Analysis of a Tragedy

This article is featured in our upcoming BJT Buyers' Guide , which will be published soon. Make sure you are signed up for a free copy here.

Federal aviation regulations include a rule that says pilots cannot “operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.” No such federal rule applies to passengers, although accident records show that from time to time, they essentially conduct themselves in a careless and reckless manner.
A BJT review of turbine business aircraft accident reports over the last 25 years reveals several notable occurrences when passengers, operators, or owners unwittingly contributed to the accident’s probable cause or the degree of injury, including to themselves or others. In many cases, the aircraft owner or operator implicated in an accident was not onboard the aircraft when it crashed.

If in Doubt, Don’t Move About

The most common type of injury to passengers results from not wearing a seat belt. While this might seem obvious, in some situations it’s not as easy as it sounds to ask folks to buckle up. For instance, note the confusion in this March 3, 2023 accident of a corporate jet in which an unrestrained passenger perished when the pilot inadvertently induced unexpected, sudden, and severe up and down movements of the aircraft. According to accident investigators, the seat belt fasten sign always being on during the flight likely caused the confusion.

In post-accident interviews with investigators, the captain reported that the seat belt sign was on for the entire flight and that his regular practice was never to turn it off. “It is likely that the passengers had no expectation for the seat belt sign to be turned off at any time during the flight, given that they regularly flew with this flight crew,” said investigators in the final report. “As a result, the passengers had to use their own judgment regarding whether it was safe to get up and move about the cabin. Had the flight crew used proper procedures, the passengers would have been warned of possible oscillations and [the crew] could have made an announcement to ensure that they were indeed seated with their seat belts fastened.”

Regardless of the investigation conclusion in the aforementioned accident, many operations fly with the seat belt sign on at all times to be safely prepared throughout the flight for surprise turbulence, as might happen in clear air or from the wake of a larger jet ahead, as we see in the next scenario.

On Aug. 8, 2019, a private jet flying in smooth air suddenly encountered unexpected wake turbulence. The seat belt sign was off. Unsecured objects, passengers, and the flight attendant were thrown about the cabin, resulting in several minor injuries and one serious injury to a passenger. Investigators attributed the injuries to the seat belt sign being off.

On March 21, 2018, three passengers on a business jet were injured when they ignored the seat belt sign that had just chimed and illuminated. The crew was desperately trying to get the passengers attention by flashing the sign on and off. During the descent for arrival, the pilots turned on the fasten seat belt sign and flashed the sign again when the airplane began encountering light turbulence. Despite the flight crew’s multiple seat belt warnings, three of the five passengers were not strapped in during the turbulence. One of the unbelted passengers was seriously injured, while the other two received minor injuries.

Timing was everything in the Nov. 21, 2021 accident that happened on a fractional operation. While in cruise flight, with the seat belt sign off, unexpected light turbulence started to buffet the airplane. The crew turned on the seat belt sign. Moments later, the flight encountered moderate turbulence just as one of the passengers was returning to his seat from the lavatory. The passenger fell and broke several ribs.

A passenger was hurt under similar circumstances on a March 29, 2022 flight in a corporate turboprop. The pilot reported that while descending, the airplane encountered “a sudden pocket” of severe clear air turbulence. Just before the encounter, the seat belt sign was activated, and the passengers were verbally instructed by the pilot to make sure their seat belts were on. A passenger who was in the process of restraining himself when the turbulence hit banged his head on the cabin ceiling, causing a serious injury.

An airplane owner was bounced against the sidewall and seriously injured on a March 1, 2015 flight when he stood up while his business jet was still in motion. After landing, the pilot was unable to stop the jet on the remaining runway. It rolled off the end of the runway for several hundred feet and was substantially damaged. The other five passengers aboard kept their seat belts on until the aircraft’s motion ended. The owner had stood up to go to the cabin entry door before it became clear to him that the airplane was not going to stop on the runway.

Staying Safe on the Surface

Passengers also have to be cautious when the aircraft is on the ground, whether it’s moving or not. A fractional operator reported that, after landing, while parked at the ramp, the pilot left the flight deck to open the cabin door. He “found the lead passenger standing in front of the main cabin door waiting to exit the aircraft,” said the investigation report. “The pilot was able to open the door, but did not have room to exit ahead of the passenger as was normal procedure.” As she started down the airplane’s airstairs, her foot slipped. She landed on her knees and was able to catch her balance by grabbing onto the hand rails, but not before she fractured her ankle.

During a brake check while taxiing out for takeoff on Dec. 30, 2005, a passenger had released her seat belt to switch seats, when a sudden stoppage occurred. She fell into the aisle. After the co-pilot helped her, she decided to continue the trip to its destination. About one week later, the pilot learned that she had a hairline fracture on her collarbone.

