Jeff Guzzetti

NTSB Stresses the Importance of Aircraft Maintenance and SMS for Part 91 General Aviation Operators That Fly Paying Passengers

By Jeff Guzzetti

It’s about time.

The NTSB recently held two public Board Meetings to support the notion that preventing maintenance-related accidents is NOT just for the commercial airline industry that fly big jets under FAA’s stringent “Part 121” rules.  Sadly, several recent fatal accidents — all involving paying passengers — of small, propeller or rotor-driven general aviation (GA) aircraft have sullied the reputation of smaller commercial operations conducted under FAA “Part 91” rules. While the NTSB has a long history of concerns about these types of operations, the agency is no longer soft-peddling the issue.

During its meeting on March 26, the NTSB discussed and released their findings for a report entitled: Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under 14 CFR Part 91. ( The largest portion of GA activity consists of pilots flying for their own personal or business purposes in single‑engine airplanes. Passengers on these types of Part 91 flights usually know the pilot, and expectations about safety are based on personal relationships.  However, a wide variety of other GA operations can provide flight services for paying passengers who likely have no knowledge of the level of safety afforded by the pilot or aircraft.

These accidents represent small and diverse segments of GA that transport the public for money, yet are governed only by Part 91 regulations. Why? Because their flight purposes are either exempt from the rules that apply to air carriers or are not covered by any other regulations. These Part 91 operations, which carry thousands of paying passengers each year, are not held to the same maintenance, airworthiness, and operational standards as air carrier, on-demand, and air tour operations conducted under Parts 121, 135, and 136, respectively.  That needs to change.

These “excepted” operations include local commercial air tour flights, sightseeing flights in hot air balloons, parachute jump flights, and “living history” flights conducted aboard historical military aircraft. In addition, some Part 91 commercial operators have exploited these exceptions by carrying people for money for purposes other than the exceptions intended, allowing them to avoid more stringent rules.

The safety issues of Part 91 revenue passenger-carrying operations cited by the NTSB were based on the findings from eight fatal accident investigations between 2010 and 2019, including two recently concluded investigations of accidents in Hawaii and Connecticut:

  • On June 21, 2019, a Beech King Ai,  operated as a Part 91 local parachute jump flight, stalled and crashed after takeoff from Dillingham Airfield in Hawaii. The pilot and 10 passengers were fatally injured. The NTSB determined that the probable cause of this accident was the pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall.  However, they also stated that a significant contributor to the stall was: “the failure … to maintain the airplane in an airworthy condition and to detect and repair the airplane’s twisted left wing, which reduced the airplane’s stall margin.
  • On October 2, 2019, a Boeing B-17G bomber crashed during a precautionary landing at Bradley International Airport in Connecticut following an engine problem. Both pilots and five passengers were killed, while the crew chief and four passengers were seriously injured. The airplane was operated as a Part 91 local sightseeing flight.  The NTSB determined that the probable cause was the pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. However, the board also stated that a contributing factor was the “inadequate maintenance while the airplane was on tour, which resulted in the partial loss of engine power to the Nos. 3 and 4 engines”

Everyone knows that airlines have an extensive safety infrastructure, are subject to stringent safety rules of Parts 121, and receive the highest levels of FAA oversight. However, flights operated under Part 91 are subject to much less stringent pilot training and aircraft maintenance requirements with minimal Federal oversight. The Board expressed the need for greater safety requirements and oversight for these operations, and they issued new recommendations to the FAA to:

  • Develop safety standards or regulations for revenue passenger-carrying operations that are currently conducted under Part 91 including requirements for maintenance.
  • Identify shortcomings in the current regulatory exceptions that would allow revenue passenger-carrying operators to avoid stricter regulations and oversight in operations.

Two weeks later, on April 6, the NTSB met again to finalize its 2021 – 2022 “Most Wanted List of Transportation Safety Improvements.” (  The Most Wanted List is a communication tool through which the NTSB identifies its top safety improvements that — if executed — will prevent accidents. The list covers all modes of transportation, but the primary item for aviation is “Require and Verify the Effectiveness of Safety Management Systems(SMS) in All Revenue Passenger Carrying Aviation Operations.”  

