adverse W

eather

Continued VFR Flight In

to Adverse Weather



ater

Failure to Avoid Objects or O

bstructio

ns

Failure to Avoid Airc

raft/Both Airb

orne

Aerobatics Below Safe Altitude


Poor Preflig

ht Planning - W

eather

24

FAR Part 91 - Single Engine - Piper

1377

660539 501

423 412340 325 280 264

0

200

400

600

800

1000

1200

1400

1600

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Improper L


Failure to

Extend Landing Gear

Failure to


ctions

Landing Gear Retra


re

Failure to


Overrun End of R



in

Poor Preflig

ht Planning - F

uel Quantity

Poor Preflig

ht Plan/Airc

raft Perfo

rmance

25

FAR Part 91 - Single Engine - Fatal - Piper

139

119

106

5546 45

29 28 27 26 26

0

20

40

60

80

100

120

140

160

Failure to


Lost Contro

l in Adverse W

eather

Insufficient T


nroute

Continued VFR Flig

ht Into Adverse W

eather

Failure to

Avoid Collision with

Ground or Water

Failure to


ctions

Misc/Pilot U

nsafe Acts

Failure to

Avoid Aircraft/B

oth Airborne

Poor Preflig

ht Planning - W

eather

Pilot In

capacity - E

xcludes Alcohol

Exceed Load Design

26


487

306

207

159

111 110 94 88 85 83

0

100

200

300

400

500

600

Landing Gear Retra


re

Failure to


ctions

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Failure to

Extend Landing Gear

Landing Gear Positio

n and Warning


in



spection of A

ircraft

Overrun End of R


Unsafe Acts by Third Party

27

FAR Part 91 - Single Engine - Fatal Beechcraft

4239 39

18 17 1715

1310 10

0

5

10

15

20

25

30

35

40

45

Failure to


Insufficient T


nroute

Lost Contro

l in Adverse W

eather

Poor Preflig

ht Planning - W

eather

Failure to


Ground or Water

Continued VFR Flig

ht Into Adverse W

eather

Improper In

strument P


anding

Poor Preflig

ht Planning - F

uel Quantity

Pilot In

capacity - E

xcludes Alcohol

Failure to

Avoid Aircraft/B

oth Airborne

28

FAR Part 91 - Gliders

98

85

5449

4135 34 34

27 27

0

20

40

60

80

100

120

Failure to


Poor Preflig

ht Plan/Airc

raft Perfo

rmance

Landed Short

Improper O

peration Flig

ht Contro

l in Air


in

Improper L


Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Failure to


ctions


spection of A

ircraft

Collided with

Object on Final A

pproach

29


487

306

207

159

111 110 94 88 85 83

0

100

200

300

400

500

600

Landing Gear Retra


re

Failure to


ctions

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Failure to

Extend Landing Gear


n and Warning


in



spection of A

ircraft

Overrun End of R



30

FAR Part 135 - Multiple Engine

409

192

138118

10579

66 66 63 54

0

50

100

150

200

250

300

350

400

450

Landing Gear Retra


re

Failure to


ctions

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Failure to

Extend Landing Gear


n and Warning




t/Axle/Truck


spection of A

ircraft

Struck Bird

in Flig

ht Path

31

FAR Part 135 - Multiple Engine - Fatal

25

22

11

86

5 5 54 4 4 4 4

0

5

10

15

20

25

30

Insufficient T


nroute

Improper In

strument P


anding

Lost Contro

l in Adverse W

eather

Failure to


Ground or Water

Poor Preflig

ht Plan/W

eight and Balance


g)

