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Vectors For Safety - August 2022

Safety Initiative Update

Remove it!

The control locks that is! It can happen to even the best pilots - don't let it happen to you! On July 24, 2021, noted aviator Dale Snodgrass was killed in the crash of his recently purchased SIAI-MARCHETTI SM-1019B. The NTSB probable cause states: "The pilot’s failure to remove the flight control lock before departure, which resulted in a loss of airplane control and impact with terrain. Contributing to the accident was his failure to perform an adequate preflight inspection and flight control check before takeoff." We will probably never know if this resulted from complacency, distraction, or something else. An easy way to avoid this is to always check "controls free and correct" before beginning a takeoff. Click here to download the NTSB accident report from their website.

Confirm it!

The correct lever that is. I am not a fan of touch-and-goes. One of the many reasons why is the increased risk of incorrect configuration of the airplane after it lands and before it takes off again. The need to quickly make configuration changes provides opportunity for error. Retracting the landing gear instead of the flaps in a very serious incorrect configuration. We must confirm each switch or lever we touch to be the correct control. Of course, we must do it quickly before we run out of runway. A better idea is to do full-stop/taxi back landings. Click here to download an accident report in which a Diamond 42 had the landing gear snatched out from under it during a touch-and-go. Yes, I know that safety circuits are supposed to prevent that from happening but they do not always work.

Use it and use it again!

A mnemonic of some sort to verify that the airplane is configured for landing that is. The old standard is GUMPS (gas-undercarriage-mixture(s)-prop(s)-seatbelts. There may be something different that you prefer, but it is crucial to verify that the airplane is properly configured. There is a gear-up landing just about every day in the U.S. Sometimes the ASIAS report shows multiple gear-up landings on a single day. These usually do not cause personal injuries, but the airplane is frequently substantially damaged. With the present shortage of replacement parts, extensive downtime and and eye-watering repair bill can be expected. Click here to download a sample accident report from the NTSB.

Activate it!

The pilot controlled lighting system that is. Landing during the hours of darkness on an unlit runway is dangerous. Flight planning should include noting the frequency to use to activate the lights since it is not always the UNICOM or tower frequency. Then, of course, we must remember to do it. Click here to download a related accident report from the NTSB.

Consider it!

Human error is at the root of most general aviation accidents. My Human Factors Ground School online course, valid for all three Wings credits at the basic level, is being offered for a limited time for $50 off. Click here for complete info and to enroll at the discount price.

Cheer it!

Granddaughter Sara passed her Instrument Rating checkride on July 22. She then immediately departed in the family C-172 for AirVenture. Next step is some time-building and then the Commercial Pilot Certificate. Keep making grandpa proud and always remember to fly like your life depends on it!

Attend it!

We have not addressed multiengine flying very much on Vectors. But if you are a multiengine pilot or are planning to become one, check out this webinar, "Multiengine Flight Dynamics", presented at two different times by Bob Katz. August 15,2022 at 7:00 PM Eastern Time and August 18, 2022 at 7:00 PM Pacific Time

Read it!

I have reduced the prices for all my publications to encourage summer reading! Scroll to the bottom of the blog or click here to visit my Author Page on Amazon.

Avemco Insurance sponsors Gene Benson
Gene's Blog

When 98% is not a Passing Grade

The following is a fictional story of a general aviation flight that did not end as planned. Fictional, components of several accidents are combined to create the narrative. Going by the daily ASIAS reports issued by the FAA, a scenario similar to this one plays out one or more times each day in the U.S.

After our fictional narrative, we will look at some of the pilot’s decision points to see what was done right and what perhaps should have been done differently.

A generally competent and moderately proficient pilot has embarked on a 290-mile cross country flight in a flying club’s Cessna 172M. A VFR flight plan has been filed and flight following will be used. The pilot has never landed at the destination airport but has studied the airport diagram and knows that there is a single runway aligned 330/150 degrees. The airport diagram shows the runway to be 2,400 feet long, paved, and 50 feet wide. Trees with a height of 50 feet are depicted near the approach end of Runway 33. The airport is non-towered and unattended with no weather reporting capabilities. Wind direction and speed must be estimated by observing the windsock located about 200 feet northeast of the runway midpoint. Density altitude at the time of arrival is estimated to be about 3,000 feet. The pilot recognizes that the destination airport is much different from the home, tower-controlled airport which has two runways, one 6,000 feet long and the other 4,500 feet long. The two runways are angled 60 degrees from each other, considerably reducing the need to land with a significant crosswind.

