#19: 330 accidents in five years.

I have looked at every Part 91, Part 133, and Part 135 accident report since 2019 and can now report back on what I’ve learned about commercial aviation crashes. It’s…a lot.

These two planes should not be touching each other. (Oct 31, 2019, Corporate Air collided with a general aviation aircraft in Honolulu. Probable Cause: failure of the Cessna Caravan pilot to set his parking brake before looking down in the cockpit.)

This is going to be a bit of a numbers-heavy newsletter, but I promise to liven it up with some images of a few unusual accident photos. (None of which involved fatalities.) I’ve also got a wee bit of an update on my cosmic ray book-writing and the lawsuit so if that is your thing, skip to the end.

A reminder on how I do what I do

I heavily use the NTSB aviation accident database for aviation accident research. While my long term interest is mostly in small commercial operator accidents, or those companies that operate under Part 135 of the Federal Aviation Regulations, having worked in the industry and studied it for years I know that companies do not always classify flights in an obvious way. A company may be a certificated Part 135 operator, like Guardian Flight which I wrote about last month, but it could be involved in an accident while flying under the more lenient general aviation rules known as Part 91. For non aviation folks this can get really complicated, but suffice to say if you are not flying for hire during a leg of your trip (so, for a medevac that means the company employs everyone onboard and you haven’t picked up the paying passenger yet), then it’s a nonrevenue flight and thus could be conducted under the easier rules of Part 91. (I won’t get into all the rules differences, but this is a pretty common thing to do.) This gets sticky for the NTSB database because if you are only searching under Part 135 accidents then you will miss accidents like Guardian Flight’s 2019 crash in Alaska or 2022 crash in Hawaii, both of which occurred under Part 91. The only way to catch all of the accidents involving Part 135s is to, well, look at all of the accidents.

Now you can understand why this newsletter has taken so long to write¹.

So, this is what I found

Between January 1, 2019 and December 31, 2023, there were 330² accidents involving Part 135 operators. They resulted in 166 fatalities and 88 serious injuries. 222 of the accidents were conducted under Part 135, 91 under Part 91 and 17 under Part 133. (The Part 135 operations included cargo, medevac, charter or “on demand” and commuter). 124 of them occurred in Alaska. (I will have more to say in the future on why that is not as significant of a figure as you might think.) The company with the most accidents (twelve) was Air Methods. The company with the most fatalities and injuries (eleven) was Guardian Flight. Air Evac EMS, Cape Air and Yute Commuter Service each had seven. Four of Cape Air’s accidents involved bird strikes, so I don’t think they are indicative of the company’s policies or procedures. Overall, there were twelve accidents involving birds in nine different states and two territories (the US Virgin Islands and Northern Marianas).

Bird strike on a Beechjet 400A in Georgia, July 15, 2022.

Medevacs are an area of concern

There are 44 medevac-related accidents in my spreadsheet involving 20 different companies. (Eight of these were classified as Part 91.) They occur all over the US in both fixed wing and rotorcraft although there are significantly more with helicopters. As I wrote above, Air Methods³ has twelve accidents in the database. Other medevac companies with multiple accidents include Air Evac EMS with seven and Guardian Flight with four. (Air Evac EMS has had three more accidents in 2024.) I am working on a ten-year analysis of medevac operations where I can dig deeper into trends for both the industry and specific companies. This is a big project though and will take me several months to complete.⁴

Some initial thoughts on this segment of the industry: there are a lot of fatalities in medevac crashes. There are the eleven deaths in three separate accidents for Guardian which is by far the most severe record, but also six for Air Evac EMS in two different crashes this year, four for Aeromedevac in a 2021 accident in California, three for Security Aviation in a 2019 accident in Alaska, and three for Survival Flight in a 2019 accident in Ohio.

The most common Probable Cause for medevacs is failure to maintain clearance from terrain, typically while landing. There are also some odd issues, like an ambulance that collided with a helicopter while arriving to pick up a patient, a Beech C90 which collided with a deer on landing and a pilot who was updating his logbook and flew into the ground. (There were no injuries in those accidents.) Overall, it is decision-making that is the primary issue. This would seem to point to the cockpit, but I see some questions about hiring, training, operational control and oversight. Also, this photo illustrates why you should not fly while on cocaine.

Air Methods crash on July 29, 2022 in Alabama. From the report: “The pilot also had a history of obstructed sleep apnea (OSA) and had called out sick the day before the accident, reporting a stomach illness. At the time of the accident, the pilot likely was experiencing some impairing effects from alcohol use and may also have been experiencing impairing effects related to his use of cocaine.” Investigators could not tell which one of these many issues (or a combination) caused the pilot to lose control.

What Five Years of Part 135 Probable Causes Can Tell Us

Looking at all 330 accidents, and setting aside the strange things like the logging crew chief who threw a chainsaw bar into a rotorcraft blade and a nurse whose lithium battery exploded in her uniform during takeoff, similarly to the medevac accidents, the most common accident causes for Part 135 accidents overall are related to decision-making. There are poor landing site choices; failure to maintain control on takeoff, landing, or approach; failure to maintain altitude, airspeed or to lower landing gear, and improper decision-making on approach or go-around. (This means an approach should have been called missed early on or a landing should have been aborted.)

There are accidents due to fuel starvation (eight) and eleven which occurred while taxiing. Thirty-nine crashes involved some sort of known mechanical failure including this Paradise Helicopters accident in Hawaii on June 8, 2022 in which there was an in-flight separation of the tail boom during a sightseeing flight. Three people were seriously injured.

