Oklahoma Basketball Team Crash Spurs Overhaul of Oversight

An educational institution learns about safety the hard way

The 2001 crash of a twin-turboprop carrying the Oklahoma State University (OSU) basketball team illustrates how a potpourri of latent hazards can combine with deadly consequences. The object lesson for operations large and small is that latent hazards are like traps, and the goal is to disarm them before they can spring on the unwary, the complacent, or the inexperienced.

The case involves the crash of a Beechcraft King Air 200 on the night of Jan. 27, 2001, near Strasburg, Colorado. The airplane, operating as Jet Express Services, was one of three flying the OSU basketball team from Broomfield, Colo., to Stillwater, Okla., after a game between OSU and the University of Colorado at Boulder. All 10 aboard were killed.

The National Transportation Safety Board (NTSB) investigated, and just recently published its final report of the accident. The safety board determined that the pilot flying became disoriented and lost control of the airplane. This is one of those cases where investigators looked hard at the operational milieu in which the flight was undertaken and the “lack of oversight” for team travel.

The airplane was donated for the round trip to Colorado. The 55-year old part-time pilot, who had a day job as partner in a local accounting firm, had more than 3,600 hours as a multi-engine pilot in command, with 767 hours in the King Air 200. He was a certified flight instructor. A Federal Aviation Administration air safety inspector, who previously had given the pilot a check ride, said in a post accident interview that the pilot “had a tendency to lock in on a problem and not fly the airplane.”

The 30-year old copilot had 1,200 hours of experience in a multi-engine aircraft. The NTSB report indicated that the copilot was eager to fly for an airline and “was logging flight time as fast as he could.” He had not received any formal training in King Air airplanes. Essentially he was along for the ride.

For the post-game return to OSU, the plane took off at 5:17 p.m. local time (right about sunset). NTSB investigators concluded it was 314 pounds overweight but within center of gravity (CG) limits. The sky was overcast at 1,500 feet; visibility was one and a half miles in light snow and mist.

The airplane reached its approved cruising altitude of 23,000 feet at 5:32 p.m. Three minutes later, the airplane’s Mode C transponder ceased transmitting, the result of what the safety board concluded was a “complete loss of a.c. electrical power.” This failure, the board’s report said, “would have rendered most of the pilot’s flight instruments inoperative.” Two minutes later, it crashed, the grim end of “a graveyard spiral resulting from pilot spatial disorientation,” the board said.

According to the report, “The pilot probably did not sense the right descending turn at first because the airplane’s bank was entered gradually.”

“As the airplane’s bank angle and descent rate began increasing, the pilot’s spatial disorientation most likely persisted … any head movements that the pilot made while attempting to diagnose the electrical system malfunction might have exacerbated his spatial disorientation because of the motion sensing organs of the inner ear,” the report explained.

However, the pilots were not without instruments. They had airspeed, altitude, attitude and turn and slip instruments on the right side of the cockpit, which were d.c. powered. The copilot could have been asked to fly the airplane because the instruments were more easily viewed from his position in the right seat.

Twinning for trouble

Nonetheless, the accident reinforces the case for twinning a standby attitude indicator, a point raised previously in this publication (see ASW, March 17). A standby instrument, powered separately from the failed circuit and placed in the pilot’s direct field of view, would have provided an instant recourse to the dead instruments with their inoperative flags popped up. Of course, it takes training for pilots to be conditioned to the imperative to shift focus – and reliance on – the standby instrument.

In the case of the accident King Air 200, the pilot flying did not have that option. The airplane was not equipped with a standby attitude indicator. A source close to the investigation explained, “The King Air was designed and certificated for single pilot operation and also to a lower certification standard – although the FAA would say ‘different’ – than air carriers. Therefore, it does not have some of the equipment found on an air carrier, such as standby instruments.”

“Of course, the issue is that passengers are unaware of the difference in the certification of a King Air versus, say, a B737. They assume it’s all the same,” the source added.

Single-point failure potential

The safety board concluded that a wiring failure or short circuit could have caused the loss of a.c. power, but its report also pointed to a number of potential single-point failures. The King Air 200 is equipped with two inverters, either one of which is capable of providing a.c. power to the airplane. However, NTSB investigators identified three electrical components that are common to both inverters – the inverter selector switch, the inverter select relay, and the avionics inverter select relay.

Should one of these components fail, a.c. power could be lost even though both inverters were working. It is noteworthy that modern aircraft electrical systems can be significantly lacking in redundancy while meeting all certification standards. Note also that a copilot is not required if the aircraft is equipped with a serviceable three-axis autopilot. However, when the a.c. power fails: the autopilot fails, the only usable (d.c. powered) attitude indicator is on the right hand side where there need not be a copilot, and the circuit breakers are on the right side at knee level, which could induce an unusual attitude as the pilot in the left seat leans across to examine them, and probably with a passenger obscuring the way.

None of these components was recovered from the accident site; there is no relevant failure history on them, and investigators could not make a definitive determination as to what caused the a.c. system to fail. The electrical failure was cited as a contributing cause in the crash, the primary cause of which was that of the pilot’s failure to assess the cues he did have of a.c. power loss and to utilize the remaining functional instruments (and the copilot) to retain control of the aircraft.

The cultural context

Having pinned the probable cause on the pilot, the safety board nonetheless dwelt at some length on the organizational and cultural context in which this flight took place. The board found “numerous deficiencies, unsafe practices, and deviations from regulations occurred during the flight.”

“The management required for a safe operation appears to have been absent, which was a ‘significant’ factor in this accident,” the report noted. For example, OSU’s flight department had no records on the pilots or the airplane. Because it was a donated flight, the trip was not coordinated with the manager of the flight department.

The policy changes put in place since the accident speak for themselves. It is another case of previously slack rigging being tightened after running aground, not beforehand. Thomas H. Huxley’s remark in 1877 about knowledge as the basis for safety applies: “If a little knowledge is a dangerous thing, where is the man who has so much as to be out of danger?” A requirement to respond to that question might put safety programs and management decision-making in a new perspective.

Twinning is a term that was coined some years ago for the philosophy of close juxtaposition of critical flight instruments which are essentially there to back each other up (and so require subconscious ongoing cross-check – i.e. the failure of one to replicate the other’s movement becoming cause for instant alarm). Examples are altimeter and standby altimeter, main attitude display and its backup/standby attitude instrument. An HSI (horizontal situation indicator – compass) will not immediately kill you if it fails. However a faulty attitude indication will. Why? A good example is the Air India B747 that crashed in 1978 over the inky-black water west of Bombay. Once the pilot flying got past a certain attitude in pitch and roll, the heavy aircraft was quite unrecoverable at that altitude. A classic example is the Korean Air Lines (KAL) B747F freighter that crashed Dec. 22, 1999, on initial climb out of Stansted, UK. There was an apparent failure of the attitude director indicator, a “comparator” buzzer sounded three times as the captain expressed concerns over his distance measuring equipment (DME) indication.

The moral of the story is that it is essential to be able to quickly recognize a failed/frozen/erroneous attitude instrument. As things now stand in many airplanes, one can have a failed/frozen instrument with or without OFF flag – become uneasy and perhaps look hopefully across the cockpit and see the standby and first officer’s instruments also dynamically in a state of flux (as the airplane enters its unusual attitude). The pilot should be able to rely upon a good F/O’s cross-check, but experience has shown that the classic cases after take-off always have the F/O involved in changing frequencies and communicating (or data-inputting to the flight management system, FMS). In the Air India case the first officer was aware of the captain’s failed instrument but the captain would not relinquish control and died chasing his failed instrument.

Source: http://www.iasa.com.au/osu.htm