About 35 miles from the destination airport, the pilot passes near an airport with an operating control tower and monitors the ATIS for wind and weather. The ATIS reports a broken ceiling at 5,000 feet, visibility greater than 10 miles, temperature at 84 degrees F. dew point at 55 degrees F. and wind variable from 250 degrees to 290 degrees at 12 knots gusting to 20 knots. The ATIS also reports that Runway 26 is in use. The pilot decides that the wind favors Runway 33 at the destination airport and recognizes that there will be a gusty crosswind from the left on landing. Based on the knowledge of the runway length and the trees at the approach end of the runway, a full-flap landing is planned. The pilot checks the fuel and notes that the left tank indicates about a quarter full with the right tank showing about half full. A decision is made leave to the fuel selector where it is, on the BOTH position and there will be plenty of fuel should a go-around or diversion to another airport be necessary.

The pilot reports to ATC that the destination airport is in sight. ATC ends the flight following by telling the pilot no traffic is observed between the present position and the airport and that a frequency change is approved. The customary position reports are begun and are broadcast on the CTAF throughout the approach. The pilot descends to pattern altitude and makes a complete circuit of the pattern to study the runway condition, the obstacles on the approach, and the windsock which indicates that the wind approximates that of the ATIS report for the nearby controlled airport. While on left downwind leg, the pilot makes note of moderate turbulence and the need for a 12-degree wind correction angle. Flaps are extended to 10 degrees and then to 20 degrees while on base leg. Knowing the importance of a stabilized approach, the pilot gets established on final approach and further extends the flaps to the full 40 degrees available.

The pilot established a left wing-low/right rudder approach to manage the crosswind and is holding 65 knots for the approach speed. Small power adjustments are made as needed to maintain the approach path to safely clear the trees. The gusty crosswind requires some struggling to due to the needed constantly changing aileron and rudder inputs. The pilot passes over the trees with more attitude than was intended and suddenly perceives that the touchdown point will be farther down the runway than expected. The sight picture is much different from the home airport with the runway appearing to be very short. Since the obstacles have been cleared, the pilot closes the throttle to expedite the touchdown. The high drag from the flaps and the slip due to the crosswind correction produces a rapid increase in the rate of descent. The airplane lands hard on the left tire and bounces back into the air. The airplane then turns about 10 degrees into the wind, makes runway contact again, this time with both main tires, and travels off the left side of the runway.

As the pilot applies heavy braking to bring the airplane to a stop, the nosewheel and the left main wheel simultaneously find soft ground and dig in. The left wheel fairing is shattered on impact. The airplane momentarily lifts off both main wheels and rolls toward the left. The left wingtip strikes the ground, shatters the fiberglass wingtip, and crumples the outboard 8 inches of the wing leading edge. The airplane pitches forward, causing the prop to strike the ground bending both tips and causing the engine to cease running. Finally, the airplane settles in the upright position on the landing gear.

The pilot, alone in the substantially damaged airplane, takes a moment to gain composure and restore a clear head before turning the ignition switch and fuel selector to the OFF position. The pilot then unfastens his restraint and opens the door to exit the airplane. Though there is no evidence of leaking fuel, the pilot moves a few yards away from the airplane.

The pilot looks around and does not see anyone at the airport. Since the airplane’s empennage is just a few feet off the runway, the pilot realizes that it might pose a hazard to landing airplanes and wants to report it. Remembering that the flight plan has not yet been closed, the pilot, via mobile phone, closes the flight plan and also reports the accident. The next call is to the president of the flying club that owns the airplane. After making sure the pilot is not injured and that the accident has been reported, the president instructs the pilot to call 911 so that local police can investigate if they desire. Since the pilot made the flight to visit relatives in the area, a call was made to inform the relatives that there had been an arrival, but not as had been planned.

The airport manager, a part-time employee, hearing police, fire, and ambulance sirens headed toward the airport. The manager offered to accept the job of moving the airplane away from the runway and securing it.

This airplane will require many dollars to be spent due to the actual damage which will also require and engine teardown inspection because of the prop strike. Plus, it will likely need to have the wings removed and be transported via truck or trailer to a location where the repairs can be accomplished. The flying club will be without the use of this airplane for an extended period due to parts and labor shortages.