The King Air and B-17G accidents were cited again in the meeting because the NTSB determined that, besides the inadequate maintenance, organizational safety management failures played a role in those accidents. The NTSB stated that widespread adoption of SMS by Part 91 (and Part 135) operators could have a positive safety impact. They also encouraged Part 91 and 135 operators to voluntarily implement such SMS  — while simultaneously urging the FAA to require them – so that the safety of these operations can be improved. SMS was designed to be scalable so that operators could integrate safety management practices tailored to their specific operation.

I recognize that the public likely does not expect small, GA flight operations to have the same level of safety that airlines do; however, it is not unreasonable for the public to expect flights that are, at a minimum, conducted in appropriately maintained aircraft. It’s about time that these smaller operations to stop hiding behind the exceptions whenever they provide flights to the public for money. 

Looking for the Bright Side by Remembering History

By John Arcari

John Arcari

I suspect a number of you aviation maintenance industry folks might know that I spent just short of thirty years service working for Pan American World Airways, from 1958 to 1987. When I resigned from Pan Am, I went on to become the VP, Aircraft Maintenance for Tower Air, an American flag carrier serving international destinations and supporting military personnel movement operations, worldwide.
I hired on with Pan Am in 1958 as an aircraft cleaner to work through the busy summer time flying schedule, cleaning airplanes in the hangar at our JFK, NYC Airport, main aircraft maintenance base. At that time, Juan Terry Trippe, our chairman& CEO, was a aviation legend in his own time. When Labor Day came by in September, I was made a full time employee and in October, 1958, I was upgraded to full aircraft mechanic. And…so began my journey of many years with Pan Am that proved to be so educational and fruitful in my life!
Trippe was a dreamer, and in the early 1920s after serving in the Navy during WWI, Trippe began to get the urge to go into the airline business. He knew the finance business, but he just darned loved airplanes. He got some of his Navy buddies and college pals to dig up some cash to invest in a Trippe scheme to fly from Key West Florida to Havana, Cuba carrying American and Cuban mail and a passenger here and there. So, in October of 1927, in a leased Fairchild FC-2,  Pan Am became alive and a real operating airline. On October 29, 1927 a Pan Am owned Fokker V11 Tri Motor made the return flight to the USA.
Now at that time the roaring twenties were still roaring, but the storm clouds of a massive destructive depression was on the way, worldwide, quite similar to our depressed situation today, with such hardship and fear for millions of folks here in the USA and around the entire world. The health crisis has heavily impacted our beloved airline industry. 

However, none of those negative circumstances stopped or derailed the “Trippe Dream” of having a worldwide airline system. So, before  Charles “Lucky Lindy” Lindbergh  jumped off on his historic non-stop flight from Long Island, New York to Paris, France, Trippe made certain he stumbled into “Lindy” on Long Island. He convinced Lindbergh to join Pan Am after his historical, non-stop  jaunt across the sea! Lucky Lindy and his wife Anne, whom Lindbergh taught to fly, worked as a team flying through thick and thin. Charles and Anne did pioneer flight activity through the 1930s Great Depression across the world, including laying out safe routes to Alaska,  Siberia,  Japan and China. They also mapped route excursions in Latin, South America and the Caribbean. They to were both dreamers.

Then came the pilot of the century Captain Edwin Musick, an auto racer auto mechanic and the best Pilot in the world, in my opinion. Musick rose to become the chief pilot at Pan Am very quickly and flew and commanded many pioneer flights beginning in Florida/Cuba and extending around the world. Sadly the magnificent Musick was killed in a crash in the Pago Pago area of the South Pacific, near American Samoa. Musick was honored across the world. All of these capers were accomplished in the hardest of times in the USA and round the world, the 1930s era of the Great Depression. The world was in pain, but Trippe, Lindbergh, Music and many others like them in our beloved industry, stayed the course and birthed the airline industry that has changed this world a number of times, for the positive.

Just keep in mind my great band of aviation brothers and sisters in common…more positives were yet to come from the dreams and likes of Trippe and Lindbergh. the Boeing 314 Clipper, the Boeing Stratoliner, the Boeing 707 and the Boeing 747 might have never been developed, if not for the inputs of both Trippe & Lindbergh!

