[Editor’s note: Today we bring you a guest submission by Leon “Pete” Kelley, an FAA Aviation Safety Inspector, following the recent release of the NTSB’s final report on the fatal Oct. 1, 2023 crash involving aviation safety advocate, Richard McSpadden Jr.]
Buddy Holly and the Day the Music Died
On Feb. 3, 1959, Buddy Holly was killed in a plane crash near Clear Lake, Iowa. When the Rock & Roll Hall of Fame was created in 1986, John Fogerty inducted Buddy Holly. The class of 1986 also included Elvis Presley, Chuck Berry, James Brown, Ray Charles, Little Richard, Jerry Lee Lewis and Robert Johnson. Not bad company!
In 1954, Buddy Holly launched a musical revolution by modernizing traditional genres, including blues, country, and bluegrass, for a youthful audience. He brought an innovative approach to songwriting and a unique sound that set him apart from other musicians of his time.
Don McLean’s song “American Pie” was released in 1971 and was the No. 1 U.S. hit for four weeks in 1972. The song repeated the lyric “the day the music died,” referring to the Feb. 3, 1959, crash, and the phrase became popularly synonymous with it.
“American Pie” reflected the deep cultural changes, profound disillusion and loss of innocence experienced by many from McLean’s generation. McLean later revealed the meaning of the song’s lyrics when they, along with a manuscript and notes, were sold at auction for $1.2 million in 1995.
He said that, basically, things were heading in the wrong direction, life was becoming less idyllic, and that it was a morality song in a sense.
Richard McSpadden Jr. and the Call for Aviation Safety
The NTSB published the final report last month on an accident that claimed the life of a consequential advocate for aviation safety.
On Oct. 1, 2023, Richard McSpadden Jr., the preeminent advocate for aviation safety in general aviation and AOPA’s Air Safety Institute senior vice president, died in an airplane accident near Lake Placid, New York. The aircraft was returning to the airport due to a partial loss of engine power for undetermined reasons.
McSpadden, a former commander of the Air Force Thunderbirds, was a highly respected accident analyst. AOPA reported that during his tenure leading the Air Safety Institute, McSpadden ushered AOPA’s safety education arm into the YouTube era, introducing a popular new video series focused on improving the general aviation safety record and expanding pilots’ knowledge and skills.
His approach centered on five principles of safety: have knowledgeable people, train them well, keep them proficient, put them in reliable, modern equipment and surround them in a culture that supports good decision-making.
It’s the reliable equipment portion of his safety prescription that contributed to his death, and this is what we should advocate for to honor him.
Measuring McSpadden’s Legacy
If we created an Aviation Safety Hall of Fame today, I would induct Richard McSpadden Jr. The inaugural class could include, along with McSpadden, Jerome “Jerry” Lederer, C.O. Miller, Dr. S. Harry Robertson III, James Reason, Sidney Dekker, Bill Waldock and Jeff Guzzetti—very good company.
I hope that McSpadden’s death can have an enduring legacy and impact on aviation safety by drawing attention to an aspect of aviation safety that needs advocacy: ensuring safe, reliable, and airworthy aircraft.
The Principles of Maintenance and the Culture of Safety
McSpadden’s five principles of safety for aircraft maintenance would be: have knowledgeable mechanics, train them well, keep them proficient, provide them with appropriate tools and test equipment, and surround them in a culture that supports good decision-making.
Time and cost pressures work against all these principles.
It is the intent of the regulations that require inspection of aircraft and the performance of maintenance between required inspections that the result be safe, reliable, airworthy aircraft. When this required outcome is not obtained, it so seldom results in death that it becomes a siren’s song with the lyric that inadequate maintenance is safe.
Inappropriate and inadequate maintenance practices, including failure to follow procedures, can too often become a normalized deviation from what the regulations require. We become seduced into thinking this new normal is safe enough when, in fact, it is not. Then, very occasionally, it results in tragedy.
The causes of inspection failure and the ineffectual performance of maintenance are too seldom determined or adequately addressed in accident investigations or the aggregate analysis of accidents. To honor the safety advocate Richard McSpadden Jr., we should all advocate for improving the practice of aviation maintenance in general aviation.
Disclaimer
The guest author is an FAA ASI. The views expressed here do not represent the views of the United States, the U.S. Department of Transportation, the Federal Aviation Administration or any other federal agency.
