NTSB neglecting duty on small plane crashes

The first flight of 8-year-old Caryn Stewart's life was supposed to be a quick sightseeing tour over eastern Iowa in her uncle's four-seat Piper Cherokee.

Nervous and excited, she sat quietly behind her mother and next to her sister as Andy Bryan, a cousin, drove the single-engine plane down Runway 17 at Scott Municipal Airport.

The airplane elevated briefly and plunged into a field where it exploded into flames. Caryn suffered severe burns that scarred her torso, back, arms, legs and face. Her mother, cousin and 11-year-old sister were killed, part of a massive and growing death toll from small-aircraft crashes.

Manufacturing companies and federal investigators would say Bryan lost control of the Piper on that Easter Sunday in 2005. But company documents and government records pointed to a different cause: a faulty carburetor that the manufacturer later urged airplane owners to remove because it was causing engine failures.

Nearly 45,000 people have been killed over the past five decades in private planes and helicopters — almost nine times the number that have died in airline crashes — and federal investigators have cited pilots as causing or contributing to 86% of private crashes. But a USA TODAY investigation shows repeated instances in which crashes, deaths and injuries were caused by defective parts and dangerous designs, casting doubt on government rulings and revealing the inner workings of an industry hit so hard by legal claims that it sought and won liability protection from Congress.

Wide-ranging defects have persisted for years as manufacturers covered up problems, lied to federal regulators and failed to remedy known malfunctions, USA TODAY found. Some defective parts remained in use for decades — and some are still in use — because manufacturers refused to acknowledge or recall the suspect parts or issued a limited recall that left dangerous components in hundreds of aircraft.

The manufacturers involved paid hundreds of millions of dollars in settlements that received little or no public attention until now and that need not be disclosed to federal regulators. In addition, civil-court judges and juries have found major manufacturers such as Cessna, Robinson Helicopter, Mitsubishi Aircraft, Bell Helicopter and Lycoming Engines liable for deadly crashes, ordering them to pay hundreds of millions of dollars in compensatory and punitive damages.

The verdicts contradict findings of the National Transportation Safety Board, which typically conducts limited investigations into crashes of private aircraft and asks manufacturers to look for defects in their parts, even if the manufacturers are being sued over a crash.

Judges and juries have spent weeks hearing cases that took years to prepare and unearthed evidence that NTSB investigations never discovered.

A Florida judge, finding that Cessna Aircraft Co. had known for "many years" of a potentially lethal defect in thousands of planes but hadn't fixed it, wrote in 2001 that the company could be guilty of "a reckless disregard for human life equivalent to manslaughter."

A USA TODAY review of tens of thousands of pages of internal company records, lawsuits and government documents found defects implicated in a series of fatal crashes of small planes and helicopters. The deadly defects include:

  • Helicopter fuel tanks that easily rupture and ignite, causing scores of people to be burned alive after low-impact crashes that were otherwise survivable;

  • Pilot seats that suddenly slide backward, making airplanes nose-dive when pilots lose grip of the controls;

  • Ice-protection systems that fail to keep airplane wings clean during flight and fail to warn pilots of dangerous ice buildup that causes crashes;

  • Helicopter blades that flap wildly in flight and separate from the mast or cut through the helicopter tail;

  • Airplane exhaust systems that leak exhaust gas, causing engine fires;

  • Carburetors such as the one in the Iowa crash that flood or starve engines and had been causing midair engine failures since at least 1963 when the federal government notified the manufacturer of "a serious problem" with its carburetor that had caused a recent fatal crash.

Manufacturers say crashes are caused by pilot errors or neglect of their aircraft.

After the Iowa crash, engine maker Lycoming and carburetor maker Precision Airmotive blamed the pilot in the face of a lawsuit by Caryn Stewart's father and uncle. In April 2013, after a judge rejected Lycoming's request to throw out the case, the companies paid the two men a $19 million settlement, court records show.

Ruling against Lycoming, Philadelphia Judge Matthew Carrafiello found evidence that the company might be culpable. Carburetor problems "have persisted since the 1960s," the judge found. Lycoming had returned "copious amounts of faulty carburetors" to its supplier and the company "knew of ongoing problems" with the carburetors "and of numerous plane crashes resulting from such problems."