Folks in our industry and folks in many other industries are hurting at this time…but I believe the end is in sight and we will all come back stronger than before. The simple fact remains, this world of ours cannot truly reach its great destiny of positives without out airplanes bringing us together, whether it be for business, pleasure, travel, new ventures, movement of supplies and goods or visiting out own beloved families and friends.

We simply must band together, support each of us that makes up this magnificent airline puzzle, have faith in each other and our industry.We will be OK soon, just as Trippe, Lindbergh nd Musick were as the 1930s Depression came to an end. We shall return, stronger, better and more successful then we ever were! Have Faith, trust each other and trust in our Lord and trust in yourselves…and most important never stop dreaming. At eighty years young, I am not a naysayer, a doomsday fool and I have not stopped believing in our great destiny yet to come. I have not stopped trying, I never give up dreaming and I never will until my days have ended. We are coming back. big time…the world awaits!  I want to hear these words uttered and uttered over and over again.  “Captain, we have tower clearance for take-off…V1… rotate, landing gear up!”

Off we go – the glory of flight will soon return!

AAR Paves the Way to Improve MRO Safety with SMS

By Jeff Guzzetti

You may have seen the news clip last month in Aviation Maintenance announcing that the FAA now recognizes AAR’s Aviation Services as the first independent MRO to have a fully functional Safety Management System (SMS).  “AAR´s SMS implementation meets the expectations of the Flight Standards Service SMS Voluntary Program guidance,” the FAA stated. “Thank you for your continued commitment to improve aviation safety … and congratulations on your momentous achievement.”

Momentous indeed.  Airworthiness is a critical aspect of aviation safety. This noteworthy achievement should grab the attention of our industry because of the example it sets for other MROs to prevent aircraft accidents and injuries. AAR is the largest independent MRO operator in North America and the third largest in the world. The company employs over 3,000 technicians and provides maintenance for over 950 aircraft and 24,000 components every year.

The recent “Part 5” requirement to implement a SMS has only been levied on Part 121 major airline operations and maintenance. Other aviation entities such as MROs, Part 135 operators and training providers do not (yet) require SMS.  Still, AAR went ahead and volunteered to meet the mandate anyway by participating in FAA’s SMS Voluntary Program.

This is no easy task – especially for a large MRO and especially if you want to do it right. Don’t believe me? Spend some time poking around FAA’s internet page entitled “Voluntary Implementation of SMS which can be found here:

As a former FAA and NTSB investigator, I know first-hand that accidents occur due to the unique operating environment of an organization. SMS is a process in which day-to-day safety issues are discovered, analyzed and corrected internally by the organization, not its regulator. With its emphasis on risk management, SMS fills the gaps between “common cause” risk factors that are addressed by traditional regulations and those that are more elusive within an individual operation.

SMS is a fundamental shift in the way companies do business in that it emphasizes safety management in the same manner as business management. It may be too much to expect, but I believe everyone in aviation should be able to rattle off the four components of a SMS as if they were required memory items:

  • Safety Policy— Establishing senior management’s commitment to continually improve safety
  • Safety Risk Management — Identifying and assessing hazards in order to control their risks
    • Safety Assurance — Evaluating risk control strategies with audits and self-reporting
  • Safety Promotion— Training and communications to promote a positive safety culture

The first type of recognition into the FAA’s SMS Voluntary Program is as an “Active Participant” which is attained when the local FAA certificate management team (CMT) acknowledges the MRO’s “Implementation Plan” and the CMT’s “Validation Project Plan” for SMS. The second and final step is the SMS “Active Conformance” acknowledgement — achieved once both plans have been executed as intended and the SMS has been validated by the FAA for its design and performance.

In AAR’s case, the company’s Rockford, Miami and Oklahoma facilities began their SMS development process in late 2018. The Rockford facility received “Active Conformance” status while Miami and Oklahoma City are “Active Participants.” The fourth of AAR’s four U.S. facilities is in Indianapolis and it will soon be joining the other three within a few months.  Safety is journey, not a destination, and AAR gets it.

AAR’s achievement is all the more impressive given its circumstances several years ago when it under public scrutiny for not always emulating the best safety and compliance practices. You may remember the negative publicity about an Allegiant Airlines jet that nearly lost control on takeoff from Las Vegas in August 2015. The investigation revealed that the airline’s maintenance provider at that time – AAR — failed to insert a cotter pin on a critical flight control component and have another technician conduct a secondary inspection to ensure it was installed. Other repetitive maintenance issues were also discovered. AAR was on the cusp of being fined by the FAA and having its MRO certificate suspended.

