Another New Edition of "Old Pilot Tips" is Available

Episode #29 in our series explains, in less than one minute, a tip to on ensuring your tires are safe for flight. Click here to check out "Respect the Tires."

New "Airworthiness Concern Sheet" issued by the FAA

This important sheet addresses an issue with manual fuel primer pumps. If you fly an airplane with a carbureted engine, check this out here.

Recommended Video

Many accidents categorized as runway excursions mention crosswinds in the probable cause. We have a video for that! Check out Crosswind Essentials in our "Essential Vectors" playlist on YouTube.

Recommended Online Course

Many of us will be venturing out during the good weather months to attend gatherings and events. We might be heading for an aviation event, a wedding, a graduation party, a reunion, or just a flying vacation. We would like to be sure our journey to and from our event is uneventful. Consider some recurrent training by taking our course, "Getting Together Uneventfully." Completion of the course is valid for 1 Credit, Basic Knowledge Topic-3. Click here to visit the course.

Now Offering a Full-Day Landings Workshop

Delivered either virtually or on-site, this in-depth program delves deep into making better and safer landings. Valid for 5 FAA Wings credits, this program can benefit pilots of all certification and experience levels. For more information or to schedule the workshop for your group or organization, click here or email gene@genebenson.com.

Virtual Presentations for any Size Group Available for Free!

Flying Clubs, Pilot Associations, CAP, QB, 99s, FBOs, Flight Schools can all have no-cost virtual presentations courtesy of Avemco. Wings credit is available for all presentations. Virtual presentations can attended by members of your group wherever they may be, can be projected to a group at a central facility, or both simultaneously. Click here to download my updated presentation catalog. Concerned about the technology? Click here to download a Virtual Presentations Setup Guide. Email me at gene@genebenson.com for questions or to discuss scheduling.

Recognition

Recognition is the ability of the brain to recover past information stored in our memory. That stored information is compared to stimuli presented to us through our five senses. This is essential for us to recognize a familiar face and recall details about the person, recognize a traffic sign and recall what action we must take, or recognize the sound of heavy rain and take action to stay dry. For the pilot, it allows the recognition of each flight instrument, what it is showing us, and to recall what action we should take regarding our flight. It allows us to recognize symbols on an aeronautical chart and recall their meanings. It allows us to recognize the sound of a misfiring engine and recall what actions we should take.

Pilots rely heavily on their recognition skills to identify runway signs and markings, flight and navigation instrument displays, aeronautical chart symbols, signs of hazardous weather, and much more.

With a significant decline in recognition, normal daily life would be difficult if not impossible. Even a slight decline in recognition can have a detrimental effect on a pilot’s ability to fly safely. Recognition is fundamental to other cognitive skills. If a stimulus is incorrectly recognized, other cognitive skills may work correctly, but may work to solve a problem that does not exist while ignoring a real problem.

Recognition skills may be adversely affected by Alzheimer’s Disease or other forms of dementia. It can also be associated with schizophrenia or dyscalculia. Stroke and chronic traumatic encephalopathy (CTE) (think repeated head injuries from playing football or boxing) can result in recognition decline.

Improve Recognition
Like other cognitive skills, recognition can be improved with some mental activities. Word games, card playing, doing jigsaw puzzles, memorizing lists that require association such as all the state capitols, or names of all U.S. presidents in order of when they held office can improve recognition and other cognitive skills.

Click here to download the free "Aging Pilot Report."

Written in Blood

In every corner of aviation, our rules and procedures are written in blood. These guidelines have emerged from meticulous analyses of numerous crashes by experts in their fields. No agency or entity aims to arbitrarily restrict operational freedom through regulations.

Airlines and other commercial operators face more scrutiny than non-commercial general aviation but lapses in compliance still happen.

For non-commercial general aviation, following regulations and procedures is mostly voluntary. Preventative enforcement is rare, and penalties for non-compliance after a crash are usually minimal. The bigger threat for pilots or operators is the civil lawsuit that often follows a crash, but in most cases, the insurance company bears that burden.

A noticeable decline in compliance has been observed in the aviation safety community. Whether due to a reduced threat of enforcement, cultural changes, or something else, it's a dangerous trend.