None of that information was included in the NTSB investigation, which was aided by Lycoming and Precision and blamed Andy Bryan, the pilot, for "failure to abort the takeoff" and "failure to maintain adequate airspeed during takeoff."

"It was just like a conviction when they said that," said Greg Bryan, Andy's father and the airplane owner. "That's your son's legacy — our family's legacy — that we did something to cause this terrible accident."

Chapter 2: Small planes, helicopters crash three times per day

The danger of private airplanes and helicopters — known as "general aviation" — far exceeds that of airline flight. In 2013 alone, there were 1,199 general-aviation crashes — more than three per day on average —killing 347 people, injuring 571 and destroying 121 aircraft, federal records show.

A domestic passenger airline hasn't crashed since Feb. 12, 2009, when 50 died on Colgan Air Flight 3407 near Buffalo.

While the airline crash rate has plummeted to near zero, the general-aviation rate is unchanged from 15 years ago — and roughly 40 times higher than for airlines.

"When you look at aviation, the place where people are getting killed is general aviation. Year after year, we are killing hundreds of people in general aviation," said former NTSB chairwoman Deborah Hersman, who left in April to become president of the National Safety Council.

The crashes have killed tens of thousands of amateur pilots in single-engine airplanes, police and rescue workers in emergency helicopters, farmers in agricultural sprayers and business executives in corporate jets.

No other country has a similar death toll. The U.S. has more than twice as many general-aviation aircraft as every other nation combined and is home to leading manufacturers and a powerful lobby, which persuaded Congress in 1994 to bar injury and death claims involving aircraft and parts that are more than 18 years old. That is important protection: Roughly three-quarters of the nation's 220,000 general-aviation aircraft are more than 18 years old.

The law was enacted after multimillion-dollar settlements and verdicts — including a $29 million verdict against Cessna for a crash that killed three and $22 million against Mitsubishi for a crash that killed five — which escalated insurance costs and forced some manufacturers into bankruptcy.

Judges have dismissed many lawsuits under the 1994 law. But major verdicts continue because the law allows claims concerning newer parts and against manufacturers that allegedly covered up defects.

USA TODAY found 80 lawsuits involving 215 general-aviation deaths since 1994 that resulted in a manufacturer paying a settlement or damages of at least $1 million. The verdicts include $70 million against General Electric for a helicopter crash that killed nine; $48 million against parts-maker Doncasters for a crash that killed six, and $26 million against Lycoming for a crash that killed three, including a 10-year-old girl.

As damages have mounted, manufacturers have stonewalled plaintiffs' attorneys and federal officials in recent major cases. Judges have sanctioned and scolded companies for withholding information in at least a dozen cases, USA TODAY found.

The $26 million verdict against Lycoming came in a carburetor-defect lawsuit after a judge found the company had repeatedly refused to turn over documents to plaintiffs. In February 2013, Washington state Judge Monica Benton found that Lycoming "has been in continuing contempt of court" since 2011 and decided to hold it liable for the 2008 crash. A jury later awarded the surviving family $26 million, which includes $6 million in punitive damages. The award is being appealed.

In a lawsuit blaming a crash on a failure of a computerized cockpit display, federal magistrate Janice Stewart of Oregon rebuked manufacturer Avidyne Corp. in a 2010 hearing for its "failure to produce" documents, calling it, "at best, grossly negligent."

The government was stonewalled, too. Two years earlier, when the NTSB investigated failures of the cockpit displays, Avidyne refused to give the board information about displays that had malfunctioned. Avidyne called the request "overly broad, not relevant and onerous," according to NTSB records.

Sikorsky Aircraft withheld from the NTSB and plaintiffs an analysis it did in 2009 after seven oil workers and a pilot were killed when one of its helicopters crashed en route to a Gulf of Mexico oil rig. Sikorsky did not release the analysis, which showed problems with its helicopter model that crashed, until nearly 11/2 years after it was written — three months after the NTSB cleared the company.

Federal magistrate Karen Wells Roby wrote that "the only plausible reason" for Sikorsky's delay is because the analysis was "adverse to Sikorsky's interests." Roby ordered Sikorsky to pay $577,000 in legal penalties.

