Virtual Aviation Safety Stand Down
I am excited to be the host as well as a presenter at the Northeast Virtual Aviation Safety Stand Down. The event will run on Saturday, September 12 from 9 AM till 1 PM Eastern time. Rather than the typical fifty-minute presentations, we are planning to feature a few more presenters which means a few more topics. Presentations will have a duration between 20 and 30 minutes each. This is the first in a series of regional events. Presenters will be from the Northeast U.S. We are still finalizing the list of presenters and topics. The event will be free to attend. Registration for the event will open on August 15. Attendees may be eligible to receive all three FAA Wings credits at the basic level. Click here to visit the event website. Sponsor opportunities are still available. Click here to download the sponsor information sheet.
Additional events to cover the remainder of the U.S. are planned. They are also listed on the event website. If you are interested in being a presenter and/or sponsor for any of the upcoming events, please contact us here.
New Program: Personal Safety Audit - for Pilots
I frequently receive emails from pilots requesting to engage my services as an instructor for some aspect of ground training. I am glad to do that, but as we proceed, we often discover additional areas that need some bolstering. Realizing that a top-to-bottom approach to safety is better than trying to plug a couple of holes and missing other weak areas, I created a new program. I am calling it the "Personal Safety Audit - for Pilots." A pilot will be assigned an instructor/mentor who will conduct virtual meetings to identify weak areas or areas identified by the pilot. The instructor/mentor will make study assignments as appropriate, and conduct additional virtual meetings to discuss the assignments completed and make assignments to be completed before the next virtual meeting. All assignments are available online for easy access. All instructors involved are very experienced and competent, but I will be happy to personally work with any of my subscribers if requested.
The program includes up to four hours of individual virtual meetings with the instructor/mentor. Completion of the program will qualify for all three FAA Wings credits at the basic level plus both Wings credits at the advanced level. The program fee is $279 but subscribers may click here to receive a $20 discount. If you have donated to the Safety Initiative within the past two years, you have earned a very special deal on this program! To discuss your special donor price, contact me at firstname.lastname@example.org.
"Are the Wheels Down?"
My non-pilot wife always appeared to have complete confidence in me as a pilot with one exception. She was always concerned that I would forget to extend the landing gear prior to our touchdown. I have no idea why she had that concern since I had never landed gear-up nor had I ever almost landed gear-up. She knew that I was a stickler for checklists, briefings, and standard procedures. Yet, each and every time we on our way down final approach, she would ask, "Are the wheels down?" It became somewhat of a joke between us so I asked her to record her question and I installed the recording as her ringtone on my phone. I sometimes get some very strange looks when I am in public and my pocket loudly inquires about the position of the landing gear.
But cute anecdotes aside, we may have a pandemic in progress but we also have an epidemic of airplanes landing with the wheels in the wrong position. As I read the daily ASIAS reports, it is rare to have a day in which a gear-up landing is not included. Sometimes there are multiple gear-up landings reported. Of course, it works the opposite way for an amphibious airplane landing on the water. The landing gear must be retracted or the airplane will generally flip onto its back upon touchdown. Less common than gear-up landings on the runway, several gear-down landings on water have appeared in the ASIAS reports over the past month. For pilots flying amphibious airplanes, the key is to have appropriate checklists for each kind of landing (water or land) and use them. A short final briefing should also be memorized for each type of landing.
Complacency is a Constant Threat
On 24 April 2019, a Beechcraft B200, was on a positioning flight in Canada. The captain was receiving line indoctrination training from the training pilot, who assumed the role of first officer during the flight. While in cruise flight, the crew declared an emergency due to a fuel issue. They attempted to divert to an airport but landed 750 feet short of the landing threshold. There were no injuries, but the airplane received substantial damage.
The investigation found that the flight crew had multiple opportunities to identify the shortage of fuel on board the aircraft. Before takeoff, when the captain asked if the aircraft was ready for flight, the first officer replied that it was, not recalling that the aircraft required fuel. Then, while performing the Fuel Quantity item on the After Start checklist, the captain responded to the first officer’s prompt with an automatic response that the fuel was sufficient without looking at the fuel gauges. As a result, the aircraft departed Winnipeg with insufficient fuel on board to complete the planned flight.
During the flight, the crew did not include the fuel gauges in their periodic cockpit scans nor did they confirm their progressive fuel calculations against the fuel gauges. As a result, their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
Most of us have a good set of checklists and use them well. But complacency is always looking over our shoulders and waiting for a chance to strike. If complacency can strike a couple of professional pilots, including a check airman, it can strike anyone. We must make sure that checklists are followed precisely each and every time.
