Wednesday, June 10, 2020

System/Component Malfunction/Failure (Non-Power): Dassault Falcon 50, N114TD; fatal accident occurred September 27, 2018 at Greenville Downtown Airport (KGMU), South Carolina

Stephen George Fox 
April 27, 1952 - September 27, 2018



















































The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Columbia, South Carolina
Honeywell; Phoenix, Arizona
Dassault Falcon Jet Corp.; New Castle, Delaware
BEA; FN

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 

https://registry.faa.gov/N114TD


Location: Greenville, SC
Accident Number: ERA18FA264
Date & Time: 09/27/2018, 1346 EDT
Registration: N114TD
Aircraft: Dassault FALCON 50
Aircraft Damage: Substantial
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 2 Fatal, 2 Serious
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled

Analysis

The flight crew was operating the business jet on an on-demand air taxi flight with passengers onboard. During landing at the destination airport, the cockpit voice recorder (CVR) recorded the sound of the airplane touching down followed by the pilot's and copilot's comments that the brakes were not operating. Air traffic controllers reported, and airport surveillance video confirmed, that the airplane touched down "normally" and the airplane's thrust reverser deployed but that the airplane continued down the runway without decelerating before overrunning the runway and impacting terrain. Post-accident examination of the airplane's brake system revealed discrepancies of the antiskid system that included a broken solder joint on the left-side inboard transducer and a reversal of the wiring on the right-side outboard transducer. It is likely that these discrepancies resulted in the normal braking system's failure to function during the landing.

Before the accident flight, the airplane had been in long-term storage for several years and was in the process of undergoing maintenance to bring the airplane back to a serviceable condition, which in-part required the completion of several inspections, an overhaul of the landing gear, and the resolution of over 100 other unresolved discrepancies. The accident flight and four previous flights were all made with only a portion of this required maintenance having been completed and properly documented in the airplane's maintenance logs. A pilot, who had flown the airplane on four previous flights along with the accident pilot (who was acting as second-in-command during them), identified during those flights that the airplane's normal braking system was not operating when the airplane was traveling faster than 20 knots. He remedied the situation by configuring the airplane to use the emergency, rather than normal, braking system. That pilot reported this discrepancy to the operator's director of maintenance, and it is likely that maintenance personnel from the company subsequently added an "INOP" placard near the switch on the date of the accident. The label on the placard referenced the antiskid system, and the airplane's flight manual described that with the normal brake (or antiskid) system inoperative, the brake selector switch must be positioned to use the emergency braking system. Following the accident, the switch was found positioned with the normal braking system activated, and it is likely that the accident flight crew attempted to utilize the malfunctioning normal braking system during the landing. Additionally, the flight crew failed to properly recognize the failure and configure the airplane to utilize the emergency braking system, or utilize the parking brake, as described in the airplane's flight manual, in order to stop the airplane within the available runway.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing.

Findings

Aircraft
Brake - Failure (Cause)
Scheduled maint checks - Not serviced/maintained (Cause)

Personnel issues
Decision making/judgment - Flt operations/dispatcher (Cause)
Use of policy/procedure - Flight crew (Cause)

Organizational issues
Maintenance records - Operator (Cause)

Factual Information

HISTORY OF FLIGHT

On September 27, 2018, about 1346 eastern daylight time, a Dassault Falcon 50, N114TD, was substantially damaged when it was involved in an accident at Greenville Downtown Airport (GMU), Greenville, South Carolina. The two pilots were fatally injured, and the two passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on-demand air taxi flight.

The airplane departed from St. Pete-Clearwater International Airport (PIE), Clearwater, Florida, at 1230. According to the cockpit voice recorder (CVR), during the approach to GMU, the flight crew had difficulties understanding the navigation fixes that air traffic control had provided. The CVR also showed that the flight crew did not use any prelanding checklist or discuss that no braking was available with the brake system in the "#1-ON" position (the pilot was the copilot for the previous four flights in the airplane, during which this condition was present). At 1345:34, the CVR recorded the sound of the airplane touching down. At 1345:38, the pilot stated that the brakes were not operating. He and the copilot commented about the lack of brakes several more times before the airplane went over an embankment and came to a stop.