Mechanicals can be a singular event or can point to larger company decision-making and control issues as part of a larger picture. You don’t know until you look deeper. (Paradise Helicopters had two accidents in 2019 and another one this year.)

To thoroughly study the decision-making and operational control issues for Part 135, as well as any role the FAA plays in those areas of concern, would mean digging deeper into individual companies to see what else was going on before an accident occurred. I did this with Yute Commuter Service for a 2022 article for AIN. I was primarily writing about the multiple fatality commuter crash near Kipnuk involving the company in 2020, but was aware there were three accidents in the year before: a mechanical, a taxi issue and a loss of spatial awareness during night VFR. Once I researched further, I found pilot hotline complaints to the FAA, written concerns from the company’s Principal Operations Inspector, upheaval with the chief pilot position and, things like this dating from an ownership change in 2017:

He purchased Yute in 2017 and relocated it from Kodiak to Bethel. Spangler served as the company’s DO and Turrentine was initially the chief pilot. Prior to the Kipnuk flight, the company crashed five times under their oversight, including one accident in 2018 when the pilot—who had over 21,000 hours—permitted a cargo handler with no flight experience to sit in the left seat. During takeoff, the pilot lost rudder control and the aircraft veered off the runway and hit a small ridge. The FAA later characterized this accident as allowing a “non-company unqualified pilot to attempt takeoff.”

There were other events and occurrences at Yute following Renfro’s purchase that drew the attention of the FAA. These included multiple issues with not grounding the aircraft during refuel, failure to secure baggage doors during preflight, the failure of a nose gear actuator on approach, collapsed gear resulting in a prop strike, failure of a pilot to maintain control on landing in Nightmute, and, in April 2019, failure of a pilot to maintain control when landing in Bethel, which resulted in the wing and propeller contacting the runway. The company did not report this event to the FAA.

This type of research is not possible for all the companies involving Part 135 operators between 2019 and 2023⁵, but it is possible for me to conduct for some and it should be done for many. Accidents are typically the end of a slow-burning trend for aviation operations which is why when I see a company in a crash that seems “out of nowhere”, I always wonder what sorts of incidents, events and occurrences, etc. were happening before the accident.

What I do with this information next

I pitched an article on what I’ve learned in building my spreadsheet to an industry publication and it has been accepted. I’m not going to say who, because I don’t want to jinx it, but it’s a decent payment (more than I’ve received in the past) and well regarded. I’m hoping to have that in to an editor in the new few weeks.⁶ There will be more there than I’ve covered here and I’m looking forward to digging into the Probable Causes in particular.

I still want to get ten years in the database and am moving forward with 2024 while also starting on 2018. Much of 2024 is Preliminary Reports only however, so I learn a lot more from the past than the present. (And the NTSB can run weeks behind on even listing an accident in the database, especially if it is minor.)

One thing is obvious - you can not focus only on Part 135 classified accidents when studying Part 135. By ignoring Part 133 and Part 91, you miss a lot and we really should be trying our best to miss nothing at all.

In other news…

My lawyer is in court next week to argue that since we won we do have a right for legal fees even while the Plaintiff states they intend to appeal. In anti-SLAPP cases that are appealed the Plaintiff typically must file a bond for awarded fees with the court. Both my lawyer and AIN’s team have filed for fees. The fees are high because this case has cost a hella lot of money. We shall see what the judge decides.

I’ve been trying not to think about all of that by reading about cosmic ray research in the 1920s and ‘30s. This is partly because I wanted to add another chapter about the big personalities involved, and the big conflicts, as I think it adds to the drama of the book I’m writing (and is true to the subject). It’s fascinating to see how some folks were so certain they were right in the conclusions about the rays until they had to accept they were wrong. (Let’s just say that failure does not go over well with Nobel Prize winning physicists.) I still find the mountaineers to be the most interesting part of this project, but it’s hard to ignore squabbling scientists who take their frustrations out on each other with passive aggressive comments in grant proposals.

I hope you are having a happy and healthy holiday season. I plan to get one more newsletter in before the end of the year where I will explain how much the aviation industry in Alaska is dependent on the US Postal Service and how much the people of Alaska are dependent upon the aviation industry. (In other words, privatizing the USPS would be devastating for Alaska.)

As always, thanks to all of you, especially the paid subscribers, for your kind support of my work.

1. I also look at Part 133 which is rotorcraft external operations, like logging. If the company was a Part 135 that was operating under Part 133 at the time of an accident, then I include it in my spreadsheet.

2. I’m always nervous to put an exact number on a figure like this because without fail, I will later find some accident that I missed or, in the case of 2023, a lot of accidents are still open and do not have anything other than a single page description listed in the NTSB database and it’s impossible to tell if they involved a Part 135 or not. So, the 330 figure could creep up a little bit as reports are finalized next year. (I’m honestly freaked out right now that I’ve missed something in putting together this newsletter.)

3. One of the Air Methods accidents was on a Part 91 flight that was not related to medevac operations at all, so I have included it as a Part 135-involved flight, but not a medevac flight. (Now do you see how complicated this classification business can get?)

4. Originally it was going to be a 2024 pitched article but got delayed by lawsuit drama. I am planning to pitch it next year and I’m also submitting a grant proposal for financial support in researching it.

5. It’s the sort of work that could be done for a funded academic position or someone in the NTSB or FAA. If someone wants to pay me to do it, I’m ready to send out FOIA requests right now.

6. Everything, including this newsletter, was delayed this week by my husband’s emergency appendectomy. He’s on the mend, but that was 2024 just kicking us one more time.