After a corporate turboprop twin landed at night and stopped on the ramp on June 15, 2001, a passenger was seriously injured by walking into a propeller blade after exiting the aircraft. “It was dark out. I exited the plane to proceed to the hangar,” she told investigators. “There was no ground support crew, stairway, or ladder to exit the plane. There was no lighting. The pilot gave no commands prior to passengers exiting…or what direction to go once we exited. As it turned out, once you exited the plane, the direction to the hangar put you in a path directly into the propeller.”

According to the investigation report, however, there was a ground crew present, and they said “she just ran into the back side of the [windmilling] prop and [we] could not stop her.” It was stated by one of the other passengers that she desperately needed to use the bathroom and “just bolted when the aircraft stopped.” Investigators faulted the passenger for the accident.

One rule of thumb: unless directed otherwise by a ground or air crew member, when exiting, walk straight out and don’t make any turns until you have reached at least the end of the wing. Exiting helicopters requires extra vigilance because if the main rotor blades are not rotating, they can droop to the height of an average person. Beware that tail rotors also pose a risk.

Pressuring the Pilot

Pressing demands—subtle or blatant—on the crew to land at the planned destination under any circumstances is not justified. It could be interpreted as “interfering” with the duties of the crew, prohibited by federal regulations. More importantly, it adds unnecessary stress on the pilots, who are already under self-imposed pressure to arrive at the intended destination on time. An owner was guilty of this in a recent fatal accident of a business helicopter.

On July 4, 2019, a twin-engine turbine helicopter crashed into the sea after taking off on a dark moonless night over water. The two pilots and five passengers were killed. Investigators said the probable cause was spatial disorientation, which happens when pilots suddenly lose their sense of position, direction, and motion when there are no external visual references. Contributing to the pilots’ decision to make the flight was “external pressure” via direct communication from the helicopter owner.

Six people died on Feb. 7, 1990, when a single-engine turbine helicopter crashed while trying to land at a remote site during snow squalls. The pilot could not recall the accident, and the surviving passenger refused to be interviewed by investigators. A former employee reported that “company officials pressured pilots to complete their flights in spite of marginal weather conditions.”

Charter and tour operators competing for passenger business have also been blamed in accidents for pressuring their pilots to complete missions. The June 25, 2015 fatal crash of a single-engine tour turboprop is a case in point. Investigators determined that the probable cause of this accident was the pilot’s decision to fly into poor visibility and the operating company’s culture, “which tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures…affecting air tour operators; [the company’s] lack of a formal safety program; and its inadequate operational control of flight releases.”

Be careful what you wish for is an apt description for the following May 5, 2021 accident: After becoming aware that another business jet flying to the same destination was scheduled to arrive two minutes sooner, the crew of the accident airplane increased speed to complete the flight first. The final investigation report concluded that this was done to “accommodate passenger wishes.”

On the cockpit voice recorder, the pilot said, “I’ll speed up. I’ll go real fast here.” Apparently, they went too fast because heard on the cockpit voice recorder was the overspeed warning tone. Seconds from landing the captain stated, “goal achieved,” and the co-pilot remarked, “final lap.” They won the race, but the victory was fleeting. The aircraft’s excessive speed on landing caused the airplane to overshoot the end of the runway and end up substantially damaged. No one was injured. Investigators said the accident was due in part to the crew’s “motivation and response to external pressures to complete the flight as quickly as possible to accommodate passenger wishes.”

On March 29, 2001, one of the most tragic and avoidable business aircraft accidents on record killed all 18 aboard. As soon as the pilots warned the passengers that the weather at their destination may force them to fly to an alternate airport, demands to complete the flight were constant and unrelenting. The 15 passengers, a flight attendant, and the two pilots were killed when the chartered business jet crashed on a dark and stormy night. The passengers, the company that chartered the aircraft, and the charter operator were implicated in the cause. The aircraft’s onboard recorders and post-accident interviews unveil the main circumstances leading up to the accident.

First, the pilots were dealing with various sources of operational challenges, on top of which was the charter customer’s “near-demands” to land at their planned destination despite worsening weather.

Second, “According to the charter customer’s business assistant, his employer became irate when he was informed about the possible diversion to an alternate airport,” said the final report. “The business assistant also said that he was told to call the charter operator and emphasize that the airplane was not going to be redirected.”

Finally, the flight attendant escorted a passenger to the cockpit “jumpseat”—a fold-out seat directly behind the pilots. The presence of this passenger in the cockpit, especially his being a paying charter customer, “most likely further heightened the pressure on the flight crew to land” in deteriorating weather and after the airport’s nighttime curfew.

To discourage passengers and owners from putting crews in these kinds of untenable positions, many aircraft owners and charter companies require signed or verbal agreements that their passengers cannot make operational demands to the crew. Customers must acknowledge that the pilot has sole authority over the operation of the aircraft. This understanding is critical, and your life might depend on it.