Failure to

Avoid Aircraft/B

oth Airborne

Exceed Load Design

Continued Flig

ht into Area Severe Turbulence

Undetermined

Misc/Pilot U

nsafe Acts

Operation Below VMC

Failure to


32


9

6

3

2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

Insuffic

ient T

errain

Clea

rance

- Enro

ute

Impro

per Instr

ument P

roce

dure Durin

g Takeo

ff/Lan

ding

Inadeq

uate Pref

light In

spec

tion of A

ircraf

t

Engine Colle

ctor/T

ailpipe/N

ozzle

Lost Contro

l in A

dverse

Wea

ther

Excee

d Load D

esign

Failure

to Avo

id Collis

ion with

Gro

und or Wate

r

Lost Gro

und Refe

rence

Durin

g Night V

FR

Elevato

r Tab

Contro

l Sys

tem

Aircraf

t Fuel

System

Fuel Boost

Pump

Attitude G

yro an

d Indica

tor Sys

tem

Wing Spar Stru

cture

Power Lev

er

Undeterm

ined

Recipro

catin

g Engine Cyli

nder Sec

tion

Attempt O

peratio

n with

Defe

ctive

Equipment

Control In

terfer

ence

by Pas

senger/

Crew

Misc/Pilo

t Unsa

fe Acts

Delay A

ction in

Aborte

d Takeo

ff

Failure

to Follow A

pprove

d Instr

ument P

roce

dure

Continued

VFR Flight In

to Adve

rse W

eather

Pilot/C

rew M

isman

aged

Ac S

ys

Continued

Flight in

to Area

Severe

Turbulen

ce

Poor Pref

light P

lanning - W

eight a

nd Bala

nce

Poor Pref

light P

lanning - A

ircraf

t Perf

orman

ce

Impro

per Man

agem

ent/F

uel Tan

k Sele

ctor

Inadeq

uate Spac

ing - Wak

e Turb

ulence

33


10

7

4 4

3 3

2

1 1 1 1 1 1

0

2

4

6

8

10

12

Insufficient T


nroute

Improper In

strument P


anding

Failure to

Avoid Collision Ground or W

ater


g)

Lost Contro

l in Adverse W

eather

Failure to

Avoid Aircraft/B

oth Airborne

Operation Below VMC

Overrun End of R


Misc/Pilot U

nsafe Acts

Fuel Unport,

Fuel Not a

t Outle

t

Improper O

peration Flig

ht Contro

l in Air

Reciprocating Engine Cylin

der Sectio

n

Reciprocating Engine System

34

FAR Part 135 - Multiple Engine - Fatal - Beechcraft

6

3 3 3

2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

Impro

per Instr

ument P

roce

dure Durin

g Takeo

ff/Lan

ding

Lost Contro

l in A

dverse

Wea

ther

Poor Pref

light P

lanning - W

eight a

nd Bala

nce

Failure

to Main

tain A

dequate

Fly Spee

d

Insuffic

ient T

errain

Clea

rance

- Enro

ute

Continued

Flight A

rea Sev

ere Turb

ulence

Poor Pref

light P

lanning - F

uel Quan

tity

Misc/Pilo

t Unsa

fe Acts

Operatio

n Belo

w VMC

AC Power Dist

ributio

n System

Attitude G

yro an

d Indica

tor Sys

tem

Engine Cowlin

g System

Engine (Turb

ine/Turb

oprop)

Fuel Contro

l/Carb

uretor

Engine (Rec

iproca

ting)

