Stop it!
It is time to stop tiptoeing around this issue and tackle it. Some non-instrument rated pilots (and some rated but not current or proficient rated pilots) decide to fly in instrument meteorological conditions (IMC). The result is often loss of life to the pilot and the passengers. How can we stop pilots from engaging in this extremely hazardous activity? The answer is quite simple. We cannot. So maybe we need to shift some of our focus from seeking total abstinence to mitigating the risk.
Our model is current society. We know that many people will not follow the rules so we put mitigation strategies in place. We tell people not to use recreational drugs, but we equip EMTs and police officers with NARCAN just in case. We tell teenagers not to drink alcohol but we instruct them not to drive if they do. We also tell teens not to engage in sex, but we provide protection just in case.
So how do we mitigate the risk to the VFR pilot who decides that flying into the clouds is okay? We conduct a campaign to increase proficiency in attitude instrument flying. I call on all flight instructors to push attitude instrument flying skills at every opportunity. Raise the standards you require for initial certification. Make it a focal point of flight reviews and rental airplane check-outs. I call on flying club presidents or safety officers to push it at safety meetings. I also call on my colleagues in aviation safety work, including my fellow FAASTeam Representatives, to put some additional emphasis on it in upcoming presentations.
We need to encourage pilots of all levels to sharpen their skills in flying the airplane solely by reference to the flight instruments. We can use real airplanes or simulators of just about any level. However, we do need to be aware that the ability to duplicate conditions conducive to producing spatial disorientation is not available in the basic simulators. Emphasis needs to be on preventing loss-of-control. Recovery from unusual attitudes must also be addressed, but many of the accidents that I have reviewed happen at an altitude that is too low for recovery. See Gene’s Blog below for more on this topic.
Study it and Practice it!
We are all familiar with the TV commercials for legal services. It drives me crazy when they make it seem like being in an automobile accident is equivalent to winning the lottery. One firm locally shows young, attractive, energetic individuals telling how this firm got them anywhere from a quarter million to three million dollars from their accident. The fine print says that these are actors portraying actual clients. Somehow, I think that the actual clients may no longer look and act like these actors. The other bit of fine print states that past performance does not guarantee future results. That may be the only honest fact to come out of these ads and it applies to many things in life, including flying. High-time, experienced pilots sometimes have tragic accidents. We must not believe that our experience, regardless of how much we have, will inoculate us from having an accident. We must strive to be as knowledgeable and as proficient as we can be. Our previous flights are history and do not guarantee future results. We are only as good as our next flight.
Lock It!
I am seeing more frequent reports of parts being stolen from airplanes. As any airplane owner knows, parts are very costly and now, more than ever, are more difficult to obtain. Anything that is valuable and difficult to obtain has the potential to attract criminal activity. So, to the extent practical, it is a good idea to lock the airplane and the hangar. Unfortunately, unlike a car in which the hood cannot be released without entering the vehicle, most airplane cowls can be opened either via a simple latch or a with a screwdriver. Plexiglass windors are easily broken to gain entry. That being said, the preflight inspection and pre-taxi checklists need to be conducted with great care. If a part is missing, we want to know it while we are still on the ground.
Enroll in it!
It is officially spring and the weather is more summer-like in many places. About a year ago, I presented a webinar, sponsored by Avemco Insurance, titled Avoiding the Summertime Gotchas'. The same material is available as a free, online course with the same title. It addresses numerous issues associated with summer flying and course completion, including a brief quiz, is valid for 1 credit Basic Knowledge-2 and 1 credit Advanced Knowledge-2 in the Wings program. Of course, it is also valid for the Avemco Safety Rewards Program. Click here to enroll in the course.
Subscribe to it!
Many of you know that in addition to aviation, I have a passion for applying human factors to improving human performance and reducing errors. I am now writing a biweekly post on LinkedIn titled, "The Being Better Blog." A new article will be posted every other Wednesday. The first four editions are up now and the edition will be available on April 13. I am beginning with a series of articles on decision making. To see the articles in sequence, you must scroll to the bottom and work your way up. You do not need a LinkedIn account to view or subscribe to the blog. Click here to check it out.
