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Vectors For Safety - April 2023

Safety Initiative Update

"Just This Once"

We premiered our new program, "Just this Once" sponsored by Avemco Insurance at the Syracuse, NY Safety Stand Down on March 25. Thanks to all those who attended! Please check out the associated YouTube video (not valid for Wings credit) and free online course (valid for wings credit Master Level Topic 2).

Gone West

David Pepple, well-known aviation maintenance expert and flight instructor in both airplanes and helicopters, passed away on March 19. Dave was also a close personal friend. He will be missed on both a personal and professional level.

New Episode of "Old Pilot Tips"

Our latest episode of "Old Pilot Tips" is now available. The topic of this one-minute video is the much maligned but quite useful vertical speed indicator or VSI. Check it out here.

Positive Exchange of Flight Controls

Whether instructing, receiving instruction, or flying with another pilot, it is critical to establish who is in charge of the flight and to have an agreed upon system for the exchange of flight controls. No one was injured, but a Cessna 172 ended up inverted beside the runway last May in Western New York State when a student did not return control to the flight instructor. The NTSB Probable Cause states, "The student pilot’s excessive pitch during takeoff resulted in a loss of control and impact with terrain. Contributing was the student’s failure to relinquish the controls when ordered by the instructor." Click here to download the accident report from the NTSB website.

Recommended Video

Even with the now widely used ADS-B, midair collisions still occur. March 7th saw a fatal collision in Florida between a Piper Archer and a Piper J-3 on floats. For a brief refresher on collision avoidance, please consider watching our YouTube video, "Avoiding the Midair Collision."

Avemco Insurance sponsors Gene Benson
Gene's Blog

Hitting Stuff

I was the stereotypical airport kid. My frequent visits to the small, relatively local airport, in which I did various work in exchange for free rides and a few lessons, allowed me to get to know the many pilots who also spent much time at the airport. Four of those pilots were good friends and partners on a V-Tail Bonanza. I was even able to mooch a couple of rides in that magnificent bird. I began to look up to them as idols and friends. For several weeks they had been talking about their upcoming trip. I do not recall their destination, but I know that it was for a golfing weekend several states away. I was not there when they departed, but a quiet and sad mood was evident at the airport when I next arrived. My four idols had flown into a mountain and were all deceased. I do not know the circumstances, but they were apparently involved in what we now call a controlled flight into terrain or CFIT crash.

That crash made a lasting impression on me. It was the first airplane crash in which I knew the victims. CFIT crashes became my most studied type when I began my accident analysis work a couple of decades later. What have I learned over these many years? Sadly, I have learned that not much has changed. The same factors that led to CFIT accidents fifty years ago are still prominent causes of CFIT accidents today.

As a recent example, a CFIT accident gained national attention in November of 2022 when a Mooney managed to become entangled in power lines putting a large section of Maryland in the dark. News media across the country showed photos of the airplane precariously suspended above the ground with the passengers still inside. What was the cause? The NTSB has not yet completed their investigation, but either the airplane was flying too low or the wires were too high. Smart money is on the former.

Volumes have been written on CFIT accidents and how to avoid them. I have written articles, created videos, and conducted webinars on the subject. I will not rehash what has been published in the past, but I will provide some basic things that I have learned and practiced over my many years of flying.

I will begin with mountain flying. A search of the NTSB database reveals numerous CFIT crashes, many of them fatal, resulting during flight in mountainous terrain. There is a saying that I use frequently in my error reduction work that states, “We don’t know what we don’t know.” That is generally true, but I do know that I don’t know very much about mountain flying. My experience with mountain flying is simply enjoying the beautiful vista provided by the mountains while looking down from 30,000 feet. The one thing that I do know about mountain flying is that it requires significant knowledge on the subject and that it should not be undertaken without significant training on how to accomplish it safely. So, any pilot who is considering any sort of mountain flying is highly encouraged to seek out quality training. Many pilots who attempt mountain flying without training now have the title, “The Late” preceding their name.