Air traffic controllers at GMU reported that the airplane touched down "normally" at a standard touchdown point on the runway. They saw the airplane's thrust reverser deploy and watched as the airplane continued down the runway without decelerating. An airport security video captured the airplane's touchdown and showed that the thrust reverser and the airbrakes were deployed. The video also showed the airplane as it continued to the end of the runway and went over the embankment.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate and a type rating for the Dassault Falcon 50 with a limitation for second-in-command privileges only. He also held type ratings for Learjet and Westwind business jets.

The co-pilot held a private pilot certificate with ratings for airplane single and multiengine land. He did not hold any type ratings nor did he hold an instrument rating.

AIRCRAFT INFORMATION

The Dassault Falcon 50 was a midsize long-range business jet. The three engines were mounted at the rear of the airplane with the left engine identified as No. 1, the center engine identified as No. 2, and the right engine identified as No. 3. A thrust reverser was located on the No. 2 engine. The airplane was equipped with two independent hydraulic systems, which provided hydraulic power to several onboard systems including the airplane's brakes. System 1 provided hydraulic pressure for normal braking (with antiskid), while system 2 provided hydraulic pressure for emergency braking and parking brake. Selection of normal or emergency braking was done via a switch labeled "BRAKE" that was located on the instrument panel. The "#1-ON" position of the switch selected normal braking utilizing system 1, and provided antiskid protection, while the "2-OFF" position selected emergency braking and did not provide antiskid.

Review of the airplane maintenance records revealed that, on August 13, 2018, a 12-month avionics check was completed, at which time the airplane had accumulated 14,003 total hours and 7,541 total cycles.

According to the operator's director of maintenance, the airplane had been kept in storage in a hangar for about 4 years. In June 2018, a work order was generated to return the airplane to a serviceable status. The work order included a 12-month inspection, a 12-month or 500-hour inspection, a 24-month inspection, and a 36-month inspection. The work order also indicated that 1C, 3C, and 5C checks were to be completed and that a total of 103 discrepancies found during the ongoing inspections needed to be addressed. The work order was about 60% complete at the time of the accident, and there were no maintenance log entries made indicating that the airplane was airworthy and returned to service.

The work order did not include removal of the landing gear for overhaul. The last overhaul of the landing gear (main and nose) was completed on July 23, 2002. During the overhaul, the electrical harness for the landing gear position sensors and antiskid transducers was removed and replaced. The overhaul interval was 12 years (plus a grace period of 5 months) or 6,000 landings, whichever came first. As a result, a landing gear overhaul should have been performed no later than December 23, 2014.

METEOROLOGICAL INFORMATION

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site as well as runway and tire track evidence showed that the airplane departed the left edge of the runway near the departure end, traveled across the flat grassy area at the end of the runway, continued down a 50-foot embankment, and came to rest on the airport perimeter road about 425 ft from the runway. The wreckage was oriented on a heading of about 160°. There was no fire. Fuel was observed leaking from the wings at the accident site. The nose landing gear was separated and found about midway down the embankment. The fuselage was separated immediately aft of the cockpit area. The slats and flaps were extended. Both the right and left airbrakes (spoilers) were extended. Both main landing gear were fractured at the trunnion and displaced aft into the flaps.

A review of the airplane braking system components at the scene of the accident showed that the parking brake handle was in the stowed position and the brake switch was found in the "#1-ON" position. Next to the brake switch was a sticker indicating, "ATA# 32-5 'INOP' DATE: 9/27/18" (ATA code 32-5 involves the antiskid system). Detailed examination of the wheel speed transducers that the antiskid system used showed signs of field splices on the right-side inboard and outboard transducers and no signs of field splices on the left-side inboard and outboard transducers.

Computed tomography performed on the antiskid system components revealed a broken solder joint on the left-side inboard transducer and a bent pin connection on the right-side inboard transducer. Functional tests of the antiskid wheel speed transducers revealed a failure in the operation of the left-side inboard wheel speed transducer; the other three transducers passed their respective functional tests. Visual inspection of the wiring for the right-side wheel speed transducers found that the wiring to the right outboard transducer was reversed.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies of the pilot and copilot were performed by the Office of the Medical Examiner, County of Greenville, South Carolina. Their cause of death was multiple blunt force injuries.

Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. The results for the pilot were negative for carbon monoxide, ethanol, and drugs. The results for the copilot were negative for carbon monoxide and ethanol; ketamine, an anesthetic that
is often used during attempted resuscitation, was detected in the copilot's specimens.