Recipro

catin

g Engine Cyli

nder Sec

tion

Collided

with

Objec

t on Final

Approac

h

Didn't Fly

Assigned

Altit

ude IFR C

learan

ce

Undeterm

ined

Continued

VFR Flight In

to Adve

rse W

eather

Inadeq

uate Snow/Ic

e Rem

oval fr

om Airc

raft

Miscell

aneo

us Misu

se Fuel

System

Issued

Impr C

onflictin

g Insts

Pilot In

capac

ity - E

xcludes

Alco

hol

Inadeq

uate Spac

e Ac/W

ke Turb

ulence

35

FAR Part 135 - Single Engine

114

7873

69

48 4541 38 35

31

0

20

40

60

80

100

120

Failure to


ctions

Landing Gear Retra


re


in

Improper O

peration of B

rake/Flight C

ontrol o

n Ground

Unsuitable Terra

in Snow/Ice Area

Insufficient T


nroute

Failure to

Extend Landing Gear

Overrun End of R


Failure to


Continued VFR Flig

ht Into Adverse W

eather

36


31

1614

87

5 5 54

3

0

5

10

15

20

25

30

35

Insufficient T


nroute

Failure to


Continued VFR Flig

ht Into Adverse W

eather

Lost Contro

l in Adverse W

eather

Failure to


Ground or Water

Improper O

peration Flig

ht Contro

l in Air

Poor Preflig

ht Planning - W

eather

Poor Preflig

ht Planning - W

eight and Balance

Failure to


ctions

Improper M

anagement/Fuel T

ank Selector

37

FAR Part 135 - Single Engine - Fatal - Cessna

20

10

76

5

3 3 32 2 2 2 2

0

5

10

15

20

25

Insufficient T


nroute

Continued VFR Flig

ht Into Adverse W

eather

Failure to


Lost Contro

l in Adverse W

eather

Failure to


Ground or Water

Improper M

anagement/Fuel T

ank Selector

Improper O

peration Flig

ht Contro

l in Air

Failure to


ctions

Improper In

strument P


anding

Downwind Takeoff or L

anding

Poor Preflig

ht Planning - W

eight and Balance

Poor Preflig

ht Planning - W

eather

Poor Preflig

ht Planning - A

ircraft P

erform

ance

38

FAR Part 135 - Single Engine - Fatal - Piper

6

4

3 3

2 2

1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

Insufficient T


nroute

Failure to


Poor Preflig

ht Planning - W

eather

Poor Preflig

ht Planning - W

eight and Balance

Continued VFR Flig

ht Into Adverse W

eather

Exciter

Unauthorized Actio

n

Failure to


ctions

Pilot In

capacity - E

xcludes Alcohol

Improper O

peration Flig

ht Contro

l in Air

Lost Contro

l in Adverse W

eather


g)

Attitude Gyro and In

dicator System

39

FAR Part 135 - Single Engine - Fatal - Beechcraft

1 1

0

1

2

3

4

5

6

7

Failure to

Follow Approved In

strument P

rocedure

Inadequate Flightt/S

upervision (Pilo

t)

1

Appendix

FAR Part 91 - All Engines Improper Operation of Brake/Flight Control on Ground 6108Improper Landing Flare/Bouncing on Touchdown 4215Failure to Extend Landing Gear 3359Landing Gear Retraction/Extension System Failure 3284Failure to Avoid Objects or Obstructions 2095Failure to Maintain Adequate Fly Speed 1891Poor Preflight Planning - Fuel Quantity 1786Overrun End of Runway During Landing 1424Selected Unsuitable Terrain 1213Full Fuel to Fuel Low/Exhaust 1212

FAR Part 91 - All Engines - Cessna Improper Operation of Brake/Flight Control on Ground 2737Improper Landing Flare/Bouncing on Touchdown 2315Poor Preflight Planning - Fuel Quantity 1137Landing Gear Retraction/Extension System Failure 1123Failure to Extend Landing Gear 1027Failure to Avoid Objects or Obstructions 918Failure to Maintain Adequate Fly Speed 741Full Fuel to Fuel Low/Exhaust 741Overrun End of Runway During Landing 663Selected Unsuitable Terrain 516

FAR Part 91 - All Engines - Piper Improper Operation of Brake/Flight Control on Ground 1473Landing Gear Retraction/Extension System Failure 930Failure to Extend Landing Gear 890Improper Landing Flare/Bouncing on Touchdown 810Failure to Avoid Objects or Obstructions 593Failure to Maintain Adequate Fly Speed 453Overrun End of Runway During Landing 424Selected Unsuitable Terrain 351Poor Preflight Planning - Fuel Quantity 323Full Fuel to Fuel Low/Exhaust 293

2

FAR Part 91- All Engines - Beechcraft

Failure to Extend Landing Gear 711Landing Gear Retraction/Extension System Failure 693Inadvertently Retracting Landing Gear 488Improper Landing Flare/Bouncing on Touchdown 451Improper Operation of Brake/Flight Control on Ground 258Failure to Avoid Objects or Obstructions 197Improper Management/Fuel Tank Selector 156Overrun End of Runway During Landing 146Failure to Maintain Adequate Fly Speed 140Gear Indicated Down/Locked, Gear Collapsed 120