So on to some things that I do know about. I believe in using instrument flying techniques to avoid hitting terrain as much as possible when flying VFR. No instrument rating is required to do that. Airports that have an instrument approach also publish a departure procedure if necessary for terrain avoidance. The U.S. Terminal Procedures Publications can be downloaded free of charge from the National Aviation Charting Office. Simply locate the departure airport and then the departure runway. If necessary, a minimum climb gradient is stated as feet per nautical mile. Then go to the end of the same publication and locate the “Rate of Climb/Descent Table.” Locate the stated minimum climb gradient down the left side and then go across to the anticipated ground speed on climb out. The intersection will show the minimum rate of climb needed to safely depart that runway. The final step is to calculate the expected rate of for existing conditions from the airplane performance charts. If a 450 ft./min. climb rate is necessary but the performance chart says the rate of climb will be 300 ft./min for the given conditions, a safe takeoff from that runway cannot be made. Of course, be sure to allow a safe margin in addition to the calculated values. Yes, that sounds like a lot of work, but it pales compared to a lengthy recovery from a crash on takeoff.

Another instrument procedure is to compare the route of flight with the IFR enroute chart. Those charts can also be downloaded for free from the National Aviation Charting Office. A minimum enroute altitude (MEA) will be provided for each route segment. Flight at or above this altitude along that route will be clear of all terrain and obstacles.

The Sectional Charts also offer area guidance. Each sector has a bold altitude, expressed as two digits printed in the center. Flying above that altitude will also provide safe clearance from terrain and obstacles in that section. Of course, the highest sector altitude can be excessive if a lone mountain sits in that sector. If that is the case, carefully study chart for obstacles and terrain in the area of the planned flight. My practice when flying at night is to never fly lower than the highest sector altitude, even if it means modifying my route.

Airplanes also strike obstacles during a VFR approach to a runway. If vertical visual guidance is provided by a PAPI or VASI, it is there for a reason so it is prudent to follow it. If there is no vertical guidance, extreme care must be exercised when approaching that runway. Wires are nearly invisible from the airplane, but a line of poles probably indicates that wires are strung between them. My simple rule at night is to never land on a runway that does not have working vertical guidance.

Do these things sound like overkill? Remember that our job as pilots is to manage risk. Developing a habit of doing these things as part of preflight planning is big step in managing the risk of having a CFIT crash.

broken image

The following article is reprinted from the NASA CALLBACK PUBLICATION #513 of October 2022.

Parachutes, Paragliders, and Power

Parachutes and paragliders, powered or not, have enjoyed a recent surge in popularity. This increased popularity, however, has unveiled an old threat wrapped anew. The airborne conflict has, in these operations, manifested itself in unorthodox ways from unusual vantages, while some surrounding issues have also been revealed. A resulting collision is unthinkable, but the threat must be addressed. Parachutes and paragliders often appear in locations that surprise other pilots. They have been spotted at various positions in airport traffic patterns and in and around skydiver drop zones. They have been seen at altitude over water, on tow behind surface vessels, and at low altitude over private property. Speeds relative to other aircraft precipitate additional complications. (This article is too long to include in this space. Click here to download the entire article in PDF format.)

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 training accident in a Cirrus SR20 did not result in any injury to either the student or the instructor, but a lower altitude of just a few feet might have brought a very bad ending to the flight. The NTSB report includes the following, "The cross-country flight was being conducted by a flight instructor and pilot in conjunction with an instrument rating course from a Part 141 flight school. According to the flight instructor, upon reaching the decision altitude, they transitioned to a visual descent to the runway. During the descent, the airplane impacted trees and the flight instructor assumed control of the airplane and continued to the runway for landing. The airplane sustained substantial damage to the fuselage, right wing, and both horizontal stabilizers. The pilot stated that after terminating use of the view limiting device and she transitioned to visual references, she continued to glance back at the glideslope indicator, which showed that they were low on the approach. Shortly thereafter, a tree appeared in front of them, about the same time as they felt the impact. She stated that the precision approach path indicator (PAPI) would not turn on and there was not a current Notice to Air Mission (NOTAM) for the outage."


