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Vectors for Safety - August 2021

Safety Initiative Update

Webinar Report

Our most recent webinar in the Avemco Pilot Talk series was conducted on July 13. It presented some of the common "gotchas" of summer flying. It is not a coincidence that we scheduled the event to run just prior to AirVenture. Even though an FAA error caused the mass emailing to be sent with an incorrect link, we were able to quickly pull together a list of people who had attended or at least registered for our other recent webinars, send an email notification of our own, and salvage the event. Attendance was only about half what we typically have, with 447 folks attending and 418 earning Wings credit. Having worked with the FAASTeam for many years and having issued more than 23,400 Wings credits, I was frankly quite disappointed at the lack of interest in correcting the problem.

For those who missed the event, a recorded version is available, but viewing it is not valid for Wings credit. A free online course that is valid for Wings credit upon completion of the quiz, is also available. Links to these, along other references on the subject, can be found on the event reference page.

I want to give special recognition to Layne Lisser and Rares Vernica for their assistance during these recent webinars. They have been extremely valuable in monitoring the Q&A, alerting me to technical issues, and many other things during the presentations. The smoothness of the presentations is mainly attributed to their assistance.

Safety Initiative 2.0

It is time to reimagine our Safety Initiative. Since I began the project in 2004, many things have changed and some things have not changed. The changes include different platforms for presenting content, the desire for receiving content in smaller doses, and the need for all content to be mobile friendly. Things that have not changed significantly include needless injury and death from highly avoidable aircraft crashes.

How can we improve and/or enhance the Safety Initiative? I would really appreciate it if you would spend a few minutes thinking about that question and sharing your thoughts with me. I began to create a survey, but the survey only asks your opinions on ideas that I propose. I am looking for original thought, honest opinions, and creative ideas. I would like input on how to expand our reach to more pilots and also how we can better serve our existing subscribers. What content should we provide and which platforms should we use? How important is Wings credit to you? Please be a part of Safety Initiative 2.0 and send your thoughts to

Checklist Caution!

Those of you who have followed my work for a few years know that I am a firm believer in checklists. You also know that I have encouraged pilots to enhance checklists provided by the aircraft manufacturer when necessary. I have always stressed that a manufacturer's checklist can have items added, but we must never omit an item that the manufacturer included. The second accident analysis this month illustrates that point, plus it supports the premise presented in my blog below.

Gene's Blog

Keep it Tight!

We have all been in airport traffic patterns in which the downwind leg could almost be logged as cross-country time. This is more common at non-towered airports, but sometimes we find the same mess even when controllers are involved. At best, the huge traffic pattern is inconvenient and can be costly. Think Hobbs meter. At worst, it can increase the likelihood of a hazard.

The hazard in question is making an off-airport landing due to loss of engine power. The very large traffic pattern puts the airplane out of gliding distance to the runway for a longer time than would a tighter traffic pattern. That might seem like an insignificant detail until we realize how many instances of power loss occur in or near the traffic pattern.

Fuel exhaustion, fuel management, carburetor ice, incorrect management of fuel pumps, misalignment of fuel selectors, failure to enrichen the mixture, and other items are the common causes of power loss in the vicinity of the airport. Of course, we should do careful flight planning and use our checklists to help avoid these issues. But human error cannot ever be completely eliminated. Being within gliding distance of the runway can make the difference between a mildly embarrassing end to the flight and possibly a disastrous one.

It is naïve to say that we should always remain within gliding distance of the runway when in the pattern. As soon as one other airplane widens the pattern, the other airplanes have little choice but to follow. As additional airplanes enter a traffic pattern and the pattern begins to get crowded, the pattern will grow wider. This is similar to a crowded highway. As more vehicles enter, the traffic slows and eventually becomes stop-and-go, with the area of stopped traffic getting larger. Since airplanes cannot come to a stop, our crowded pattern gets bigger and bigger to accommodate the additional airplanes. The larger pattern means that each airplane will be spending more time out of gliding distance to the runway.

Of course, heavy traffic is not the only reason a traffic pattern might grow large. Some pilots prefer to fly an over-size pattern and insist on doing so. That serves no useful purpose and should be considered rude behavior. If the traffic pattern is at a public airport, there is always the possibility that another airplane will enter the pattern and be forced to join in for this wide scenic ride around the airport environment. Now we have two airplanes spending more time than necessary out of gliding distance to the runway. Pilots have a right to fly a pattern that makes them comfortable and we certainly want to ensure time to set up a stabilized approach. The Piper Comanche pilot will likely opt for a slightly larger pattern than pilot of the Piper J-3 Cub. But if every pilot put emphasis on minimizing time spent out of gliding distance to the runway and flew a pattern at a size that met their minimum comfort level based the airplane being flown, we would all have safer traffic patterns.

What can an individual pilot do if their local airport is plagued by an unnecessarily large traffic pattern? Like most problems, we need to identify the causes and find possible solutions. A little time spent observing the traffic might provide
some insight into the causes. If the cause is simply too many airplanes in the pattern, it must be brought up to the airport authority or whoever manages the airport. A solution might be to limit or discourage touch-and-goes during peak times. I have operated out of several airports that did that and it is not as inconvenient as it may seem. If the practices of a particular pilot or two are causing the large pattern, a friendly, non-confrontational discussion might help. Perhaps a local safety meeting could help. One or two pilots, acting proactively and not obnoxiously can make a difference.