Great issue of FAA Safety Briefing
The July/August issue of the FAA Safety Briefing publication is especially good. I am probably biased, since the issue is all about human factors in general aviation, but I consider it a "must-read" for all GA pilots. Read or download it at https://www.faa.gov/news/safety_briefing/
Is the Cure Worse than the Disease?
By Gene Benson
Those of us who do aviation safety work identify a problem and then try to find ways to mitigate it. The process could be analogous to medicine in which a disease is identified and a cure is sought. There have been some unfortunate experiences over the years in which the identified cure has turned out to be worse for the patient than the disease had been. The analogy may be coming back to aviation in one mitigation strategy.
Just about every flight instructor, including myself, has admonished their students, “If the landing doesn’t look right, go around!” Have we perhaps helped our students avoid an accident or incident limited to bent aluminum and fractured pride while facilitating a fatal accident? This is one of the things that, figuratively speaking, keeps me up at night.
Landing accidents have a low lethality index and frequently produce only minor if any injuries. Go-around accidents have a very high lethality index. Nobody wants to see a bent airplane with bruised and frightened passengers resulting from a landing accident. But the sight of a go-around accident with a crumpled, possibly burning, airplane with the local medical examiner enroute is even less desirable.
Statistically, the go-around maneuver can be dangerous. A conscientious flight instructor makes sure that the student is competent in performing a go-around prior to authorizing solo flight, a practical test for a certificate or rating, or endorsing a flight review. As time passes proficiency wanes in the absence of practice. Flying a different make or model airplane may require different procedures for performing a go-around. A pilot struggling on final approach might be on the way to a landing accident that will result in bumps and bruises along with thousands of dollars in airplane damage. But if that pilot remembers the admonition of an earlier flight instructor and attempts to execute a go-around while not proficient in the maneuver, the result might be a fatal accident.
While it is possible that we might reduce the number of fatal accidents by telling pilots to complete the landing no matter what and to never go-around, just land. I do not believe that any of us are willing to settle for that, so here are some recommendations. If you are an instructor, please consider teaching these. If you are a pilot, please consider following these.
Part 1: Steps to reduce the likelihood of needing to execute a go-around.
- Do thorough preflight planning to be familiar with the destination airport, its environment, and the weather.
- Plan to have sufficient fuel upon arrival to allow for a diversion to an alternate airport if conditions warrant.
- Maintain sterile cockpit procedures during the approach.
- Use all appropriate checklists.
- Follow stabilized approach guidelines. (Go-around may still be required, but the need to go around will be recognized earlier and at a higher altitude.)
Part 2: Increase proficiency in the go-around maneuver.
- Recognize that recommended go-around procedures can vary considerably between airplane makes and even within models from the same manufacturer.
- Know the best angle of climb (VX) and best rate of climb (VY) airspeeds for each make and model of airplane flown and review them prior to each flight in that kind of airplane.
- Study the recommended go-around procedures for the airplane being flown prior to every flight.
- Make a habit of reviewing the go-around procedures while approaching the destination airport or while on downwind leg.
- Practice go-around procedures for each make and model flown regularly.
Pilots taking these steps will reduce the probability that a go-around will be needed. They will also be better prepared to successfully execute the go-around if necessary. We all should continue to be resolved to abandon a bad approach and get out of harm’s way, but we must be prepared to do it safely.
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.
Accident #1 - WPR14CA392
This accident involved a Cirrus SR22. The airplane received substantial damage, but the pilot, who was the sole occupant, was uninjured. The NTSB accident report includes the following: "The pilot reported that the airplane touched down normally, but shortly thereafter the right wing lifted from a gust of wind. The pilot applied full power and full right aileron but was not able to keep the wing from lifting; the left wing tip subsequently struck the runway. The airplane then veered to the left, went off of the runway surface, and impacted the ground in a left-wing-low attitude before it came to rest upright about two feet from a cement block building. The empennage had sustained substantial damage due to impact forces. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation."
News Photo Credit: Elko Daily Free Press (Annotated by GB)
The NTSB probable cause finding states, "The pilot's failure to maintain directional control during landing roll in gusty wind conditions, which resulted in a runway excursion and collision with terrain."
The pilot reported that he knew the wind was variable with gusts over thirty knots and density altitude of 8,000 feet. The 63-year-old pilot also reported having 8,800 hours total flight time 1,995 in the make and model. He had a current FAA medical certificate and a current flight review.
