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Vectors for Safety

May 2020

Website Update Complete

Vectors for Safety has been experiencing record growth over the past few months and has outgrown being a part of my website. That is great news because it means that we are reaching many more people with our safety message. So, the safety initiative now has its own domain and website, vectorsforsafety.com. Didn't notice? That's fine. The link in the May 1 edition of "Vectors" brought you here! Click here to visit the home page of the new site.

Pilot Talk

April was a very busy month! Our "Pilot Talk" series began with the simple goal of bringing a few pilots together to chat about whatever was on their minds. The original purpose was to simply provide an activity to occupy some time while many of us were staying at home. Following suggestions from attendees, we began designating a topic for discussion. Rather than create new content and only be able to do one or two presentations, we rolled out "previously enjoyed" presentations. That increased the popularity of the project and necessitated moving from a Zoom Meeting subscription to a Zoom Webinar subscription. The nice folks at my sponsor, Avemco Insruance, stepped up to provide financial support for that. Thanks to Avemco, we now have a webinar subscription with 500 seat capacity. We are also live streaming the events on YouTube to accommodate overflow.

We conducted eight "Pilot Talk" sessions in April, following two session at the end of March. I want to give a shout-out of thanks to my friend and colleague Layne Lisser who graciously agreed to assist with the presentations. Layne monitored the technical side of things and assisted with the chat function, leaving me free to concentrate on the presentation.

Five more sessions have been scheduled and it appears that at least two more will be added. One of the sessions will feature a fellow FAASTeam representative from Montana, Kurt Kleiner, doing a presentation on mountain waves. The "Pilot Talk" section of this website has all upcoming events listed and will be updated as new events are scheduled. Click here to see the scheduled events.

By way of motivation to join, or to encourage other pilots to join any or all of the "Pilot Talk" series, Avemco Insruance has a Safety Rewards Program that provides a discount on insurance premiums for those who take safety-related courses or sign-in to watch safety related videos or presentations. They have assured me that the "Pilot Talk" presentations qualify for the discount which is provided at the time of quote or renewal.

More on Ignition Switch Keys

A few months ago, I wrote a blog about ramp accidents and propeller safety. One of the accidents I featured involved an engine starting though the pilot had removed the ignition from the ignition switch. Investigation had revealed that the key was worn which allowed it to be removed from the switch when the switch was not in the OFF position. The NTSB has taken up the cause on this subject and has created a very good video. Click here to check it out on the NTSB website.

Fuel Selector Woes

Is the fuel selector in the airplane you fly stiff when you move it? Or does it appear to be too loose? Those might be signs of trouble. More than 100 accidents have resulted from a loss of engine power which was traced back to a faulty fuel selector valve. As fuel selectors wear, the fuel selector handles may be difficult or even impossible to turn. If a pilot applies too much force, the internal components can fracture and obstruct the fuel flow, resulting in a total loss of engine power. Click here to see a Safety Alert on the NTSB website.

More on Drug Use - Watch Out for Supplements

Last month we discussed the NTSB's study on drug use among pilots. A reader who is also an FAA Safety Inspector made me aware of the danger of some dietary supplements. I did some research and found that there is a very real danger of impairment from some OTC dietary supplements even when used alone, but especially when used in conjunction with prescription medications. We get similar messages from the big players such as Mayo Clinic, Johns Hopkins, the National Institute of Health, Web MD, and more. I lifted these items from the Mayo Clinic website: Product claims may be misleading. Dosage is unclear. Side effects may occur. Drug interactions are possible. Herbal supplements aren't monitored by the Food and Drug Administration the same way medications are. Talk to your doctor.

Recorded FAA Webinar on Aging Pilots

The FAASTeam recently presented an excellent webinar on aging pilots. Whether you are an aging pilot or just associate with aging pilots, you will find this interesting. It is realistic and not preachy. The recording is available on YouTube. Click here to check it out.

Flying as a Stress Reliever?

One of my recent "Pilot Talk" presentations was titled, "The Terrible Triad - Fatigue, Stress, and Medications." We discussed how each member of that triad lowers our capability, moves us closer to the task requirements curve, thereby decreasing the margin of safety. After that presentation, I received an email from an attendee who reported his way of relieving stress. That was to go flying. I can relate to that because I too, in the past, have gone flying to relieve stress and clear my head. Given what we now know about stress and its impact on our capability, I have to question the wisdom of doing that. I would recommend engaging in some other activity to reduce stress, then going flying as a reward for being prudent.

Gene Benson's Blog

It's the Little Things

Some accidents are caused by gross violations of regulations or by gross violations of good operating procedures. We read about those and shake our heads as to why a pilot made such an egregious error. But more often, the accident was caused by something simple. Some seemingly “little thing” caused a not-so-little problem.

In the Safety Initiative Update of this publication, we saw how a worn fuel selector caused several accidents and a worn ignition key caused others. We have also seen accidents caused by chewed electrical wires with the problem originating from a rodent nest. Then there have been accidents caused by a distraction from an unlatched baggage compartment door. The list goes on.