Stow It! (Tow Bar Update)
Thanks to one of our readers, Doug, for the following idea: "In reference to stow it with the tow bar another thought would be to put a flag on the tow bar that will spring upright when the tow bar is used, like they have on cowl plugs just longer. It would be in view of the pilot when they get into the plane and hard to ignore. The tag on the throttle may be noticed too late or totally ignore, you know confirmation bias. It also requires the pilot to remember to put it on the throttle which requires an active action, whereas the flag on the tow bar is passive." Doug also provided a link to a source where a flag can be purchased economically. I think Doug's idea has merit and is worth consideration.
Save it!
The date that is. If you are within range of Western New York State please save Tuesday, May 24, 2022. My first live, in-person safety seminar in more than two years will by happening at the Genesee County Airport (GVQ) at 7:00 PM. The title of the presentation is Dealing with the Big E - Surviving an Inflight Emergency. The facility and the refreshments will be provided by Boshart Enterprises. This will be a FAASTeam event and complete details, including online registration, will be the May 1 issue of Vectors.
On the Gauges
We continue to have far too many loss-of-control-inflight (LOC-I) accidents. These are usually fatal or at least result in serious injury.
I have long objected to the wide categorization of the LOC-I events. Pilots lose control of the airplane for a variety of reasons. A pilot may stall and spin while trying to clear rising terrain or while executing a go-around, or while trying to recover from overshooting a turn from base leg to final approach, or by succumbing to spatial disorientation due to an illusion, at night or in IMC. These are all LOC-I accidents, but they do not share a common error chain. Inadvertent VFR flight into IMC is a common cause of spatial disorientation that immediately precedes the LOC-I accidents, so I would like to concentrate on that for now.
To earn a Private Pilot Certificate with Airplane Rating the applicant must demonstrate a basic level of proficiency in flying solely by reference to the flight instruments. According to the current Private Pilot-Airplane Airman Certification Standards, the applicant, solely by reference to flight instruments, must demonstrate proficiency that includes straight-and-level flight, constant airspeed climbs and descents, turns to headings, and recovery from unusual attitudes.
I know from experience that not all flight instructors and not all designated examiners maintain the same standards of performance regarding this requirement. Some newly minted private pilots have excellent attitude instrument flying skills while others exhibit marginal proficiency. But even a pilot with excellent skill with the gages needs to renew that skill periodically or it will go stale.
Think of the skill as a couple of slices of bread. We open a new loaf of bread and take in the wonderful aroma. We can imagine how good a sandwich made with that bread will taste. Before we continue with our sandwich construction, something important comes along requiring a quick trip and we leave our unused slices of bread on the counter. When we return in five days and find our bread still where we left it. But now it is stale and not very appetizing. Though requiring more than five days, our attitude instrument flying skills go stale if not used. Some of our flying skills have a much longer shelf life, but attitude instrument flying is more like bread than jerky.
An instrument rating, unfortunately, does not extend the shelf life of our proficiency on the instruments. Personally, I know that if I have a lapse of even thirty days without flying solely by reference to the instruments, I have a lag time in becoming comfortable upon entering IMC. That lag time, if more than thirty seconds or so, can start a path heading toward spatial disorientation and loss-of-control. Many LOC-I accidents happen to instrument rated pilots who have not flown in IMC or had some simulated instrument time in a year or more and lose visual reference.
My non-scientific and informal study of these accidents seems to indicate that if control is going to be lost due to spatial disorientation, it usually happens within the first two minutes after losing visual reference. The culprit appears to be the transition from visual reference to flying on the gauges. The pilot who is proficient in attitude instrument flying will be able to make the transition easier and faster than the non-proficient pilot. A technique that I have always used is to, when possible, make the transition to the instruments about thirty seconds before going totally on the gauges. For example, if climbing into an overcast, I switch to the instruments a little before reaching the clouds. That gives a little time for the transition rather than having to make an immediate switch.