FAR Part 91 - Multiple Engine Landing Gear Retraction/Extension System Failure 1553Failure to Extend Landing Gear 809Improper Landing Flare/Bouncing on Touchdown 327Inadvertently Retracting Landing Gear 327Failure to Avoid Objects or Obstructions 291Improper Operation of Brake/Flight Control on Ground 278Overrun End of Runway During Landing 218Landing Gear Actuator 183Inadequate Preflight Inspection of Aircraft 166Main Landing Gear Strut/Axle/Truck 157

FAR Part 91 - Multiple Engine - Fatal Lost Control in Adverse Weather 80Insufficient Terrain Clearance - Enroute 79Failure to Maintain Adequate Fly Speed 71Failure Avoid Collision Ground or Water 66Improper Instrument Procedure During Takeoff/Landing 53Operation Below VMC 32Pilot Incapacity - Excludes Alcohol 24Failure to Avoid Aircraft/Both Airborne 21Exceed Load Design 18Poor Preflight Planning - Weather 18

3

FAR Part 91 - Multiple Engine - Cessna

Landing Gear Retraction/Extension System Failure 596Failure to Extend Landing Gear 219Improper Landing Flare/Bouncing on Touchdown 79Failure to Avoid Objects or Obstructions 75Improper Operation of Brake/Flight Control on Ground 73Overrun End of Runway During Landing 56Landing Gear Actuator 52Main Landing Gear Strut/Axle/Truck 50Brake 45Inadequate Preflight Inspection of Aircraft 45

FAR Part 91 - Multiple Engine - Fatal - Cessna Lost Control in Adverse Weather 30Insufficient Terrain Clearance - Enroute 27Failure to Avoid Collision with Ground or Water 23Failure to Maintain Adequate Fly Speed 20Improper Instrument Procedure During Takeoff/Landing 17Operation Below VMC 12Continued VFR Flight Into Adverse Weather 9Exceed Load Design 8Failure to Avoid Aircraft/Both Airborne 6Misc/Pilot Unsafe Acts 6

FAR Part 91- Multiple Engine - Piper Landing Gear Retraction/Extension System Failure 507Failure to Extend Landing Gear 351Improper Landing Flare/Bouncing on Touchdown 150Improper Operation of Brake/Flight Control on Ground 95Failure to Avoid Objects or Obstructions 92Overrun End of Runway During Landing 84Inadvertently Retracting Landing Gear 83Main Landing Gear Strut/Axle/Truck 76Gear Indicated Down/Locked, Gear Collapsed 56

4


Insufficient Terrain Clearance - Enroute 27Lost Control in Adverse Weather 22Failure Avoid Collision Ground or Water 19Failure to Maintain Adequate Fly Speed 19Improper Instrument Procedure During Takeoff/Landing 16Pilot Incapacity - Excludes Alcohol 13Operation Below VMC 9Engine (Reciprocating) 8Poor Preflight Planning - Weather 6Failure to Avoid Aircraft/Both Airborne 6

FAR Part 91 - Multiple Engine - Beechcraft

Landing Gear Retraction/Extension System Failure 364Inadvertently Retracting Landing Gear 192Failure to Extend Landing Gear 183Failure to Avoid Objects or Obstructions 101Landing Gear Actuator 86Improper Operation of Brake/Flight Control on Ground 76Improper Landing Flare/Bouncing on Touchdown 73Overrun End of Runway During Landing 70Inadequate Preflight Inspection of Aircraft 53Electrical Power System 34

FAR Part 91 - Multiple Engine - Fatal - Beechcraft Failure to Maintain Adequate Fly Speed 23Insufficient Terrain Clearance - Enroute 20Lost Control in Adverse Weather 18Failure to Avoid Collision with Ground or Water 16Improper Instrument Procedure During Takeoff/Landing 15Pilot Incapacity - Excludes Alcohol 8Operation Below VMC 8Failure to Follow Approved Instrument Procedure 7Improper Operation Flight Control in Air 7Improper Management/Fuel Tank Selector 6Undetermined 6