Safety never dies. However, it takes a real personal commitment to keep it alive.
One should never ever take the soft option. Just because a pilot gets away on one occasion with scud running does not make that an argument that it is a safe practice, per se! Think, “Get Home Itis”
Good safety requires unwavering discipline in accepting professional/industry standards and not something that is expedient at the time.
BJS
Safety is a lot more complicated than we think because of the ‘human’ us. I would point anyone who has an interest in this subject to a great book by Prof Sidney Dekker ‘The Field Guide to Understanding Human Error’. It’s not expensive and it’s very readable - and opened my eyes to a very different way of looking at safety and what to do when bad things happen
I’m not going to second guess the decisions that were made. I don’t have all the evidence, but from what I understand, there weren’t many good options available at this particular airport should an engine malfunction shortly after takeoff. Sometimes even the very best decisions are unable to guarantee a safe outcome. Such is the nature of the aviation world we inhabit. If we decide to leave the ground, we must eventually return to earth and there are no risk-free alternatives even in the best of conditions and in perfectly good aircraft.
Be careful out there, be safe out there… and RIP when the worst occurs.
The Impossible Turn claims the most experienced and the most inexperienced. The only way not to end up in a smoking hole is not to attempt it, yet every month somebody will take a try it.
The long awaited release of the NTSB report on the McSpadden accident really leaves more questions open than it solves. While we can conclude there were engine performance issues, what I find more disturbing is the fact that the NTSB comes up with the conclusion that performance issues were due to ‘undetermined reasons’ . What the NTSB did focus on as contributory to the actual accident where weight and balance issues and performance issues related to density altitude / center of gravity as well as pilot performance.
Over the last five to 10 years ‘undetermined reasons’ seems to be a new mantra in NTSB investigative processes . To apparently focus blame on maintenance issues based on the information in this report seems t a little far fetched at this point . I do certainly agree that McSpadden would expand his logic of safety into the maintenance world . Unfortunately lacking specific factual evidence in any accident leads us to speculate on what specific chain of events may have been present and may have been obvious to an operator . Many accidents are going into the books as labeled ‘ambiguous’ and unfortunately it looks like this will be another one .
While Maintenance is a key safety factor so is adhering to the POH for the aircraft. I think in this case the focus of maintenance safety is misplaced and the focus on operation owithin the POH should have been stressed.
the report notes the cg was forward of the forward limit by an inch. this is not trivial.
from my reading of the NTSB report"
Lake Placid accident report quick summary
Engine sounded like not at full power. This should have been caught during run up . Sound analysis estimated 2150 rpm also indicative of low power. witness stated Longer take off than Beech.,(900 to 1300 feet. vs 900 feet book values) should have been an indicator. LKP runway 4200 feet. Brief white cannot be fully explained though the carbon fouling on the plugs may be indicative of the shutdown and start up depending on how this was performed. .
Aircraft post mortem noted discrepancies w fuel drain control and lifters neither were determined to be significant to aircraft operation. carbon fouling should have been noted on runup.
NOTE however CG was calculated w pilot information and fuel load to be 1 inch FORWARD of CG limit.Loading With Abandon - Aviation Consumer an article on weights and CG of popular aircraft.
The CG limit is determined to help facilitate safe flight. While safe flight is not guaranteed while flying within weight and cg limits once you are out of these you are in effect flying illegally, flying an unsafe aircraft, and basically a test pilot. The article glossed over these facts to hang on a perceived but unproven performance limitation caused by a yet unproven maintenance issue. The real safety issue seems to be the operation of the aircraft outside it POH and design limitations. Never a good idea.
from the above unless i missed something, outside the carbon fouling which should have been noted on runup w low rpm and or a larger than normal drop in rpm w magcheck there is no real reason to focus on the maintenance of this aircraft as the cause of the accident as much as the forward cg and the pilot not noting power issue on takeoff.
The conclusion that maintenance is at fault here seems dubious at best. I’m not seeing anything other than a vaguely worded statement about “engine power loss for undetermined reasons”. My limited understanding of this accident has caused me to conclude that the pilot attempted an impossible turn and came up short of the runway. It would seem that in the not too distant past, the same maneuver was performed with a successful outcome.