ADDITIONAL INFORMATION

According to the pilot who conducted four flights in the airplane before the accident flight, upon application of the brakes with the brake switch in the "#1-ON" position, braking was normal at low speeds (estimated to be 15-20 knots) but at faster speeds, no braking was available. Braking was restored when the brake switch was placed in the "#2-OFF" position. This pilot stated that he reported the brake system failure to the company's director of maintenance after the first two flights (in late August and early September 2018) and indicated his belief that the source of the problem was the antiskid system. This pilot also stated that the last two flights occurred 7 and 8 days before the accident flight and that the accident pilot was the copilot for all four flights.

None of the available maintenance records indicated the brake system issue or showed maintenance actions that were performed to resolve the issue.

According to the abnormal procedures section of the airplane's flight manual, a failure of the (normal) brake system or an inoperative antiskid system in-part required the flight crew to move the brake switch to the "#2 / OFF" position. The manual also stated that if both normal and emergency braking was inoperative, that the thrust reverser and parking brake could be used to bring the airplane to a stop. 

History of Flight

Prior to flight
Aircraft inspection event

Landing-landing roll
Sys/Comp malf/fail (non-power) (Defining event)
Runway excursion

After landing
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Airline Transport
Age: 49, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s):None 
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 08/07/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  11650 hours (Total, all aircraft)

Co-Pilot Information

Certificate: Private
Age: 66, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 03/22/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time:  5500 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Dassault
Registration: N114TD
Model/Series: FALCON 50 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 17
Landing Gear Type: Retractable - Tricycle
Seats: 12
Date/Type of Last Inspection: 08/27/2014, Continuous Airworthiness
Certified Max Gross Wt.: 40780 lbs
Time Since Last Inspection: 0 Hours
Engines: 3 Turbo Fan
Airframe Total Time: 14002.8 Hours as of last inspection
Engine Manufacturer: Honeywell
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: TFE-731
Registered Owner: Global Aircraft Acquisitions LLC
Rated Power: hp
Operator: Air America Flight Services INC
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KGMU, 1048 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1353 EDT
Direction from Accident Site: 18°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 210°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.02 inches Hg
Temperature/Dew Point: 27°C / 22°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: St Petersburg-Clearwater, FL (PIE)
Type of Flight Plan Filed: IFR
Destination: Greenville, SC (GMU)
Type of Clearance: IFR
Departure Time: 1230 EDT
Type of Airspace: Class D

Airport Information

Airport: Greenville Downtown (GMU)
Runway Surface Type: Asphalt
Airport Elevation: 1048 ft
Runway Surface Condition:Dry 
Runway Used: 19
IFR Approach: RNAV
Runway Length/Width: 5393 ft / 100 ft
VFR Approach/Landing: Full Stop

Wreckage and Impact Information

Crew Injuries:2 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 2 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal, 2 Serious
Latitude, Longitude: 34.839444, -82.348611 (est)











27 comments:

  1. who needs brakes ? highly overrated

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  2. That jet had no business being in the air that day. Too many maintenances issues that were still out standing for anyone to think this aircraft was safe to fly charter. Whoever gave the ok for this flight should go to JAIL!!!!! For a very long time, I might add.

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  3. Jail. lawsuits, no one being a winner besides lawyers now salivating at the orgy of litigation now offered by this tragedy and a black eye to GA. Also the report mentions this is a Part 135? The fact the 2 pilots were not appropriately qualified means all Part 135 operators will now suffer more scrutiny, more fees and down the line the costs will increase. Unless it was really a Part 134.5 which it sounds it was.
    Which makes me wonder how stupid or greedy, or both, everyone in this operation was to skimp on a few bucks here and there to have a properly maintained aircraft and a properly licensed personel in a field ripe with litigation and where a simpel HazMat violation can be in the millons. A case of Dunning-Krueger run amok?

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  4. ^^Well you can bet the families of the dead unqualified crew already have the sharks knocking on their doors selling them the idea that it was Dassault Aviation SA and its corporate parent Groupe Industriel Marcel Dassault S.A. which were ultimately responsible for their deaths. Same with the injured passengers who likely have been contacted by wrongful injury ambulance chasers.

    Corporate jet sales have taken a nose dive as it is from the global C-19 pandemic and it will be many years before, if ever, their new jet sales recover fully. Dassault is in the middle of the new Falcon-X development now, rumored to park itself as a 2000 replacement (Challenger 350/Praetor 500 competitor). Last things Dassault need are multi-million dollar lawsuits which almost always are settled out of court as the cheaper option even if frugal.

