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Vectors for Safety - May 2021

Safety Initiative Update

A new Safety Concepts page added to the Vectors for Safety website. This page will be a reference for some of the safety concepts, such as the stabilized approach, that we often refer to in our publications and videos. This page will grow over time.

Runway Excursions Continue - The daily ASIAS report from the FAA appears to show a continuing upward trend of runway excursion events. Most of these events result in only property damage, but the word "only" refers to lack of personal injury and not to the cost of the resulting damage. In line with a webinar on preventing runway excursions sponsored by Avemco that we did in February, we also have an online course valid for Wings credit. For those interested in the subject but not desiring Wings credit, the accompanying video is available on YouTube.

Reminder: It is not Just About Us - On March 16, a Bonanza careened out of the sky and struck an SUV that was travelling down a street in Pembroke Pines, Florida. The SUV contained a mother and her four-year-old son. Click here to read or download the preliminary accident report on the NTSB website.

Gene's Blog

Gene’s Most Wanted List The NTSB’s Most Wanted List almost always includes some items related to small, GA airplanes operating under Part 91. The most recent MWL for 2021-2022 does not contain any items that relate to non-revenue flying. I do not believe that NTSB does not have any items for us. But perhaps they have seen little progress from the FAA on many of the recent GA items listed, so they are just giving the FAA time to catch up.

Not that I claim to have the knowledge, research assets, or foresight of the NTSB, but I decided to create my own Most Wanted List in the spirit of preventing accidents involving small, GA airplanes. My list is based on my study of NTSB accident reports. I read all the accident reports that involve a fatality or serious injury, as well as many of the reports from the accidents that resulted in minor or no injuries.

When I select an accident to analyze more deeply, I access the NTSB accident docket and read the Pilot-Operator Report.  Surviving pilots are asked to submit this report and most do. It is interesting, and sometimes revealing, to read the pilot’s own words as to what happened and what could have been done to prevent the accident. Most pilots who submit the report appear to be honest about the events and have given serious thought as to how the accident could have been prevented. I suspect that a few others would blow up a polygraph machine.

The accident docket also contains the toxicology report of pilots who died in the accident, record of conversations with other involved parties, wreckage diagrams, radar tracks, and the photos that I use when I publish an accident analysis.

With that explanation behind us, my Most Wanted List for the remainder of 2021 includes eight items. I consider all eight items to be of equal importance. I will present the first four items this month and the remaining four items next month.

One:

All pilots will understand and apply stabilized approach principles to each and every approach. Most landing accidents occur as a conclusion to an unstabilized approach. The NTSB Probable Cause may not state that the approach was unstabilized, but applying the listed conditions to stabilized approach criteria makes the case. The concept is rather simple, we memorize the criteria for a stabilized approach and decide on a stabilization altitude based primarily on the kind of airplane we are flying. If the airplane deviates from any of the criteria below the stabilization altitude we will go around or execute a missed approach. Of course, a Part B to this requires us to maintain proficiency in the go-around procedures for each airplane that we fly. Click here for more information on stabilized approaches.

Two:

All pilots and (at least) front seat passengers will be secured with shoulder restraints and all installed lap belts and shoulder restraints will be maintained in good condition. Shoulder restraints greatly improve the survivability of a crash, but also significantly reduce the chances of life changing injuries. Relative to other costs involved in flying, the cost of adding shoulder restraints if the airplane is not already equipped is very reasonable. Additionally, all restraint systems, including belts, buckles, and attach points, must be regularly inspected and replaced if needed. (show accident link) Click here to view or download an FAA brochure on the subject.

Three:

All pilots will engage in a defined recurrent training program. Regardless of how much we fly, we still need to refresh and renew our knowledge and skills. Regulations regarding recurrent training for small GA airplanes operating under Part 91 are non-existent or at least sorely inadequate. On a scale of 0 to 10, with zero being completely unsafe and ten being as safe as practically possible, just meeting the legal requirements would put us at a score of about 1.5. And that is only if the pilot is flying the same kind of airplane as was used for the flight review. Ridiculously, regarding small GA airplanes, a pilot may complete a flight review in any aircraft for which the pilot is rated and it counts for all aircraft in which the pilot is rated. The pilot who owns and operates a Beech Baron can save some money by renting a Cessna 150 for a flight review and thereby meet regulatory requirements.

The FAA Wings program can establish a great framework for a recurrent training program provided the pilot creates a profile that accurately and honestly reflects the pilots flying. An unfortunate, but common practice is to list only airplane and single-engine land in the category and class section. Since only activities pertinent to the pilot’s profile will be generated, earning a phase of Wings may not have much meaning in the larger safety picture. Done properly, the Wings program can substantially move the needle on our safety scale up to at least 8.0.

Four:

All pilots will perform thorough preflight planning and engage in flight monitoring. The airplane is not a car in which we can begin a trip with little regard to the weather and figure out our routing and fuel needs along the way. Aviation safety absolutely requires preflight planning and flight monitoring. Some of the most easily preventable crashes result from a lack of adequate planning and monitoring. Common causes of crashes in this category include VFR flight into IFR conditions, fuel exhaustion, lack of takeoff or other performance planning, and operation outside the weight and/or balance limits. These crashes cover the spectrum from the simplest to the most complex airplanes and from the newly certificated private pilot to the most seasoned pilot with the highest certificates and ratings. (Show accident)

Accident  Analysis

Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

This very preventable accident occurred in Georgia in October of 2018. The 70-year-old private pilot and sole occupant of the Piper PA-28-180 died in the crash. The pilot had a current Class 3 FAA Medical Certificate and a current flight review. He had 339 hours total flight time including 262 hours in this make and model. The purpose of the flight, according to local media, was to visit his grandchildren.