Today is a different story. Kudos to AAR for committing to the arduous journey of voluntarily implementing a SMS. AAR is already reaping the benefits.  “Employees are excited about SMS because it provides an easy way to share their thoughts on how we can take our quality and safety practices to the next level,” a representative of AAR recently told me. “It helps to create a culture [where] people want to work every day.” 

Improving and promoting an organization’s safety culture is key because it is the “glue that binds” people together toward a goal that is larger than themselves. A quick glance at AAR’s annual reports and public records show that performance goals for safety have been established, its stated corporate value is “Quality First, Safety Always,” and FAA enforcement actions are nearly non-existent.

That said, I offer this unsolicited word of caution to AAR and any other MRO or organization that seeks an effective SMS program. In safety management, everyone has a role to play; however, the expectations that lead to a positive safety culture are created and maintained at the top of the organization. Leadership enables success only by its continuous adherence to what they profess, how they allocate resources, where they align their organizational goals and when they exude a strident unwillingness to compromise.  Without the continuous commitment of all levels of management, an effective safety program cannot exist.  SMS should not merely be a binder of slogans and processes that collects dust on a shelf. It must be fully integrated into the fabric of an MRO’s daily operations.

To conclude, I congratulate AAR for this achievement, and I am hopeful they will reach – and maintain — “active conformance” at its other MRO locations. Implementing the SMS framework is scalable with the size and complexity of any MOR or organization. AAR has paved the way. I look forward to seeing many other independent MROs follow their path to safety.





Bob Barron

Human Factors Training: How Do You Know It’s Working?

By Bob Baron, Ph.D

The Aviation Consulting Group

As your company’s Human Factors (HF) instructor, you have just finished conducting a two-day HF course for 20 aircraft mechanics. So, here’s a question for you: Was the training impactful enough to make a difference in on-the-job behaviors, and if so, is it possible to quantify the effects of the HF training?

Let’s start with the first part of the question. Unquestionably, the experience of the HF course itself can make a big difference in whether or not the mechanics absorb and transfer the classroom skills to the real world. A poorly developed, mundane course will likely bore the attendees and negatively impact the intended outcome of the training. This, combined with a disinterested instructor, who tells war stories for the entire course, or just reads the slides, pretty much guarantees that the training will be a waste of time for all concerned!

Now let’s shift to the second part of the question. With the assumption that the training course is well-developed and delivered, we want to know if we can observe and quantify the behavioral changes that have taken place as a result of the training. In other words, is there a positive transfer of knowledge, skills, and attitudes to the real world? To answer this question, we need to measure the performance objectives. Those objectives include, but are not limited to, building an awareness of errors and error-provoking conditions, and how the mechanic uses that awareness to minimize, or prevent, the commission of maintenance errors. To know if the HF skills, knowledge, and attitudes, as a result of the HF training, are having an effect, we can use the following methods:

Safety Performance Indicators (SPIs)

You already have, among others, the following SPIs-

  • Accidents
  • Incidents
  • Occurrences
  • On-the-job injuries

Use these indicators to look for trends on a year-over-year and/or month-over-month basis. If HF training is newly deployed, then theoretically there should be a downward trend in these indicators. If HF training has been an ongoing process, we hope to also see an ongoing downward trend. But trend is the key word. There will be safety events, even during downward trends. When safety events do occur, were they due to Human Factors? If so, you might need to further reinforce the transfer of training to the job. What went wrong? Why? How can we prevent it from happening again? Do we need to add/modify/expand on a particular HF topic in the training course (i.e., focus on particular problem areas such as fatigue, procedural deviations, assertiveness, communication, etc.)?

It should be noted that these SPIs can have both upward and downward trends, and that we are using correlations with the HF training. But, correlation does not mean causation, as there may be other intervening variables. However, with a strong correlation, we can be pretty confident in the results.



One of the most effective ways of determining whether there is behavioral change is by direct observation. Take a look around the hangar. Are the mechanics doing things the way they are supposed to be done? Or, are you noticing deviations from procedures (i.e., skipping functional checks, signing off inspections that were not completed, working on tasks from memory, etc.)?