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  5. Predatory lending, human trafficking, corruption and predatory lawsuits are the hallmark of catabolitic capitalism which is now running amok thanks to the pandemic and the economic destruction which makes those greedy and selfish concentrate inward on what to take advantage of. Any field perceived as having leftover capital to loot (pardon the pun given the social circumstances) is ripe for the taking. I noticed a large uptick in malpractice, negligence and slip and fall lawsuits in Florida's readily available public records as people who are unemployed and feeling the pinch look to take it away from someone else with renewed vigor regardless of the merits.
    Btw "catabolitic" literally means eating itself away just like a hungry organism is consuming its muscles and organs in the last stages of depletion.

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  6. It appears to me the operator is still in business and providing airplanes they've maintained... for folks to fly in. If this is true, how is it possible?

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  7. I'm curious as to why the final report doesn't say anything about the crew being unqualified. That sounded rather serious to me. Is the Falcon 50 required to have two type-rated pilots or only one? Why was the PIC's type rating limited to SIC only?

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  8. I wonder how this could have been a fatal accident. The cockpit wasn't compromised in terms of survivable space. Were they not wearing a seat belt/shoulder harness?

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    Replies
    1. You would expect harness to be worn if brakes were out, but those guys did not sweat the details. Here is an example video where no shoulder harness is in use on someone else's F50.

      https://youtu.be/IwA1VgqFffI

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  9. @MarcPilot - Government is supposed to keep business (capitalism) in check. But we all know both are in bed with each other (politicians). It doesn't matter which party either. BOTH are in bet with crony capitalism.

    @JonDown - Things move real slow in the world of government bureaucracy.

    @Roca - It does. The pilot in command (left seater) was only qualified in the Falcon 50 to be a second in command right seater in 135 operations which this was (chartered flight for money). The right seater was not even qualified to be there as he was not turbine rated, let alone not type rated to be second in command as a right seater in the the Falcon 50 (in this flight capacity). In chartered capacity of Part 135 ops, the Falcon 50 requires two Falcon 50 rated pilots to be in the front seats, the one in left seat being captain rated, the one in the right seat that he was rated for. So yes, just like in any corporate jet that is not single-pilot certified, there are two FAA ratings to be certified for Part 135 operations in one like like the airlines (Captain, F/O).

    @Anon - That crash and the cockpit may look benign, but you have to remember it doesn't matter how well strapped in you are. Forces in a crash like this means your insides are still being shaken up like a toy rattler. Torn aortas and brains being scrambled are common reasons of deaths in auto and aircraft crashes even though the occupants were strapped in. Your exterior skin may not be going anywhere while strapped in, but your insides still want to move like jello inside a mold. And this large vertical drop to forward stop force could have snapped their necks forward too (and likely did).

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  10. It just doesn't look like a fatal crash. No fire, luckily. Plane is a write-off, though.
    Hope the passengers make a speedy recovery.

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  11. Well, the dried blood on the instrument panel is a clue...

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  12. "The right seater was not even qualified to be there as he was not turbine rated, let alone not type rated to be second in command as a right seater in the the Falcon 50 (in this flight capacity)."

    Well the right seater wasn't even a COMMERCIAL PILOT from the report. He didn't even have an instrument rating.

    Maybe someone can correct me but this plane wasn't single pilot certified either so this whole thing was 100% illegal the second they pushed on any button inside that cockpit.

    Which brings another interesting issue: No insurance coverage.

    Now this one may go to court too due to a "causality" clause i.e the ratings and qualifications of the pilots had nothing to do with the malfunctioning brakes that were not address and this after the plane successfully landed, so the qualifications of the pilots didn't matter then.

    Now what matters is that the pilots didn't bother about the critical information in the POH about the emergency (parking) brake as an alternate to stopping the plane. And here their lack of qualifications shine. Although the SIC rated pilot shall have known about this.

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  13. Plaintiffs had until 26 Sep 2019 to serve summonses. After that it is a "no-go".

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  14. Nope it's 4 years for the statute of limitation in Florida. And already lawsuits have been filed by the passengers against the company and pilot's estates per the public records

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    Replies
    1. I would like to read about that. Where can I get to that information?