So in summary, we should take whatever steps we can to maintain proficiency in attitude instrument flying, even if we never intend to fly in IMC. Many pilots have professed their intention to remain in visual conditions but find themselves in IMC for a variety of reasons. Good intentions do not always produce good results.
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.
NTSB Photo
This crash illustrates how a pilot can become spatially disorientated quickly after losing visual reference. Happening in October of 2014, three medical doctors lost their lives when a Beech Model 58 Baron crashed within five minutes of departure from Chicago's Midway International Airport. The departure was at night and in marginal VFR conditions. Though the 33-year-old pilot was instrument rated, no flight plan was filed. The intended destination was Lawrence, Kansas.
NTSB Photo
The NTSB accident report includes the following: "Radar track data showed that the airplane departed runway 22L at MDW and began climbing on runway heading (220 degrees). At 2238:01, the airplane had accelerated to a computed groundspeed of about 130 knots and climbed to an altitude of about 2,200 ft above mean sea level (msl). After reaching this altitude, when the airplane was about 3 nautical miles (nm) from MDW, the airplane then began accelerating and descending as it turned about 20 degrees to the left to a heading of 200 degrees, which was followed immediately by a turn to the right. By 2238:38, when the airplane was about 4.8 nm from MDW, the airplane had descended about 700 ft to an altitude of 1,500 ft msl. The airplane then began climbing. As the climb was initiated, a left turn was also initiated. The left turn continued while the radius of the turn decreased until the end of the radar data. During the final left turn, the airplane initially climbed about 400 ft, descended about 400 ft, and then climbed again about 1,300 ft before reaching a peak altitude of 2,800 ft msl at 2239:24. At this time the airplane was about 5.9 nm from MDW and about 0.1 nm from the accident site. The final radar data point was at 2239:29 at a recorded altitude of 2,400 ft. The final radar data point was located within 0.1 miles of the accident site, and about 6 nm southwest of MDW. The calculated rate of descent between the final two radar points exceeded 5,000 ft per minute."
NTSB Photo
The NTSB Probable Cause finding states: "The pilot's loss of airplane control due to spatial disorientation while operating in night, instrument meteorological conditions."
The NTSB reference to night, instrument meteorological conditions, even though the airport exhibited marginal VFR conditions, comes from calculating the cloud heights above the airport. The airport elevation is listed as 620 feet MSL. The official weather observation indicated broken clouds at 1,000 feet AGL (1,620 feet MSL) and an overcast at 1,700 feet AGL (2,360 MSL). The radar track showed the unusual flight path beginning when the airplane had climbed to about 2,200 feet MSL and likely in the clouds.
His maneuvering after reaching 2,200 feet MSL may indicate that he realized he had gone into clouds and was attempting to regain VFR conditions. If so, the maneuvering would have likely induced or accelerated the onset of the spatial disorientation.
The bottom line is that flying VFR at night in MVFR conditions is not a good idea.
We do not know why the instrument rated pilot did not file and IFR flight plan. Perhaps he lacked confidence in his proficiency in flying in IMC.
A human factors analysis would question whether a busy professional had neglected necessary practice to maintain instrument flying skills and perhaps decided to avoid flight in the IFR environment. The concept of success transfer would also be considered. We often see a person who is very skilled and successful in one area assume that the success will automatically transfer to another area, such as flying. This can also be fed our one of our cognitive biases, illusory superiority in which we all believe that we are a bit better and more capable than the other person.
Click here to download the accident report from the NTSB website.
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.
The pilot and sole occupant of a Lancair Legacy died in the crash which happened in Missouri in October of 2019. The 65-year-old private pilot was instrument rated and had about 1,590 flight hours total time, all of it in this make and model. He had logged 33 hours in the last 90 days.