Photo source: NTSB


Photo source: NTSB

The NTSB probable cause finding states, "The pilot’s failure to ensure adequate terrain clearance during an approach. Contributing to the accident was the flight instructor’s delayed remedial action when the airplane descended too low after transitioning to a visual descent to the runway."


Photo source: NTSB

The flight instructor provided a detailed statement to the NTSB regarding the flight. That report includes the following, "Approximately 25 miles away from the KANQ airport, we obtained the local weather. My student briefed the approach and completed all the required checklists. We contacted Fort Wayne approach and requested vectors for the RNAV 5 into KANQ. After the request, we began receiving vectors to the FAF. We followed ATC instructions and were cleared for the approach prior to the FAF and switched to KANQ’s traffic frequency. Once within 10 miles of the airport, I turned on the airport lights. Immediately, I noticed that the PAPI for runway 5 was inoperative—there was no NOTAM for the inoperative equipment. Per the instrument approach plate, we began a descent to 2800 feet. We made our standard radio calls on the frequency for the uncontrolled field. Our aircraft intercepted the glide slope when it came alive and began our descent to keep it centered. Before reaching the Decision Altitude (DA), I attempted to turn on the airport lights for a second time to try to turn the PAPI lights on. Again, the PAPI lights did not turn on. Upon reaching the DA, the glideslope and CDI were centered.

When we reached 1475 feet, I instructed my student to go visual. We both were gaining a grasp of our depth perception at the airport. As there were no lights in the airport vicinity, other than the runway lighting, there was an extreme "black hole approach" optical illusion. My student makes the callout on frequency at 2 nautical miles from the runway. We continued our visual descent at a normal rate to the runway with our CDI centered when we made impact with the top of a tree. We saw it while we hit it. There was no time to react before impact."

The 335-hour total flight time, age 23 instructor made a withdrawal from the bucked of luck and a deposit into the bucket of experience. the CFI's statement to the NTSB also includes, "I believe that this situation happened due to the black hole approach optical illusion in conjunction with the PAPI lights being inoperative." The CFI also went on to explain that this was a learning experience and listed specific steps to be taken to gain knowledge.

What lesson can we learn from this? First, we must realize that the lack of a NOTAM does not guarantee that everything will be working normally. NOTAMS do not file themselves. Someone must recognize that something is not working and put forth the effort to file the report. I am aware of a small, now closed, turf runway airport that was not practical for use in the winter due to deep snow on the runways nor in the spring due to the extremely soft and wet surface. No NOTAM was ever filed and there was no mention of seasonal operations in official publications. As pilots, when we become aware something such as a PAPI is inoperative, we must decide whether or not to continue. If we decide to press on, we must quickly formulate a plan to compensate. An effective plan might have been to assume a higher DA than what was published. In this case, there was still vertical guidance available through the glide slope indicator, but continuing descent below DA assumes visual reference. Apparently, in this case, the "black hole" interfered with being able to accurately determine a safe visual glide slope so a go-around or missed approach should have been initiated. As a general rule, any time there is confusion close to the ground, especially at night, it is prudent to immediately abandon the approach and reassess the situation from a safe altitude.

Documents providing more information on this accident are available on the NTSB website.

Click here to download the accident report.

Click here to download the Pilot-Operator Report

Click here to download the pilots' statements.

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 that happened in June of 2021 is not only sad because of the loss of life, but it was as preventable as it gets. A 51-year-old pilot and her 6-year-old granddaughter died in the crash of a Piper PA28-140 in Utah. The airplane collided with mountainous terrain at night. Unfortunately, that is not rare. What sets this crash apart is the qualifications and experience of the pilot. The causes of the crash equates to a salad of human factors.


Here is the Analysis Section of the NTSB accident report: "The accident flight was the second leg of an overnight, multi-leg cross-country from the pilot’s home airport in Northern Montana to her grandfather’s house in Southern California. The pilot was traveling with her granddaughter, and the trip was planned as a Father’s Day surprise. The pilot opted to fly overnight to avoid the heat and turbulence associated with flying over the desert during the day.