Now for a bit of analysis we will look at some of the pilot’s decision points. There are certainly more decision points but we will only address these.


Decision Point #1: Destination airport choice
The 2,400-foot runway should be well within the landing capabilities of a Cessna 172M at the estimated density altitude of 3,000 feet, even when considering the need to clear the 50-foot trees near the approach end. But when the pilot capabilities are examined, especially since the home airport had much longer runways and provided better options for handling a crosswind, the chosen destination airport looks less favorable. We recall from our narrative that the pilot passed near a controlled airport about 35 miles from the destination airport. That airport was reporting the wind variable from 250 degrees to 290 degrees and that Runway 26 was in use. Perhaps the pilot should have originally opted for this larger airport. Or maybe the pilot should have decided to change the destination to the larger airport as it was passed by since a runway more closely aligned with the wind was in use. One of our cognitive biases is continuation bias. We humans have a strong tendency to continue a task once it has begun even when evidence to the contrary exists. Our pilot probably did not consider landing at the larger airport either during flight planning or as it was being passed by.


Decision Point #2: Choice of Flap Settings
The short field landing distance chart for the Cessna 172M calls for 40 degrees of flaps and that is most likely the basis for the pilot’s decision. But experienced Cessna drivers know that flaps at 40 degrees in a gusty crosswind can make things a bit squirrely. The landing distance over a 50-foot obstacle at 3,000 feet density altitude at maximum weight with zero wind is less than 1,400 feet. That provides 1,000 feet to spare which is an adequate margin for error. This airplane was landing at much less weight and there would have been some element of a headwind component to further reduce the landing distance. Flaps at 30 degrees would have been a better choice in my opinion, but it is difficult to criticize a pilot for following the manufacturer’s procedures. (For a good explanation of how flaps react with a crosswind, see the FAA Airplane Flying Handbook, Chapter 11. Subheading, “Operational Procedures.” Click here to download it from the FAA.)

Decision Point #3 Airspeed
In our scenario, our pilot chose 65 knots for the final approach speed. The Cessna 172M Short field Landing Performance Chart calls for an approach at 60 knots. The 5 extra knots would lengthen the landing a bit, but given the gusty crosswind and the safety margin available on the landing distance, I agree with the pilot to add a little extra speed. In fact, I would have, as previously stated, used only 30 degrees of flaps and would have used 68 to 70 knots on final. The combination of less flap extension and a slightly higher airspeed would have made for a safer go-around if had become necessary.

Decision Point #4 Unstabilized Approach
Our narrative states, “Small power adjustments are made as needed to maintain the approach path to safely clear the trees. The gusty crosswind requires some struggling due to the needed constantly changing aileron and rudder inputs.” The small power adjustments fall within the criteria for a stabilized approach. The struggling with constantly changing aileron and rudder inputs perhaps indicates that the approach has become unstabilized. If we are close to the ground and struggling with anything, it is time likely time to abandon the approach. There is that continuation bias again.

Decision Point #5 Go-Around
As we said already, being on short final and struggling with anything usually indicates that a go-around is prudent. The narrative does not mention the pilot reviewing the go-around procedure while approaching the airport or while in the pattern. Knowing and reviewing the go-around procedure within a few minutes prior to making a landing accomplishes two goals. First, the procedure is fresh in the mind if it is needed. Second, it puts the possibility of making a go-around in our recent, conscious thought.

Decision Point #5A Try Again or Divert?
The pilot did not abandon the approach, but had that been done, a decision would be needed. Should the landing at the same airport be tried again or is diverting to a different airport the preferred option? In this case, a larger airport with longer runways also providing better alignment with the wind was just 35 miles away. The safest decision would have been to divert, but continuation bias, along with other cognitive biases might have strongly influenced that decision.

Decision Point #6 Power Reduction
The pilot cleared the obstacles and noted that the runway looked quite short. The pilot’s home airport had considerably longer runways and we do not know what, if any, experience the pilot had with runways of this length. Again, the pilot had to make a decision to continue with the landing or to execute a go-around. Here is that continuation bias again! The pilot had a strong desire to be on the ground and closing the throttle would expedite that, which it did. That action definitely made the approach fit the unstabilized criteria, but it was too late. Unfortunately, the combination of a hard landing, the resulting bounce, and the flap configuration (as explained in the narrative) resulted in the runway excursion and aircraft damage. The best decision regarding power would have been apply full power to execute a go-around. An alternative might have been to remove about half the power being applied, adjust pitch to maintain airspeed. That would have increased the rate of descent, but in a more moderate way. Then, the pilot could have another few seconds to decide if a go-around was indicated.