The Flight Safety Foundation’s 2024 Safety Report, focusing on airline operations, highlights growing concerns about the erosion of safety due to lapses in compliance with regulations and standard operating procedures. Foundation President and CEO Dr. Hassan Shahidi stated, “Compliance alone does not guarantee safety, but without it, safety cannot be achieved.”

This statement applies equally, if not more, to non-commercial aviation, which often involves single-pilot operations in and out of smaller airports with fewer services and without the support of dedicated dispatchers and maintenance services.

Another area of concern for non-commercial aviation, operations conducted under Part 91, is compliance with service bulletins issued by aircraft and original equipment manufacturers. These are non-regulatory, even if labeled as a mandatory service bulletin. These address maintenance issues which are not deemed to be sufficiently critical to rise to the level of an airworthiness directive, or AD, with which compliance is mandatory for all operators. Note, some mandatory service bulletins are coupled with an airworthiness directive which then requires compliance.

It's crucial for all of us to make our best effort to fully comply with applicable regulations and standard operating procedures, which would include compliance with service bulletins. These regulations and procedures should not be seen as a buffet from which we can pick and choose. It’s a whole meal and we should all clean our plates.

Reversing the trend of declining compliance will require individual action. Government agencies and industry groups can sponsor and host programs encouraging better compliance. However, individuals choosing to improve their own level of compliance and gently encouraging their colleagues to do the same will be the only effective solution.

Our Accident Analysis section this month illustrates the importance of service bulletin compliance.

Just a thought before we look at our accidents that have been analyzed for this month regarding service bulletins. We should note that from a pilot's perspective, how can we know if compliance with the service bulletins on the airplane we are about to fly are up to date? It is not easy. If we own the airplane, we can check maintenance records or engage an experienced technician to do that for us. If we are renting an airplane, it is extremely difficult. In reality, we must trust the operator to provide excellent maintenance and not just do what is required by regulation. My advice, look closely at the airplanes in the fleet. Do they look well maintained or are there bald tires, minor oil leaks, worn lap belts or lap belts only without shoulder harnesses? Are maintenance squawks addressed fully and in a timely way? If the airplanes are not maintained to a high standard, including compliance with service bulletins, think very hard about trusting the lives of yourself and of your passengers to that operator.

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 55-year-old, 308-hour, private pilot escaped injury when the Cessna 177RG he was flying lost engine power. The NTSB accident report states, "About 30 minutes after takeoff on a cross-country flight, the pilot noticed an increase in engine exhaust gas temperatures (EGTs) for all cylinders. The engine then briefly “stuttered,” and he decided to divert to an airport en route for a precautionary landing. The EGTs then returned to normal, and he decided to continue to the original destination. However, during the landing approach, the EGTs again began to rise; the engine lost all power; and the airplane landed short of the runway and struck approach lights, which resulted in substantial damage to the left wing and stabilator."

Upon first reading, it appears that the pilot's reversal of the decision to divert was flawed and possibly the result of continuation bias. However, upon reading the pilot's statement in the NTSB Pilot/Operator Report, he stated that the airport planned for the diversion was cloud covered beyond his comfort level. I will never second guess a decision made by a pilot who walks away from a crash uninjured and not causing injury to anyone else either in the airplane or on the ground.

NTSB Photo

The NTSB report continues, "Data recorded by the airplane’s engine monitor showed the EGT increases that were reported by the pilot. Disassembly of the fuel injection servo revealed significant internal corrosion and corrosion deposits along with evidence of water ingestion. The corrosion deposits likely resulted in a partial blockage (restriction) of fuel to the cylinders, which manifested itself as a lean fuel mixture. This lean mixture was consistent with the observed increase in EGTs. During the final approach, the blockage likely became severe enough to result in the total loss of power."

NTSB Graphic

And the NTSB report continues further: "The fuel injection servo manufacturer recommends by service bulletin that the unit should be overhauled either every 12 years or at the time of engine overhaul. The unit had last been overhauled 23 years before the accident, and it was not overhauled at the last engine overhaul 10 years before the accident. Additionally, the service bulletin stated that the unit should be overhauled in the event of water contamination. The unit had clearly ingested water at some point during its life, although it could not be determined when this occurred."