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.

Please allow me a bit of editorial comment before getting into the details of this accident. I chose to include this accident because it aligns with our topic of flying a traffic pattern that maximized the amount of time we spend within power-off gliding distance to the runway. But this crash illustrates so much more. First, it was easily preventable. Second, and of primary importance, it resulted in the death of a man and critical injuries to his wife. Married later in life and for not quite two years, news reports indicate that they had found real happiness together. The crash ended one life and had devastating physical and emotional impact on another. I hope that others will feel the same emotional reaction to this accident that I did and become an "evangelist for safety" by reaching out to a pilot who needs a nudge in the right direction.

This tragic crash happened in Texas on a January evening in 2016. The airplane was a Cessna 172. The pilot was fatally injured and his only passenger, his wife, was critically injured.

The NTSB accident report includes the following: "The private pilot and one passenger departed on the approximate 35-minute personal flight with an unknown quantity of fuel onboard. Later that evening, they departed to return to their home airport in night visual meteorological conditions without adding additional fuel during their stop. While on final approach to their home airport, the engine lost total power and the airplane impacted trees and terrain. The passenger stated that the engine did not sound any different during the accident flight than on any of the previous flights and that there was no indication of a problem with the airplane when the engine lost power. Postaccident examination of the wreckage revealed no usable fuel within the airplane's fuel system, and no mechanical anomalies that would have precluded normal operation; therefore, it is likely that the airplane experienced a total loss of engine power as a result of fuel exhaustion. While it is unknown what preflight fuel planning the pilot performed and the extent of his preflight inspection, it is apparent that both were inadequate; had he performed both properly, he likely would not have run out of fuel."

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Photo Source: KTLV

The NTSB accident report continues: "Recorded GPS data showed that the pilot flew the traffic pattern 400-600 ft lower than the recommended 1,000-ft above airport elevation and turned to the base leg of the traffic pattern farther from the runway than recommended. Had the pilot flown the traffic pattern at the recommended altitude and distance from the runway, it may have been possible for the airplane to glide to the runway following the loss of engine power."

The NTSB Probable Cause finding states: "The pilot's inadequate preflight planning and inspection, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's failure to maintain an appropriate traffic pattern altitude and distance from the runway, which may have allowed the airplane to glide to the runway following the loss of engine power."

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Graphic Source: NTSB

The private pilot, age 73, had 259 hours total flight time including 202 hours in the accident airplane. He had a current flight review and current medical certificate. The toxicology report detected the presence of two prescription medications, neither of them considered to be impairing. No alcohol or other drugs was detected. It does not appear that the pilot met the recent experience requirement for carrying a passenger at night, but it also does not appear that this was a factor in the crash.

This tragedy illustrates two points. First, flight planning is essential, regardless of the planned duration of the flight. The accident leg of the flight was conducted after dark and we all know that a forty-five-minute fuel reserve is required for a night flight. Whether it was complacency, optimism bias, or some other reason, we will not know. But running out of fuel is one of the most preventable causes of crashes. Second, we should keep our traffic pattern tight and at the correct altitude to maximize the time in which we are within gliding distance of the runway.

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

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Like the previous accident analysis, this one illustrates the advantages of staying within gliding distance of the runway. Additionally, it shows the need to verify that all items included in a manufacturer's checklist are included in any revision.

The accident happened in Utah in May of 2020. It involved a Cessna P210 with a 24,000-hour ATP at the controls. While the airplane received substantial damage, neither the pilot nor the passenger was injured during the off-runway landing that was necessitated by a complete loss of engine power while on final approach. In his report to the NTSB, the pilot detailed how he established best glide speed and then maneuvered to avoid a storage building, a steel pole, and other obstacles. This illustrates the importance of continuing to control the airplane until it is stopped. Had the pilot not remained in control, this crash might have resulted in serious injury or worse.

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Photo Source: NTSB

The NTSB accident report contains the following: "The pilot reported that after completing the descent/approach checklist, he turned on the auxiliary fuel pump and switched from the left fuel tank to the right fuel tank. While on final approach, the pilot reported that he neglected to turn off the auxiliary fuel pump. When he made a slight power reduction, the engine flooded and lost power. The airplane subsequently touched down in the grass short of and to the right of the runway. During the landing roll, the right wing collided with a fence pole. The right wing was substantially damaged.
The manufacturer's before landing checklist requires the auxiliary fuel pump in the 'OFF' position during
landing. A caution follows:
"Failure to turn the auxiliary fuel pump off may result in a complete power loss at reduced throttle
settings due to an excessively rich mixture."
The pilot reported that he had modified the before landing checklist which omitted the fuel pump switch

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Photo Source: NTSB

The NTSB Probable Cause finding states: "The pilot's failure to switch the fuel pump to the 'OFF' position during landing, resulting in a loss of engine power and subsequent collision with a fence during landing. Contributing to the accident was a modified before landing checklist which omitted the fuel pump switch position."

The pilot's statement in the "Operator/Owner Safety Recommendation" section of the pilot's report to the NTSB states, "Fly a steeper glideslope which will allow for glide to the runway in event of engine failure, considering headwind component."

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

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