It is important to point out that these types of observations are not meant to be punitive; but rather to identify systemic, human factors issues within the company. This can be done by surveying key people who observe the mechanics. Or, as the safety manager, you can just take a walk through the hangar at random times. You’d be surprised at how many things you will see walking from one end of the hangar to the other if you really pay attention.

Speaking of non-punitive observations, you might want to consider implementing a Line Operations Safety Audit (LOSA) for Maintenance Operations. A LOSA observation is conducted by a non-threatening company employee (typically another mechanic) who takes notes on what is happening during the course of normal maintenance activities. Once all the data are collected, then a report is written and recommendations are made to management to both reinforce the positives and improve the negatives.



Surveys can be deployed online and be anonymous and confidential. Surveys can provide a “peek” into the effectiveness of the HF training directly from the mechanics. A carefully constructed, short survey can measure attitudes, opinions, and beliefs about various aspects of the HF training.

While surveys are an excellent way of collecting a wealth of information, it should be kept in mind that surveys are subjective and any changes (if needed) to the HF training program should be based on an appropriate sample size. If your company employs 500 mechanics, and only 15 of the mechanics respond to a survey, the results will be questionable. The typical response rate for surveys is 20%-30%. Although this seems rather low, it should still be enough for statistical significance.



When it comes to interviews, trust is a must! With trust and openness, you will find that one-on-one, confidential interviews can provide an extremely useful source of information. Interviews should be done casually (avoid checklists and forms). Just listen and take notes. mechanics are generally willing to discuss things in a casual, personal interview that they may not want to bring up in other mediums. For instance, you might find a trend in mechanics not feeling comfortable submitting hazard reports in the voluntary reporting system because they feel it’s a waste of time and nothing will get done to fix the issues. You may also detect this trend in the survey responses discussed above. That’s why using a variety of methods to collect data is so important. There’s power in numbers!

Interviews can also be done in a focus group format. Just as with the one-on-one format, a focus group provides direct feedback from the mechanics. Focus groups can be more comfortable for the group attendees as they are discussing issues with other colleagues, rather than feeling singled out in a personal interview.

In either format, be sure to let the interviewees know that they have the right to refuse an interview and that there will be no repercussions if they choose not to be interviewed. Remember, this is all part of your non-punitive Just Culture.



For many companies, HF training is simply a “check the box” activity. These companies are not as concerned about the training’s efficacy (transfer to the job) as much as satisfying a regulatory requirement. That’s not what HF training is all about. You need to move away from the “check the box” approach and give your mechanics a reason to take what they’ve learned in the classroom and move it to the hangar. It starts with a well-developed HF course, with an effective and respected instructor/facilitator, and the appropriate, ongoing performance measures to ensure that the training is meeting its objectives.

On a final note, just because an HF class attendee scores 100% on the classroom written test, it does not guarantee the AMT will have the desired behavioral change on the job. Conversely, a mechanic that barely passes the written test may still have the desired behavioral change. This is one of the reasons why, in HF training, I put less emphasis on the results of written tests and more emphasis on the real test; the demonstrable transfer of knowledge to the AMTs on-the-job activities. This might include double checking work, not skipping steps, being assertive when needed, and much, much more.

Hopefully, this article has helped to answer the question of how do you know if your HF training is working. It’s a sad fact that many companies aren’t interested in reaching this level of detail regarding HF training effectiveness. But those companies that do, will undoubtedly be the ones that have a safer workforce, which in turn will show that HF training is an investment rather than an expense. The ROI will be quantifiable, and management will like that!


Dr. Bob Baron conducts aviation safety training, consulting, and program implementation for aviation operators on a global basis.

Sensitive and knowledgeable about various cultures, Dr. Baron uses his 32+ years of academic and practical experience to assist aviation organizations in their pursuit of safety and quality excellence. He has extensive experience working with developing nations and island countries. He also provides training and consulting to some of the largest airlines and aircraft manufacturers in the world, as well as civil aviation authorities and accident investigation bureaus.

If your aviation organization is interested in improving its culture, implementing programs such as Human Factors, SMS, or LOSA, or have an external, unbiased safety audit/Gap analysis, please get in touch.

Dr. Baron’s company, TACG, provides numerous training and consulting services. For more information, please go to