Chapter 3: Post-crash fires threaten helicopter passengers

One of the most gruesome and longstanding aircraft problems has caused scores of people to be burned alive or asphyxiated in fires that erupt after helicopter crashes. Such deaths are notorious because they occur after minor crashes, hard landings and rollovers that themselves don't kill or even injure helicopter occupants. The impact can rupture helicopter fuel tanks, sending fuel gushing out, where it ignites into a lethal inferno.

Using autopsy reports and crash records, USA TODAY identified 78 people killed by helicopter fires since 1992. In 36 non-fatal crashes, fire destroyed or substantially damaged helicopters after minor incidents such as rollovers, crash reports show.

Although crash-resistant fuel tanks have been available since the early 1970s, when the Army installed them and dramatically reduced soldiers' deaths, many manufacturers have not bothered because of the added cost, which the FAA has estimated at several thousand dollars per tank.

"If it's cheaper to let you die than to fix it, you're going to die," said Harry Robertson, who invented the crash-resistant "Robbie tanks" for the Army and is in the National Aviation Hall of Fame.

Robinson Helicopter Co. of Torrance, Calif., came up with a solution in 2006 that cost the company nothing. It issued Safety Notice SN-40, advising pilots and passengers to wear fire-retardant Nomex fiber suits to protect themselves in a fire.

Company President Kurt Robinson said in an interview that the notice was issued because of a crash three months earlier in Fredericksburg, Texas. A Robinson R-44 clipped a power line, fell to the ground and erupted in flames. Alec Beck died of burns and smoke inhalation, with "no evidence of blunt force trauma," and Gayla Leonard died of smoke inhalation and did not break a bone, according to their autopsy reports. Pilot Craig Nemec lived for 14 months with burns over half his body, had both arms amputated, lost his vision and underwent roughly 20 surgeries, his wife, Ellen Nemec said. In June 2007, he died.

Robinson's Nomex-suit advisory appears to have had little effect. There were 320 Robinson helicopter crashes in the U.S. after it was issued; not a single occupant was wearing a Nomex suit, NTSB reports show. "It was ignored by a large group of people," Robinson said.

Nemec called the advisory "absurd" and began pushing Robinson to make safer fuel tanks.

Safety experts and officials have recently warned about the fuel tank in the R-44, one of the world's best-selling helicopters. Its two aluminum fuel tanks are packed on either side of a 3-inch-thick steel mast that controls the rotor, said William Waldock, a crash expert at Embry-Riddle Aeronautical University in Arizona, who has been an expert witness in lawsuits against Robinson. If the helicopter rolls onto its side, the mast can rupture a tank, sending jets of fuel spurting forward into the cockpit to be ignited by a spark, he said.

"I've looked at about 14 of these, and you see essentially the same pattern in each one," Waldock said.

Problems became apparent less than a year after the R-44 went on the market when a 1993 crash killed three people near Los Angeles. Pilot Benjamin Venti Jr. and passenger Nicholas Lovoy both died from "inhalation of products of combustion and thermal burns," the Los Angeles County Coroner found. A total of 14 people have been killed and seven injured in the U.S. from post-crash fires of the R-44 and the Robinson R-22, an earlier model, crash records and autopsy reports show.

But it wasn't until roughly 2006 that Robinson began developing Kevlar fuel-tank bladders to be installed in its R-44s and R-22s. The company started selling the bladders in late 2009, for $6,800, and installing them on its new helicopters. Kurt Robinson said the bladders "significantly enhance safety" and defended the helicopters' safety record, noting that they complied with FAA regulations. Robinson became company president in 2010 and said he can't speak to crashes before then.

In March 2013, the Australian Civil Aviation Authority ordered all R-44 owners to install fuel bladders within a month or be barred from flight. Three "low-energy" R-44 crashes in Australia since 2011 had caused fires and killed eight people, the authority said.

The NTSB in January asked the FAA to issue a similar order, citing lethal R-44 fires in the U.S. The FAA said in reply that the R-44 "does not appear significantly different" from similar helicopters in terms of fire risk and is studying the matter.

After her husband's death, Ellen Nemec learned about earlier R-44 crashes that sparked deadly fires, and grew angry at the company. "Had it not been for this really insufficient fuel tank that Robinson knew about," she said, "this would have been just a bad landing."