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    2. Where can I find information about the case and the claim that has been filed?

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    3. It is old news, at:

      https://www.tampabay.com/news/publicsafety/injured-tampa-passengers-sue-estates-of-pilot-co-pilot-who-died-in-jet-crash-20181210/

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    4. Case# 18-CA-011687 Filed 30 November 2018 Hillsborough County, shows open as of a check today.

      https://hover.hillsclerk.com/html/case/caseSearch.html

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    5. It is amazing the amount of malpractice, slip and fall and other cases filed. I even saw a guy suing his neighbors for a dog attack in there.
      The way the system works is lawyers collect 30-50% of a settlement and work by contingency, and only pick easy cases of course.
      Then they go after any insurance the defendant has, in some cases the insurance companies hire a defense counsel but mostly settle vs. pursuing litigation. For them paying this "ransom" is easy as they pass on the costs to consumers.
      So this is basically the definition of "rent seeking" i.e similar to the ancient lord that would put a rope on a river and charge a fee without anything of tangible value produced. Translating the power he had over the river to extract passive income from it.
      Money is statistical power i.e you buy something and you have 100% control over it, and if you have 100% control over a medium that can generate money you can translate this easily.
      Here those knowledgeable in the arduous and complex civil process i.e lawyers use that power to extract money from the liability coverage in insurances and more rarely assets from wealthy individuals using the rules around the tort system.
      Nothing to really do with justice but mostly a financial process using liability as a financial instrument.
      This is why this system almost killed GA until GAMA and a second GAMA, covering pilots, mechanics and even passengers as well as products related to aviation, is in order.

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    6. Proven by the fact that if a mechanic or flight instructor does not have insurance, that they have a better chance of not being named in a law suit as the plaintiffs attorneys use small insurance policies as "seed" money to go after the deeper pockets such as engine/accessory and airframe manufacturers.

      These law firms have marketing departments to find and assemble cases in the name of "safety". After the award is made, the case ends, with nothing changed in the name of "safety", as this could possibly fix something that would end the firms use of this tactic to approach other plaintiffs with the promise of a large award.

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  15. @MarcPilot - you bring up a good point about not being insured. If we can't drive our autos without insurance on the highways, bare minimum being liability, then there is zero excuse for the FAA to not mandate all registered airworthy operational aircraft to require the same. It would surely cut down on the amount of yahoos out there from private to as we see here some halfass charter contractor.

    If they can't afford insurance, they can't afford to maintain their aircraft and in this case, guarantee the hiring of a qualified crew. And yes, the Falcon 50 requires two type-rated pilots up front even in private non-135 operation as it weighs over 12,500 pounds.

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  16. To the contrary we need to exempt such a small and negligible (no pun intended) field as General Aviation from lawsuits and the fact no insurance is mandated probably was the impetus behind keeping it alive as mandating it would make flying beyond the reach of anyone but the military and law enforcement which is exactly what is happening in countries like Canada or Europe at large.
    If Insurance is mandated then lawsuits will be attracted to it like vultures and imagine paying 50k a year for a 1960s Cessna 172 for basic hull coverage even if you have 3000 hrs in type then...
    If ever any sort of coverage would be mandated then it has to be made no-fault to prevent lawsuits. Passengers, Pilots and anything related to flying shall be excluded from any sort of negligence claim: YOU FLY YOU KNOW THE RISKS AND IF YOU DIE YOU ACCEPT THOSE RISKS!
    We don't see legions of motorcycle riders being sued for millions, I wonder why... maybe has to do with most of them being too poor to afford a car in the first place or just ordinary folks with a toy to drive on Sundays.
    As for air taxis once joe six pack can fly and millions of them are in the skies it will be no different than riding motorcycles and economies of scale will bring the cost of a flying manned drone to that of an average luxury vehicle while automated flying will make it easier to fly than drive a car in most likelihood.
    There will be litigation and lawsuits but not the kind of multi million settlements that plague GA currently and bring it to almost extinction with less than a few HUNDRED brand new planes sold each year and a vicious downward spiral of ever increasing liability costs, ever less customers perceived as ever more wealthy, and a US tort system sicker than the Minneapolis police department.

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  17. One of the concerns here is that some posters seem to think this was survivable accident for the pilots??? I mean - have a look at the environment for a start.

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    Replies
    1. Survivable with shoulder harnesses... Not if you face plant into the panel.

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