5

FAR Part 91 - Single Engine

Improper Operation of Brake/Flight Control on Ground 5796Improper Landing Flare/Bouncing on Touchdown 3853Failure to Extend Landing Gear 2550Failure to Avoid Objects or Obstructions 1770Landing Gear Retraction/Extension System Failure 1729Failure to Maintain Adequate Fly Speed 1666Poor Preflight Planning - Fuel Quantity 1659Overrun End of Runway During Landing 1189Full Fuel to Fuel Low/Exhaust 1116Selected Unsuitable Terrain 1094

FAR Part 91 - Single Engine - Fatal Failure to Maintain Adequate Fly Speed 557Insufficient Terrain Clearance - Enroute 403Lost Control in Adverse Weather 320Continued VFR Flight Into Adverse Weather 198Failure to Avoid Collision with Ground or Water 192Failure to Avoid Objects or Obstructions 143Failure to Avoid Aircraft/Both Airborne 119Aerobatics Below Safe Altitude 117Misc/Pilot Unsafe Acts 103Poor Preflight Planning - Weather 100

FAR Part 91 - Single Engine - Cessna Improper Operation of Brake/Flight Control on Ground 2664Improper Landing Flare/Bouncing on Touchdown 2236Poor Preflight Planning - Fuel Quantity 1098Failure to Avoid Objects or Obstructions 843Failure to Extend Landing Gear 808Full Fuel to Fuel Low/Exhaust 715Failure to Maintain Adequate Fly Speed 696Overrun End of Runway During Landing 607Landing Gear Retraction/Extension System Failure 527Selected Unsuitable Terrain 496

6

FAR Part 91 - Single Engine - Fatal - Cessna Failure to Maintain Adequate Fly Speed 213Insufficient Terrain Clearance - Enroute 198Lost Control in Adverse Weather 112Continued VFR Flight Into Adverse Weather 93Failure to Avoid Collision with Ground or Water 83Failure to Avoid Aircraft/Both Airborne 68Failure to Avoid Objects or Obstructions 65Misc/Pilot Unsafe Acts 51Poor Preflight Planning - Weather 42Pilot Incapacity - Excludes Alcohol 30Lost Ground Reference During Night VFR 30

FAR Part 91 - Single Engine - Piper Improper Operation of Brake/Flight Control on Ground 1377Improper Landing Flare/Bouncing on Touchdown 660Failure to Extend Landing Gear 539Failure to Avoid Objects or Obstructions 501Landing Gear Retraction/Extension System Failure 423Failure to Maintain Adequate Fly Speed 412Overrun End of Runway During Landing 340Selected Unsuitable Terrain 325Poor Preflight Planning - Fuel Quantity 280Poor Preflight Plan/Aircraft Performance 264

FAR Part 91 - Single Engine - Fatal - Piper Failure to Maintain Adequate Fly Speed 139Lost Control in Adverse Weather 119Insufficient Terrain Clearance - Enroute 106Continued VFR Flight Into Adverse Weather 55Failure to Avoid Collision with Ground or Water 46Failure to Avoid Objects or Obstructions 45Misc/Pilot Unsafe Acts 29Failure to Avoid Aircraft/Both Airborne 28Poor Preflight Planning - Weather 27Pilot Incapacity - Excludes Alcohol 26Exceed Load Design 26

7

FAR Part 91 - Single Engine - Beechcraft

Failure to Extend Landing Gear 528Improper Landing Flare/Bouncing on Touchdown 378Landing Gear Retraction/Extension System Failure 329Inadvertently Retracting Landing Gear 296Improper Operation of Brake/Flight Control on Ground 182Improper Management/Fuel Tank Selector 137Failure to Maintain Adequate Fly Speed 110Failure to Avoid Objects or Obstructions 96Gear Indicated Down/Locked, Gear Collapsed 91Electrical Power System 79