Chapter 4: Pilot seats slide back unexpectedly, leading to dozens of crashes

Some problems have persisted for decades as manufacturers have minimized dangers and struggled to develop solutions, which has resulted in huge jury verdicts.

As early as the 1960s, pilots and NTSB investigators were reporting that Cessna pilot seats were sliding backward on the rails designed to grip them. Airplanes crashed when pins that held seats in rail holes popped out, letting seats slide so far back that pilots could not reach the controls.

"Pilot's seat slid to full rear position on bounced landing," the NTSB wrote of a Cessna 172 hard landing on Aug. 18, 1966, in New Jersey.

Similar reports followed: "Pilot's seat slid back. Unable to reach controls" (April 11, 1969, Alaska). "Pilot's seat unlatched and moved rearward during takeoff roll" (Aug. 30, 1969, Milwaukee). "Pilot seat not locked before takeoff, seat slid back" (Aug. 8, 1971, Pennsylvania).

After addressing the problem in 1975 on its military models by suggesting the replacement of worn parts, Cessna waited until 1983 to notify civilian owners — 17 years after the NTSB first noted a problem.

But Cessna's civilian notice was a low-priority "service information letter," which said nothing about the danger of a seat sliding backwards. Its title: "Seat rail inspection guidelines."

By the mid-1980s, NTSB reports found seat sliding in 36 Cessna crashes that killed five people and injured 12. Cessna had already been sued over four other crashes that killed nine. A New Jersey jury ordered Cessna to pay $29.3 million, including $25 million in punitive damages, for 1980 crash that killed three. The case settled for $13 million, court records show.

Cessna insisted that the crashes were caused by pilots who didn't maintain the seats. The company said in a statement to USA TODAY that its aircraft are safe "when they are used and maintained as required by published guidance."

But when the FAA proposed in 1987 requiring Cessna owners to inspect seat rails and replace the worn parts, the company grew worried.

Mandatory seat-rail inspection "would result in a significant number of seat rails that required replacement," Cessna said in an Aug. 7, 1987, letter to the FAA.

The problem, Cessna added, is that "with present production capabilities, we would be unable to supply massive quantities of rails." That could ground thousands of airplanes if their seat rails were found to be worn and replacements weren't available.

The FAA tried to accommodate, according to a Sept. 4, 1987, agency memo, and encouraged Cessna to develop "an inexpensive interim modification for defective seat rails that would prevent aircraft groundings."

Cessna developed and began selling the inexpensive modification, but it was difficult to install and involved "awkward operation," Cessna noted in an internal memo. Cessna owners, who could choose whether or not to buy the modification, were so reluctant that the company estimated replacing every seat rail would take 600 years.

The crashes continued. On Aug. 14, 1989, James Cassoutt, his wife, Cindy Cassoutt, and a friend, Judy Kealey, suffered extensive fractures, burns and organ injuries when Cassoutt crashed his Cessna A-185E, which did not have the new part. After a Florida judge found that Cessna's responses to the seat problems "were neither timely nor adequate," a Florida jury awarded the three a $480 million verdict, including $400 million in punitive damages. The 2001 case settled for $41 million, court records show.

Cessna developed a safety device in 2007 that would stop a seat from sliding if the rail pins came loose, but it's unclear how many pilots installed them because the FAA never mandated their installation, despite a plea by Cessna.

In 2011, as the crashes continued, the FAA required Cessna owners to conduct more thorough inspections than previously ordered, finding that "inadvertent seat movement continues to be a safety issue."

Chapter 5: Multiple crashes tied to a fractured engine bolt

Other manufacturers have moved quickly to replace defective parts but with recalls that are as limited as possible and leave potentially defective parts in many aircraft.

Lycoming Engines faced a choice when it discovered in 1998 that two helicopters lost engine power because a bolt fractured in each of their Lycoming engines.

No one was hurt. But Lycoming had to decide what to do about thousands of similar bolts in its stockroom and inside various helicopter and airplane models.

The company recalled about 160 bolts from helicopters and removed 4,250 bolts from its stockroom "as a purely precautionary measure," according to a statement Lycoming gave the NTSB.

Lycoming issued no recall or warning for the roughly 1,100 similar bolts still in airplanes. Bolt fractures were "limited to helicopter applications," the company believed. The FAA agreed.