The NTSB Probable Cause finding states: "The pilot's inadequate preflight and inflight fuel planning and his decision to continue flight without stopping for fuel, which resulted in a total loss of engine power due to fuel exhaustion."

The NTSB accident report includes the following: "The pilot departed on a cross-county flight in day visual meteorological conditions. According to the airplane's co-owner, who spoke with the pilot before he departed on the accident flight, the airplane had about 34 gallons of fuel onboard at the time of departure. Based on his experience, this was sufficient for about 2 hours 20 minutes of flight. He suggested that the pilot top off the airplane's fuel tanks before departure. When he watched the pilot taxi the airplane past the fuel facility and take off, he subsequently sent the pilot a text message stating, "Do hope you had a fuel stop planned." The pilot replied that he would stop if he needed to. GPS data indicated that the pilot did not land at any point between the departure airport and accident site, though he passed near one airport, and directly over another airport, both of which had fuel services available. A witness reported that the airplane's engine stopped then restarted. Another witness reported that the airplane's engine was surging. The airplane subsequently impacted power lines. The duration of the accident flight was 3 hours and 10 minutes.

Postaccident examination revealed that both fuel tanks were intact; the left wing tank was empty, and the right wing tank contained residual fuel. Examination of the fuel system and the engine revealed no anomalies. Given the absence of fuel in the airplane's fuel tanks at the accident site, the duration of the flight, and the known quantity of fuel onboard at the time of departure, the accident is consistent with a total loss of engine power due to fuel exhaustion. Although the pilot passed over two other airports with fuel available, he chose to continue the flight beyond the airplane's endurance given the fuel at departure.”  

I have been advocating for years for pilots to speak up when they see something dangerous about to happen. In this case, a co-owner of the airplane did express his concern about the fuel but his warning went unheeded. The NTSB report includes the following: “A co-owner of the airplane reported that he spoke to the accident pilot before he departed from Gainesville Regional Airport (GNV), Gainesville, Florida. He and the pilot discussed the airplane's fuel load, which was about 34 gallons, and the pilot's flight plan to Tom B. David Airport (CZL), Calhoun, Georgia. Based on that conversation, he believed the pilot was going to add additional fuel to the airplane before departure; however, the pilot taxied past the airport's fuel facility and proceeded to take off. The co-owner subsequently texted the pilot, "Do hope you had a fuel stop planned." At 1243, the pilot replied, "If I need to, I'll stop in LaGrange."  

Fuel exhaustion accidents such as this are needless. If we do some basic flight planning to determine the calculated flight time based upon airplane performance, distance, and forecast wind, we can determine the estimated fuel to be consumed. Then we simply add the additional fuel needed for a comfortable reserve and arrive at the minimum fuel required. If that quantity is greater than our departure fuel load, we must plan an intermediate stop. In any case, we need to monitor our time inflight and our fuel consumption as we fly. The inconvenience of a fuel stop does not compare with the inconvenience of fuel exhaustion, even if our emergency landing is without incident. In the case of this accident, I am sure that the grandchildren would have preferred to have grandpa arrive a little late over having to hear the news that grandpa will not be around anymore.

Click here to read or download the accident report on the NTSB website.

Accident Analysis

Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

This crash is categorized as a fuel exhaustion accident resulting from improper preflight planning. It involved a Beech bonanza an happened in North Carolina February of 2016. The 68-year-old airline transport pilot was killed in the crash. However, the fuel exhaustion can teach us a lesson but the crash is illustrated here for a different reason.

The NTSB Probable Cause finding states: “The pilot's improper preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the severity of the pilot's injuries was his failure to have a properly secured shoulder harness at the time of the accident.”

The NTSB report also includes the following rather graphic description: “Examination of the pilot's lap belt and shoulder harness assembly revealed that it remained intact, but was found unbuckled with the shoulder harness not attached. The pilot's lap belt shoulder harness attachment post elastic grommet was not installed (or found in the wreckage), and, when manually assembled, the shoulder harness attachment buckle would not seat securely to the lap belt attachment post.

According to the death investigator's notes, the pilot was found deceased, slumped over in the left seat, still wearing his seatbelt. Although the airplane was equipped with a single shoulder harness (across the left shoulder), injuries sustained by the pilot were consistent with the pilot not being restrained by the shoulder harness at the time of the impact.

According to the autopsy performed by the Mecklenburg County Medical Examiner's Office, the cause of death was blunt force injuries due to airplane crash and the manner of death was accident. No significant natural disease was identified. The pilot's injuries included contusions and abrasions of the face, fractured teeth, contusions, abrasions, and fractures of the torso, disruption of the proximal descending aorta with massive left hemothorax.”

Our real lesson from this unfortunate crash is to remember the importance of ensuring the viability of our restraints. Perhaps this pilot lost his life due to a missing grommet. Was he aware the grommet was missing? We do not know for sure, but a pilot with his experience probably would have noticed that the shoulder harness did not lock securely. Did the company that owned the airplane know about the defect? Again, we do not know. Perhaps it was humanness at work. We want to complete our mission so we decide that it will be okay just this once. We never plan to crash, so why are we concerned about a missing grommet?

The airplane had the harness installed, but it was ineffective due to the missing grommet. The FAA has some interesting statistics. They say that using a shoulder harness in a small airplane would reduce major injuries by 88% and fatalities by 20%.

Let’s make sure that we always have shoulder harnesses that are in good condition and that we always use them.

Click here to read or download the accident report on the NTSB website.

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