B17 9o9 Final Report Update Recommendations

[Music] this is the b17 final report update and i guess this is number two i've been thinking about the final report and the ntsb recommendations quite a bit since juan brown and i filmed that report review we did at sun and fun last week you know and i've got some recommendations that i think were missed so stick with me on flywheel [Music] hi i'm scott purdue and today on flywire i want to talk about the ntsb recommendations from the final report and i'm going to throw a few nickels on the grass of my own on this okay the primary result announced by the ntsb final report was the probable cause of the accident and their recommendations basically they had three of them that they made to remedy similar accidents in the future or at least that's what we all expected them to do after all they are the national transportation safety board and that's their deal it's their purview it's their job is to analyze accidents and tell us what what can do to not do that in the future and uh so i'm not going to get up on a soapbox about this but uh here are the safety issues discovered by the ntsb in their years-long investigation literally it took a couple of years to do this one the need for appropriate regulatory framework for living flight history experience flights including maintenance and management policies and procedures two the need for increased faa oversight of living history flight experience operations and the need for faa oversight of living history flight operations experience operation operators safety management systems that was their three recommendations and in the press conference announcing their recommendations to the ntsb they stated that they believe that the appropriate regulatory framework would be to make all air tour operators part 135 basically commercial air carrier operators on call not scheduled operators the issue here is the very concept that more regulation will solve the problem that's all we need is more regulation the faa already had detailed has detailed maintenance and management policies and procedures that address all aspects of living history flight experience operations each tour operator has to comply i've been involved in the flight experience operations and i've even written four successful exemption letters in the past if the operator goes by the book the regulations are already there the fizz though i operated with or under was fairly proactive in their oversight and i've seen many of those inspectors many times over the years that i participated in the flight experience programs the ntsb did not comment or analyze in any depth on the breakdown of the fa oversight in the orlando fisdo who was responsible for monitoring the callings foundation program they didn't even bother asking the faa what they have done to tighten up an arguably uneven approach to local oversight of the living history flight experience programs they painted the faa with a broad brush implying that the faa had no program at all effectively the first two recommendations are the same thing and imply there's no program the third recommendation to establish oversight of the operator's sms program ignores the fact that the callings foundation was not required to have one so maybe the recommendation should have been they need to have one and they need to follow it um frankly the sns program that did have was completely informal and arguably ineffective uh i'm not going to get into super detail here about that it's not my my goal my beef here is that the ntsb did not look at this accident chain and focus on the things that broke down leading to the accident their recommendations are essentially more regulation will solve the problem and this begs the question if they even realized what regulation already existed and what violations actually took place and either they didn't care or they cynically believed that requiring every air tour operation to become a part 135 air carry operator would likely result in the whole mess going away and it's no longer a problem i suspect that is a large part of their preference for the three recommendations they give either way the ntsb recommendations are simplistic they don't address the actual problems that led to this accident and the end do nothing to prevent further accidents of this type why have we waited with baited breath for years for this report it does nothing to solve the problem and i'm going to slam a little upset about that in the interest of fairness instead of just throwing spears here i'm going to offer my recommendations as a result of this investigation of the ntsb's investigation the docket that i read the things that i think should have been looked at in more detail and things that might positively impact air tour operations instead of shutting them down completely i believe in being positive and constructive i think we owe the victims and the family this much at least i'm not to go into every single detail there's just not enough time to do that but after seeing the toxicology report highlighted in the final report and the fact that there was no mention of the significance of the either of the major fines i wanted to look into it a bit further the pilot had two serious hypertension arrhythmia drugs in his system that required special issuance approval it's standard but he has to have the evaluation and he has to have the approval he did not report the drugs in his last medical or at any time since then and in essence he lied on his medical and was in violation of the fars even flying that day he was required to report it and he didn't my recommendation is that the faa tighten up the class 1 and class 2 medical requirements for those pilots over the age of 70. perhaps even adding blood work to the examination you know and i'm getting close to not close to that number and i'm i would put myself in that that bucket this pilot had three previous dwi convictions and had