By early 2001, bolt fractures had caused engine failure in three Lycoming-powered planes, including two Royal Jordanian Falcons, a rare model of aerobatic aircraft, and the popular Piper Saratoga II. There were no injuries.

Facing another decision, Lycoming again took minimal action. It replaced bolts in all Falcons, which was easy and cheap because there were only five of the airplanes. The hundreds of Piper Saratoga II owners got no recall or warning.

Bolt fractures "were not thought to extend beyond helicopter and aerobatic applications," Lycoming told the NTSB. The FAA agreed again.

On June 7, 2002, Mississippi dentist Mark Williams was flying his Lycoming-powered Piper Saratoga II near home when the engine suddenly stopped. Williams crashed, and suffered severe fractures and internal bleeding for which Lycoming later paid him $2.85 million, according to court papers. A Lycoming metallurgist wrote that the "primary cause of engine failure" was a fractured engine bolt.

Lycoming took no immediate action. The company declined to comment on the bolt fractures.

On Sept. 8, 2002, a Piper Saratoga II flying out of New Jersey lost engine power and crashed. Two boys, ages 8 and 5, were severely burned but survived. Their parents, Michael and Sandy Kirkley, died in the crash. The FAA quickly pinpointed the cause as bolt fracture, prompting Lycoming to recall crankshaft bolts on roughly 1,000 engines in dozens of types of airplanes, including the Piper Saratoga II.

Williams received the recall notice around his 40th birthday and remembers thinking, "I would have loved to be one of the people in the recall opposed to the one who is the reason why there is a recall."

Chapter 6: Judge cites "outrageous conduct" by carburetor maker

The carburetor defects blamed for the crash that killed Caryn Stewart's mother and sister exemplify how manufacturers have endangered the public by trying to avoid recalls that would cost companies millions.

The carburetor problems involve a small component called a "float," which controls the fuel level in a carburetor pontoon in the same way a toilet-bowl float controls the water level in a bowl cabinet.

But manufacturers have repeatedly lied about what was making the floats become saturated with fuel and cause engine failure.

In the 1970s, carburetor maker Borg-Warner found that the floats' rubber composition caused them to absorb fuel, company memos show. Faced with a potentially costly recall, Borg-Warner told the FAA something different: Pilots caused the saturation by using automotive gas instead of aviation fuel.

"This statement to the FAA is in fact false," an Alaska judge wrote in 1990, awarding $6.7 million to the widow of a man killed in a 1986 crash in Alaska. The cost of replacing the defective floats would have been $23 million, which the manufacturer likely would have paid "if a manufacturing defect was acknowledged," Judge Jay Hodges wrote. The company's "failure to disclose" the actual cause of the problems "is outrageous conduct."

Hodges' verdict included $5 million in punitive damages — but it didn't stop the defects or the deception.

A new generation of floats made of brass were widely installed, but those too began causing engine failure. After a company called Precision Airmotive bought the carburetor line in the 1990s, it began making plastic floats to replace metal floats that "malfunction when a leak develops," according to a patent for the plastic float.

Yet when Precision announced the availability of its plastic floats in 1998, it said nothing about malfunctions with the brass floats. The announcement said that the new float would "improve service life and resistance to damage." The company said it would sell only its new plastic floats, but added that "brass floats may be used until stock is exhausted."

A brass float was in a Piper Cherokee that crashed Aug. 1, 1999, in Ohio, killing four and seriously injuring a teenage boy. A jury later awarded $89 million, including $64 million in punitive damages. The case settled for $20 million, according to court records.

The plastic float was the next iteration to cause engine problems, which began in the 2000s. This time, Lycoming got involved, and in late 2005 it e-mailed Precision to say that the plastic floats "can leak, allowing fuel to enter the interior of the float." At the same time, Lycoming ordered Precision to stop using plastic floats in its carburetors and to use only a new model of floats made from foam.

But Lycoming allowed plastic floats to remain in engines that were already installed in airplanes, including the Cessna 172N that Brenda Houston, a United Airlines pilot, was flying with her 10-year-old daughter and Virgil Becker in Washington state on July 27, 2008. All three were killed in a crash.

"Lycoming had a fix for that problem in December 2005," attorney Matthew Clarke told the Washington jury that awarded $26 million in damages, "but they didn't do anything to tell the thousands of people out in the field."


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