In retrospect, the accident was perhaps avoidable. The known wind conditions would challenge any pilot, regardless of experience. Maybe the plan to fly into that airport or the plan to fly on that day with those conditions should have been changed. Maybe a diversion to a more suitable airport would have been possible if the situation had been evaluated earlier in the flight. This accident was unfortunate and very costly. But it resulted in only property damage and not serious injury nor loss of life. There is nothing in the NTSB report that indicates the pilot considered or attempted to execute a go-around. Many people would criticize the pilot for this. But if we consider the gusty, changeable wind and the 8,000-foot density altitude, a go-around attempt might have made this accident tragic instead of unfortunate. In the older days of aviation there used to be a saying that any landing you could walk away from was a good one.
Accident #2 - CEN14FA249
This second accident for discussion involved a G36 Bonanza and occurred in Silver City New Mexico in May of 2014. The private pilot and his three passengers were fatally injured. The NTSB accident report includes several witness accounts of the accident. One witness saw the airplane in the pattern for runway 35. He noted that the airplane's position on downwind was "tight" in relation to the airport. The airplane began a "very tight base leg that was at least a 60 degree bank." The witness described the winds as gusty, around 25-30 knots, as would be associated with the passage of a thunderstorm. The airplane tightened the base to final turn and overshot the final approach leg. The witness estimated that the airplane's first touchdown occurred near mid-field, where it bounced and then settled to the runway. Shortly thereafter, the engine sounded as if the pilot had applied full engine power. The airplane was seen travelling down the runway and then took off. The airplane's landing gear and flaps appeared to both be down. The airplane began gaining altitude and started a slight right turn. The witness said that the airplane stalled and descended out of sight.
Another witness observed the airplane in a "tight left downwind approach for runway 35 at about 600-800" feet above ground level. The airplane's groundspeed increased in the base turn and the airplane flew through the runway's extended centerline. The airplane used at least 60 degrees of bank to correct back towards the runway's centerline. The airplane landed and then attempted to go around. The airplane went off the end of the runway at a high angle of attack, descended slightly into the valley, and then began to gain altitude. The airplane started a 15° bank turn to the east, began to descend, and the airplane's angle of attack got "steeper" as the airplane descended out of sight.
A witness near the accident site saw the airplane "gradually roll to the right, and then "sharply pitch" to the right where it impacted the ground."
The airplane impacted desert terrain near several trailer homes. A post impact fire ensued and consumed a majority of the airplane.
The NTSB report also includes the following information on the weather at the time of the accident, "Strong, variable, gusty wind, with an environment conductive to the formation of dry microbursts, was present at the airport at the time of the accident. Several lightning strikes were recorded in the vicinity of the accident site around the time of the accident. It is unknown if the presence of lightning or wind impacted the pilot’s inflight decision-making in the pattern, on approach, or during the attempted go-around. The circumstances of the accident are consistent with an in-flight encounter with a strong tailwind and/or windshear during climbout after the rejected landing."
The pilot, age 67, held a private pilot certificate with ratings for airplane single engine land and instrument airplane. The pilot flew his airplane frequently to treat patients at remote medical clinics. He had a current FAA medical certificate and a current flight review. The flight review was conducted in the accident airplane. The NTSB determined that the pilot had about 3,600 hours total flight time prior to the accident and that he had been flying an average of about 15 hours per month.
The NTSB probable cause finding states, "The airplane’s encounter with a strong tailwind and/or windshear, which resulted in an inadvertent stall. Contributing to the accident was the pilot’s continuation of the unstable approach, long landing, and delayed decision to conduct a go-around."
Once on the ground and too far down the runway to stop, this pilot had only a few seconds to decide whether to stay on the ground or attempt a go-around. Perhaps he remembered a flight instructor or two telling him to go around if the landing did not seem right. But what if he had decided to stay on the ground and most likely run off the end of the runway?
We will never know for sure, but perhaps he and his passengers would have been injured but might have survived. But better yet, what if he had recognized that his approach was unstabilized and abandoned it early to get better set up? There were thunderstorms and lightening in the area so he may have felt compelled to get on the ground. Maybe better preflight or enroute planning would have caused him to decide to wait out the storms before taking off. This pilot had plenty on his plate at the time of the accident so I only want to raise questions and not place on specific decisions. But we can all be safer if we comply with stabilized approach criteria each and every time. Click here to download a sheet on stabilized approaches.
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