What can we do to protect ourselves from having an accident caused by some “little thing” that went unnoticed or was ignored? Start by being aware of anything that is different or seems strange. An unusual noise, a control that seems stiffer or more loose than usual, a gage that is reading differently than usual, a flap that appears to be catching during movement, and so on, can be a clue to an impending problem. Having the airplane maintained by a thorough technician or a reputable shop is a good start also. We also need to listen when technician tells us that something needs attention. We have probably all been hardened by the relentless upsell attempts when having our cars serviced. I know that I am spring loaded to reject just about any recommendation for having something flushed or to replacing some obscure filter. We should be more open minded about our airplane maintenance. Any recommendation should receive due consideration. If not sure, a second opinion can be obtained. Nearly all of us have some sort of roadside assistance for our cars or trucks if something fails. Roadside assistance for our airplanes often involves ambulances and fire trucks.

Then we must consider the “little things” concerning the pilot. Last month we looked at pilot impairment. Let’s not do that. I know that none of us would intentionally fly while impaired, but I would guess that many of the impaired pilots who died in crashes did not realize that they were impaired when they started the engine. Much of the dangerous impairment comes from OTC medications that we might take without realizing the potential impairing effects. A quick self-analysis of any medication or supplement we have taken within the previous few days might be a good idea before heading to the airport.

Then, of course, we must ask why we might have needed a medication or why we might not be feeling 100%. Any illness lowers our capability and we must realize and intelligently address that. I know that the IM SAFE checklist is not perfect because our unconscious mind can influence our decisions, but it can help to steer us in the right direction.

So, let’s do our best to pay attention to the “little things.” If something does not seem right, it probably is not right. The following accident example illustrates some of the points made in this blog.

Accident Analysis

Beech Bonanza - Aircraft Maintenance

Louisville, Kentucky December 18, 2008

Fatal: 1

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

ERA09FA093 NTSB Photo

NTSB Photo

On December 18, 2008, about 0355 eastern standard time, a Beech 36 crashed in an open field within a golfing community in Louisville, Kentucky. The crash occurred during an IFR flight from the Chicago Midway International Airport (MDW), Chicago, Illinois, to Bowman Field Airport (LOU), Louisville, Kentucky. Night instrument meteorological conditions prevailed at the time and an IFR flight plan was filed for the personal flight. The airplane incurred substantial damage and the pilot/owner was killed.

A mechanic at LOU stated to an FAA inspector that he had seen the airplane on the field and had seen it fly on several occasions. He was also aware of the recent overhaul of the engine and propeller installation to the accident airplane. Several weeks before the accident, the mechanic talked to the pilot when the pilot was conducting a ground run of the airplane. The pilot stated that he was having an oil pressure problem. The pilot asked the mechanic about oil pressure adjustments. The mechanic explained the system to the pilot and advised him to have the problem checked out, especially if the engine was recently overhauled. About a week later, the mechanic was informed the oil pressure problem was related to the oil filter and that it seemed to be ok.

A witness, working at a fixed base operator at MDW, stated that the airplane arrived on December 17, 2008, about 2330 and the pilot requested fuel. When the airplane was going to depart, it returned back to the FBO. The pilot stated that there was a problem with the airplane and it was placed in the hangar. The pilot contacted a maintenance facility on the airport, but the airplane could not be seen until the next morning. The airplane was pulled out of the hanger, and the pilot tried to start the engine several times. He managed to start the engine and departed about 0220 on December 18, 2008.

According to the Louisville Approach controller, he cleared the pilot to land, when the airplane was about 9 miles out, for an approach for runway 24 at LOU. Shortly after that, the pilot communicated an emergency, advising of an “engine failure.” The local authorities were notified of a possible downed airplane in the area of the last radar contact, and the airplane was discovered later that morning, around 0600, by the local fire department community.

Examination of the engine revealed the crankshaft and counterweight assembly was fractured through at the forward fillet radius of the number 2 main bearing journal. The number 2 main bearing journal exhibited scoring consistent with bearing rotation. The number 2 main bearings’ fragments were located in the oil sump. The number 3 main bearing journal was fractured at the rear fillet area. Examination of the crankcase halves, revealed the presence of silk thread patterns and gasket making material on the sealing surfaces of the main bearing bosses, which is not part of the engine’s manufacturer maintenance instructions that resulted in improper torque values obtained during the crankcase halves assembly. The number 2 main bearing boss was severely damaged on both the left and right case halves. The damage included rotational mechanical gouging and deformation of the boss area behind the bearing, including mushrooming deformation of the boss. The engine was overhauled 58 hours before the accident.

The NTSB Probable Cause finding states: The pilot’s continued operation of the aircraft with known deficiencies. Contributing to this accident was the improper sealing of the engine case during overhaul.

ERA09FA093 NTSB Photo

NTSB Photo

Though this accident happened some time ago, it is iconic for not recognizing that a serious problem that is developing and for making a decision based more on convenience than on safety.

The pilot clearly had known for weeks that there was something wrong. He had solicited the advice of a mechanic and had been advised to have the problem checked out. About a week later, the pilot believed, perhaps erroneously, that the problem had been related to an oil filter and that the problem had been solved. We do not know what led him to believe this. He flew the airplane to Chicago but we do not know if the problem appeared again during that flight. When attempting to leave Chicago, he apparently had a problem serious enough to return to the FBO and place the airplane in a hangar. But, upon learning that he could not obtain maintenance on the airplane until the morning, he departed in night IFR conditions at about 2:20 AM.

Lack of convenience should be added to our list of accident causal factors. We know of many accidents in which pilots ran out of fuel because it was not convenient to obtain it for some reason. Here we see a pilot depart in an airplane with a known maintenance problem because it was not convenient to obtain the maintenance. What was so important about that flight that he gambled his life and lost? We cannot know the answer to that, but we should remember the circumstances of this accident if we are ever in a similar situation.

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