FAR Part 91 - Single Engine - Fatal - Beechcraft Failure to Maintain Adequate Fly Speed 42Insufficient Terrain Clearance - Enroute 39Lost Control in Adverse Weather 39Poor Preflight Planning - Weather 18Failure to Avoid Collision with Ground or Water 17Continued VFR Flight Into Adverse Weather 17Improper Instrument Procedure During Takeoff/Landing 15Poor Preflight Planning - Fuel Quantity 13Pilot Incapacity - Excludes Alcohol 10Failure to Avoid Aircraft/Both Airborne 10

FAR Part 91 - Gliders Failure to Maintain Adequate Fly Speed 98Poor Preflight Plan/Aircraft Performance 85Landed Short 54Improper Operation Flight Control in Air 49Selected Unsuitable Terrain 41Improper Landing Flare/Bouncing on Touchdown 35Improper Operation of Brake/Flight Control on Ground 34Failure to Avoid Objects or Obstructions 34Inadequate Preflight Inspection of Aircraft 27Collided with Object on Final Approach 27

8


Landing Gear Retraction/Extension System Failure 487Failure to Avoid Objects or Obstructions 306Improper Operation of Brake/Flight Control on Ground 207Failure to Extend Landing Gear 159Landing Gear Position and Warning 111Selected Unsuitable Terrain 110Landing Gear Actuator 94Inadequate Preflight Inspection of Aircraft 88Overrun End of Runway During Landing 85Unsafe Acts by Third Party 83

FAR Part 135 - Multiple Engine Landing Gear Retraction/Extension System Failure 409Failure to Avoid Objects or Obstructions 192Improper Operation of Brake/Flight Control on Ground 138Failure to Extend Landing Gear 118Landing Gear Position and Warning 105Landing Gear Actuator 79Unsafe Acts by Third Party 66Main Landing Gear Strut/Axle/Truck 66Inadequate Preflight Inspection of Aircraft 63Struck Bird in Flight Path 54

FAR Part 135 - Multiple Engine - Fatal Insufficient Terrain Clearance - Enroute 25Improper Instrument Procedure During Takeoff/Landing 22Lost Control in Adverse Weather 11Failure to Avoid Collision with Ground or Water 8Poor Preflight Plan/Weight and Balance 6Engine (Reciprocating) 5Failure to Avoid Aircraft/Both Airborne 5Exceed Load Design 5Continued Flight into Area Severe Turbulence 4Undetermined 4Misc/Pilot Unsafe Acts 4Operation Below VMC 4Failure to Maintain Adequate Fly Speed 4

9


Insufficient Terrain Clearance - Enroute 9Improper Instrument Procedure During Takeoff/Landing 6Inadequate Preflight Inspection of Aircraft 3Engine Collector/Tailpipe/Nozzle 2Lost Control in Adverse Weather 2Exceed Load Design 2Failure to Avoid Collision with Ground or Water 2Lost Ground Reference During Night VFR 1Elevator Tab Control System 1Aircraft Fuel System 1Fuel Boost Pump 1Attitude Gyro and Indicator System 1Wing Spar Structure 1Power Lever 1Undetermined 1Reciprocating Engine Cylinder Section 1Attempt Operation with Defective Equipment 1Control Interference by Passenger/Crew 1Misc/Pilot Unsafe Acts 1Delay Action in Aborted Takeoff 1Failure to Follow Approved Instrument Procedure 1Continued VFR Flight Into Adverse Weather 1Pilot/Crew Mismanaged Ac Sys 1Continued Flight into Area Severe Turbulence 1Poor Preflight Planning - Weight and Balance 1Poor Preflight Planning - Aircraft Performance 1Improper Management/Fuel Tank Selector 1Inadequate Spacing - Wake Turbulence 1

FAR Part 135 - Multiple Engine - Fatal - Piper Insufficient Terrain Clearance - Enroute 10Improper Instrument Procedure During Takeoff/Landing 7Failure to Avoid Collision Ground or Water 4Engine (Reciprocating) 4Lost Control in Adverse Weather 3Failure to Avoid Aircraft/Both Airborne 3Operation Below VMC 2Overrun End of Runway During Landing 1Misc/Pilot Unsafe Acts 1Fuel Unport, Fuel Not at Outlet 1Improper Operation Flight Control in Air 1Reciprocating Engine Cylinder Section 1Reciprocating Engine System 1