NTSB Photo
The NTSB accident report includes: "The pilot flew the airplane from Texas to Missouri three days earlier to attend the Lancair Owners and Builder Organization's annual meeting; the accident occurred on the return flight. According to the Federal Aviation Administration (FAA), there was no record of the pilot obtaining a weather briefing or filing a flight plan before his departure."
The accident report continues: "Radar information showed the airplane depart about 0825 and establish a south-southwesterly heading at altitudes between about 2,300 ft mean sea level (msl) and 2,800 ft msl. About 0846, the airplane began a descent and reached a minimum altitude about 1,525 ft msl about 0849. Over the next minute, the airplane entered a climbing, 270° left turn and slowed to a speed of about 42 kts before radar contact was lost at 0849:49, at an altitude of 1,975 ft msl."
Two witness statements are included in the accident report. The first one states: "A witness about 3 miles from the accident site heard a single-engine airplane and reported that the engine sounded as though it was "revving high." He stated that it was "a bad day to be flying" because of the thick cloud cover and mist. He estimated that when the airplane passed over him, it was a few hundred feet above the ground or lower, and that he could not see it due to the low, thick cloud cover."
The second witness report states: "A witness about 3 miles from the accident site heard a single-engine airplane and reported that the engine sounded as though it was "revving high." He stated that it was "a bad day to be flying" because of the thick cloud cover and mist. He estimated that when the airplane passed over him, it was a few hundred feet above the ground or lower, and that he could not see it due to the low, thick cloud cover."
NTSB Graphic
The NTSB Probable Cause finding states: "The pilot's continued visual flight rules flight into instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation."
NTSB Photo
Again, we see an instrument rated pilot attempting to fly VFR when conditions are not suited to visual flying. The accident report states that the last logged instrument time for the pilot was 0.5 hours of actual instrument time a little more than a year prior to the crash.
We do not know if the pilot intended to fly IFR without a clearance whether he intended to scud run, or whether he inadvertently went into IMC. In any case, proficiency in attitude instrument flying might have let him avoid spatial disorientation and saved his life.
Click here to download the accident report from the NTSB website.
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 occurred in Wisconsin in June 2018 and resulted in the death of the 81-year-old pilot, her daughter, and two of her grandchildren ages 17 and 13. The purpose of the flight was to attend a family event. The instrument rated commercial pilot, with more than 4,600 hours total flight time, including 491 hours of actual instrument time, and 90 hours in the preceding six months, chose to execute the GPS approach even though the weather was well below the published landing minimums. The flight was being conducted under Part 91, therefore it was permissible to conduct the approach and see if the runway was visible upon approach completion.
The pilot executed a missed approach, but apparently succumbed to spatial disorientation during the go-around and lost control of the airplane.
NTSB Photo
The airplane was fragmented consistent with impact forces and portions of the fuselage were partially consumed by a postimpact fire.
NTSB Photo
The pilot held a current Class 3 FAA Medical Certificate with no limitations or waivers. Toxicology testing showed the pilot to be free of any impairing substances.
The NTSB probable cause finding states: "Spatial disorientation resulting in a loss of control during the missed approach conducted in instrument meteorological conditions. Contributing to the accident was the pilot's decision to execute an instrument approach in weather conditions that were below the approach minimums."
What lessons can we learn from this crash? First, previous experience does not inoculate us from having an accident. Each flight is a new challenge. Second, beginning an instrument approach when the airport is below landing minimums adds risk. Legal and safe are not always the same. Descending to a low altitude on an instrument approach leaves little room for error. The acceleration of the go-around plus the subsequent turn can set the stage for spatial disorientation.
Was the pilot's age of 81 years somehow causal in this? There is no available evidence to substantiate this, but it is widely recognized that we all suffer some degree of cognitive decline, including slowed reaction time, as we age. While we cannot rule out aging as a factor, I can cite dozens of accidents resulting from spatial disorientation involving much younger pilots.
Click here to download the accident report from the NTSB website.
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