The airplane was not equipped with an ADS-B transponder. In order to avoid both the Salt Lake City International Airport (SLC) Mode-C and automatic dependent surveillance -broadcast (ADS-B) system out veil an adjacent military operation area (MOA), the pilot chose to fly through a narrow, mountainous corridor. Due to the altitude limitation of the MOA, the pilot could not fly over the mountain range.


Radar data confirmed that the airplane passed very close to terrain as it avoided the SLC Mode C veil, and ultimately turned into a valley and rising terrain just short of a mountain pass that led away from the airspace and in the direction of the destination. Although the moon was in a position where it would have silhouetted the mountains, it was only 50 percent illuminated, and a broken cloud layer was present that would have obscured most of the available moonlight.


The pilot had already worked a full day and departed on the flight late in the afternoon. The accident occurred at about the halfway point of the trip, about 7 hours after departure from her home airport, almost 18 hours from when she likely woke to report for work, and about the time she would normally have gone to sleep. Therefore, she was likely suffering the effects of fatigue as a result of the flight time and extended time awake. Additionally, her circadian systems were not actively promoting alertness because she was operating the airplane at a time she would normally have been asleep.


The majority of the pilot’s flight experience was as an Army helicopter pilot, with about ¼ of her flight time accrued at night, often over desert terrain, frequently with night vision goggles. Since then, she had taken a long break from flying, and recently purchased the accident airplane and attained her fixed wing private pilot’s license. The accident flight was the longest flight she had flown since leaving the Army, and her longest flight single-pilot in a fixed-wing airplane. The pilot’s decision making associated with the timing of the flight over mountainous terrain suggests overconfidence based on her previous flight experience.


The pilot was carrying oxygen to aid with her night vision; although she had taken a borrowed GPS moving map system that was capable of displaying terrain features, this was the first time she had used it, and she was likely not proficient in its operation.


The airplane crossed into the Mode-C and ADS-B Out veil twice as it followed a meandering track around the SLC airspace and came perilously close to terrain on two occasions, further indicating that the pilot was possibly suffering the effects of fatigue and either not proficient in the operation of the GPS unit or not using it. It is likely that the pilot lost situational awareness and turned prematurely into the valley, possibly mistaking it for the pass, resulting in controlled flight into terrain."

WOR21FA231 Airplane Flight Track

Airplane Flight Track Graphic Source: NTSB

WOR21FA231 Flight Track Annotated

Airplane Flight Track Showing AGL Information Graph Source: NTSB

The NTSB accident Probable Cause Finding states, "The pilot’s misidentification of a mountain pass at night, which resulted in controlled flight into terrain. Contributing to the accident were the pilot’s overconfidence based on her previous aviation experience and fatigue due to both the time of the flight and her work schedule. Also contributing was the pilot’s decision not to install an automatic dependent surveillance-broadcast (ADS-B) system, which forced a flightpath close to mountainous terrain to avoid the Mode-C and ADS-B Out veil."

WPR21FA231 Accident Path and Site

Final segment of flight path. Note smoke from large fire started by the crash. Graphic Source: NTSB


Pilot Information included in the NTSB Accident Report

WPR21fA231 NTSB Findings

This pilot had most certainly been educated in all of the above factors while serving as a military pilot. The motivation for the flight, and most likely the source of the external factors involved, was a surprise Fathers' Day visit. I think that most experienced pilots would find beginning and continuing this flight under these conditions and in this limited capability airplane, to be incredulous. Yet, the flight was begun and had a tragic conclusion.

I have written previously about something I call the "Bias Bundle Bomb." It is when three of our known cognitive biases come together and influence us to make bad decisions. It begins with illusory superiority in which we all believe that we a bit better than the other pilot. That can very certainly be fueled by having significant experience as this pilot had. Next, we have confirmation bias which allows information that supports our decision to get through while blocking negative facts. Finally we have continuation bias which provides a strong desire to continue a task once it has begun. This pilot perhaps thought that her experience gave her the edge to conduct this flight. She perhaps realized the difficulty of the flight once airborne, but her brain was blocking the magnitude of the risk involved. Then when about half the flight had been completed, her desire to continue was very strong.

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