NTSB Graphic

The NTSB probable cause finding states, "The total loss of engine power due to an inadequately maintained fuel injection servo."

Though compliance with service bulletins for Part 91 operations is not mandatory, it is highly recommended. Compliance does add to the maintenance bill, but looking at the damage to this airplane, it would have been money well-spent. And this crash could have resulted in injury or worse...

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 involved a Cessna 182C and it occurred in Lake Meade, Nevada. The NTSB accident report includes the following, "The pilot and pilot-rated passenger departed Grand Canyon National Park Airport after a fuel stop in Las Vegas, Nevada. About 30 minutes into the flight the pilot noticed a low oil pressure indication and declared an emergency. Moments later the engine sustained a total power loss and the engine seized. When it became evident the airplane could not make it to the airport, the pilot made the decision to ditch the airplane into a nearby lake. The airplane was substantially damaged during the water landing."

The 34-year-old, 815-hour commercial pilot/CFI explained in the Pilot/Operator Report that upon contacting the lake the plane flipped, and the cockpit began filling with water. He and the pilot rated passenger unbuckled and had to climb out the window. He reported that the airplane sank about 45-seconds after they got out and that they swam about 200 yards to shore.

The pilot was not injured and the pilot rated passenger reported only minor injuries. It is easy to see many ways in which this could have ended tragically.

NTSB Photo

NTSB Graphic

The NTSB report continues, "Postaccident examination of the engine revealed discoloration of the cylinder and bearing surfaces consistent with high heat signatures due to oil starvation. The engine examination revealed no preimpact mechanical anomalies except for the oil filter adapter housing, which was loose, and the gasket was torn and deformed. As the oil level was likely normal at the pilot’s previous stop and the pilot did not notice any unusual reductions in oil quantity during the service life of the engine, it is likely that the oil started to leak during the accident flight. The failure of the gasket likely allowed engine oil to exit the crankcase rapidly, resulting in oil starvation and the subsequent catastrophic failure."

NTSB Graphic

Then, the analysis section of the report concludes with this: "A review of the engine maintenance records revealed no entries that the oil filter gasket had been inspected in accordance with the mandatory service bulletin, nor was it required."

The NTSB probable cause states: "A total loss of engine power due to oil starvation resulting from the failure of an engine oil filter adapter fiber gasket."

Because a service bulletin is not required by the regulations does not mean that it is unimportant. It seems likely that the failure to not comply with the service bulletin resulted in the loss of the airplane and could have resulted in fatalities had the circumstances been different.

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 60-year-old, 2,400 hour instrument rated private pilot and his passenger were seriously injured in the crash of a Mooney M20K. The crash occurred in Texas in December of 2022. The NTSB accident report includes the following, "The airplane lost all engine power during a precision instrument approach for landing to the destination airport. After the pilot was unsuccessful in attempting to restart the engine, he performed an off-airport landing to a road, during which the airplane struck a pole and a postcrash fire ensued. There was substantial damage to the wings and fuselage."

NTSB Photo

The NTSB report continues, "Postaccident examination revealed that about 12 of the camshaft gear teeth were fractured due to fatigue cracking. The airplane engine’s camshaft gear part numbers were affected by the engine manufacturer’s service bulletin (SB) for camshaft gear tooth fracture or cracks of the teeth. The SB called for the replacement of the camshaft gear with a newer model. The intent of the SB was to eliminate the possibility of camshaft gear tooth fracture, resulting in power loss or in-flight shutdown; compliance with the SB is not mandatory for Part 91 operations. Based upon the camshaft gear part numbers, the SB was not complied with but likely would have addressed the fatigue failure of the camshaft gear teeth. The maintenance records for the airplane were destroyed in the postimpact fire and could not be examined."

NTSB Photo showing missing teeth in the camshaft gear

The NTSB probable cause states, "The fatigue failure of the engine’s camshaft gear teeth which resulted in a loss of all engine power. Contributing to the accident was the non-compliance with the engine manufacturer’s recommended service bulletin."

NTSB Photo showing burned instrument panel after the crash

Again, a crash can be traced back to non compliance with a service bulletin. All maintenance is costly, but so are crashes.

Click here to download the accident report from the NTSB website.

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