10

FAR Part 135 - Multiple Engine - Fatal - Beech

Improper Instrument Procedure During Takeoff/Landing 6Lost Control in Adverse Weather 3Poor Preflight Planning - Weight and Balance 3Failure to Maintain Adequate Fly Speed 3Insufficient Terrain Clearance - Enroute 2Continued Flight Area Severe Turbulence 2Poor Preflight Planning - Fuel Quantity 2Misc/Pilot Unsafe Acts 2Operation Below VMC 1AC Power Distribution System 1Attitude Gyro and Indicator System 1Engine Cowling System 1Engine (Turbine/Turboprop) 1Fuel Control/Carburetor 1Engine (Reciprocating) 1Reciprocating Engine Cylinder Section 1Collided with Object on Final Approach 1Didn't Fly Assigned Altitude IFR Clearance 1Undetermined 1Continued VFR Flight Into Adverse Weather 1Inadequate Snow/Ice Removal from Aircraft 1Miscellaneous Misuse Fuel System 1Issued Improper Conflicting Instructions 1Pilot Incapacity - Excludes Alcohol 1Inadequate Space Aircraft/Wake Turbulence 1

FAR Part 135 - Single Engine Failure to Avoid Objects or Obstructions 114Landing Gear Retraction/Extension System Failure 78Selected Unsuitable Terrain 73Improper Operation of Brake/Flight Control on Ground 69Unsuitable Terrain Snow/Ice Area 48Insufficient Terrain Clearance - Enroute 45Failure to Extend Landing Gear 41Overrun End of Runway During Landing 38Failure to Maintain Adequate Fly Speed 35Continued VFR Flight Into Adverse Weather 31

11


Insufficient Terrain Clearance - Enroute 31Failure to Maintain Adequate Fly Speed 16Continued VFR Flight Into Adverse Weather 14Lost Control in Adverse Weather 8Failure to Avoid Collision with Ground or Water 7Improper Operation Flight Control in Air 5Poor Preflight Planning - Weather 5Poor Preflight Planning - Weight and Balance 5Failure to Avoid Objects or Obstructions 4Improper Management/Fuel Tank Selector 3

FAR Part 135 - Single Engine - Fatal - Cessna Insufficient Terrain Clearance - Enroute 20Continued VFR Flight Into Adverse Weather 10Failure to Maintain Adequate Fly Speed 7Lost Control in Adverse Weather 6Failure to Avoid Collision with Ground or Water 5Improper Management/Fuel Tank Selector 3Improper Operation Flight Control in Air 3Failure to Avoid Objects or Obstructions 3Improper Instrument Procedure During Takeoff/Landing 2Downwind Takeoff or Landing 2Poor Preflight Planning - Weight and Balance 2Poor Preflight Planning - Weather 2Poor Preflight Planning - Aircraft Performance 2

FAR Part 135 - Single Engine - Fatal - Piper Insufficient Terrain Clearance - Enroute 6Failure to Maintain Adequate Fly Speed 4Poor Preflight Planning - Weather 3Poor Preflight Planning - Weight and Balance 3Continued VFR Flight Into Adverse Weather 2Exciter 2Unauthorized Action 1Failure to Avoid Objects or Obstructions 1Pilot Incapacity - Excludes Alcohol 1Improper Operation Flight Control in Air 1Lost Control in Adverse Weather 1Engine (Reciprocating) 1Attitude Gyro and Indicator System 1

12

FAR Part 135 - Single Engine - Fatal - Beech

Failure to Follow Approved Instrument Procedure 1Inadequate Flight/Supervision (Pilot) 1

Documents

Casual Factors for General Aviation Accidents/Incidents · Casual Factors for General Aviation Accidents/Incidents ... Landing Gear Strut/Axle/Truck: ... Precursor criteria determination