been denied a medical at one point for it and frankly where is the limit to being issued a medical certificate for dwi's is it three is it four is it six at some point there is a pattern of behavior that puts the privilege to fly in jeopardy you put other people at risk when you're flying also i was concerned by the co levels in the blood of the pile in the copilot both were close to 50 percent of a fatal dose of carbon monoxide poisoning for sure those levels would have impaired a younger healthier person and frankly i had my doubts that those levels of co poisoning would have built up from the previous days flying i thought it was specific to that flight and if there was an exhaust leak into the wing or exposure to adverse winds the crew could have been exposed to impairing levels of co poisoning during ground operations that and afterwards the disregard of best practice and gross errors of the pilot during the emergency could have been explained by co impairment prior to takeoff i wanted to know if co co was a factor in this accident and the ntsb didn't even bother investigating it so i called my friend dr brent blue besides being an md and a long time pilot he was the coroner for jackson hole wyoming and for for many years and he's an expert in carbon monoxide poisoning and he has a website aromatics.com where he sells detectors full disclosure they're good stuff i sent him the medical reports from the docket and he looked them over and reported back to me that he felt it more likely that the levels of co and the crew's blood was more likely a result of their brief exposure to the fire rather than the co exposure during ground operations so that answered my question it's unlikely that co poisoning was a factor in this particular accident but frankly that doesn't stop me from making a recommendation either and the ntsp could have done this i recommend that all air tour aircraft be equipped with a working computer-based co detector in the cockpit of each aircraft at least the enclosed ones the biplanes the open cockpit airplanes don't need it but and the crew educated on its operation and alerts i further recommend that ground leaning procedures be emphasized and taught to er all air tour piston engine operators an over rich mixture produces huge quantities of co that increase the risk for all crew and passengers during ground operations this is serious business i groundling all the time my nickel is everybody should do it i would encourage the installation of all hardwired co detectors in all piston engine airplanes without open cockpits it appears that the lacks oversight of the colleagues foundation exhibited by the orlando fisdo was systemic and endangered the public i think the answer is it did but i'm not standing in the faa shoes i think the faa should initiate an investigation to determine the appropriate actions to remedy the situation whatever the gamut is they need to look at it further i recommend that a committee of stakeholders nationally be convened to review and tighten up the training maintenance and management procedures for administering the living history flight experience programs and that the faa developed national guidance using this committee's report on how to conduct living history flight experiences and the oversight of those exemption holders and at the least i believe a more detailed training and standardized approach to multi-engine multi-crew operations be incorporated with current best practices and things such as crm saturday liking in this accident with operational procedures used by the military operators when that particular airplane was in service don't leave it up to the individual organization make it a standard across the airframe type making allowance for modifications like deleting the usage of things like turbochargers this airplane didn't have turbochargers it materially changed how a run-up should be done i also recommend that the committee review specific penalties for violations of these policies and procedures such that blatant disregard of the procedures adopted by the committee and promulgated by the faa to hold the perpetrators accountable we need to have people accountable for stuff like this you can't just violate it and go fine we risk the entire program flying as we know it uh from a few bad actors so there you have it some solid recommendations to prevent accidents like this in the happening in the future not comprehensive but it's a good start the idea is to preserve the living history flood exemption or flight experience program because it is beneficial to the general public and preserves our history i think it's critical the program has been a positive one for the entire us so let's fix what's wrong not kill a program or over regulate it to death so if you find this overreaching well so be it nobody's saying it so i think i needed to i think we all expected the ntsb to focus on fixes like this and they didn't they didn't step up the plate so let's work together fix a problem and keep them flying okay i hope you liked the video if so hit like and subscribe it looks a bit like this here and i'd like to thank my patreon supporters here uh they help me make these videos and if you'd like to help i'll leave a link uh to the patreon flywire page down below thanks for watching and we'll see you next time on flywire

Channel: FlyWire- scott perdue

Views: 12,511

Keywords: b-17 crash, b-17 909 crash, b 17 9oh9, Final Report, B17 crash recommendations, blancolirio b17, Flywire, flywire online, flywire youtube, scott perdue, beechcraft bonanza, general aviation, Aviation, F33C, V35 Bonanza, Aerobatic Bonanza, Aerobatics, Acrobatics, Flying, pilot vlog, flight training, flying vlog, cockpit, airplane audio, cfi, pilot life, bonanza, private pilot, commercial pilot, airline pilot, ATP, pilot, atc, travel, travel by plane, flying an airplane

Id: D9w9oaUPgoM

Length: 12min 35sec (755 seconds)

Published: Wed Apr 28 2021