The pilot did many more things right than wrong. Planning was done, a flight plan was filed and opened, flight following was utilized, fuel was monitored, radio calls were made on the CTAF, and more. We know that the last action by the pilot is usually not the only factor in an accident. This error chain began with the choice of a short airport. It continued with a decision to continue toward the original destination airport once the wind condition was known. The next link in the chain is the choice of the 40-degree flap setting followed by the continuing with an approach that required a struggle. Finally, the decision to close the throttle after clearing the objects produced the final link in the error chain. We must note that none of the decision or actions were grievous nor illegal. The narrative stated that the pilot was generally competent and moderately proficient. On this day, moderately proficient was not good enough to handle a gusty crosswind on a short runway with obstacles. If I was scoring the pilot based on the overall flight from planning through the airplane coming to a stopped, I would give a grade of 95%. That would be a very good grade in most cases but not in flying an airplane. We all must strive to do better.

A final note about go-arounds

In my many years and many hours of providing flight instruction, I could not begin to count how many times I have said, “If the approach does not look good and feel good to you, just go around.” Reading accident reports tells me that the go-around can be a lethally dangerous maneuver if the pilot does not execute it properly. A pilot such as the one in our fictional narrative did not execute a go-around and substantially damaged the airplane. But nobody was injured or killed. A botched go-around that results in loss-of-control is nearly always fatal. I now tell all pilots, “Make sure you are knowledgeable and proficient in the go-around procedure for the airplane you are flying, and then if the approach does not look good and feel good to you, just go around.”

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 tragic accident happened in Mississippi in June of 2018. A 69-year-old student pilot, flying solo, lost his life when the Cessna 172 crashed shortly after takeoff from a touch-and-go procedure. The NTSB accident report states:

"The student pilot obtained his first solo endorsement 10 days before the accident after he had accrued about 165 hours of flight experience. On the day of the accident, he was performing solo traffic pattern work, which included full-stop landings and then taxiing back for each subsequent takeoff. However, interpolation of radar data and the timing of the call to report the accident indicated that the pilot had performed a touch-and-go landing before the accident takeoff and flight. A witness described the airplane at a low altitude and airspeed as it crossed, at treetop height, an interstate highway immediately beyond the departure end of the runway. The airplane then disappeared below the trees. Examination of the wreckage site and the airplane wreckage revealed evidence consistent with engine power at impact and no preimpact mechanical anomaly. Measurement of the exposed threads of the flap actuator corresponded with a full-flap, 40° extension setting. According to the manufacturer's owner's manual, "flap settings of 30° to 40° are not recommended at any time for take-off." Thus, because the pilot took off with 40° of flaps, the airplane was unable to attain the normal climb speed and entered a stall/mush from which the pilot could not recover because of the low altitude."


NTSB Photo - View of Main Wreckage as Found

The NTSB Probable Cause finding states: "The student pilot's failure to retract the flaps following landing and the stall/mush that resulted during the subsequent full-flap takeoff and initial climb."


NTSB Photo - View of Flap Actuator as Found

As a flight instructor of many years and more than 8,000 hours of dual given, I have become much less of a fan of touch-and-goes. I recognize that they are necessary in some training environments. But, I believe we are providing the best and safest training for our students if we minimize the use of touch-and-goes.

I have two reasons for that belief. First, this accident illustrates what can happen if the solo student forgets to retract the flaps before executing the takeoff. That sometimes happens with the CFI onboard, but a quick reminder solves the problem. Without the CFI, that simple oversight can end very badly. My second reason for not favoring touch-and-goes relates to depriving the student of the experience of slowing the airplane, exiting the runway, coming to a stop, and configuring the airplane. We have multiple daily runway excursions in the U.S. I believe that more practice in slowing and stopping the airplane could help to alleviate that problem.

On a related subject, I an not a fan of stop-and-go procedures either. They do provide the student with practice in stopping and reconfiguring the airplane. But they also teach the student, at least on a subconscious level, that it is not necessary to use all available runway for the takeoff. It seems hypocritical for us, as instructors, to preach that we should always use all the available runway but then practice stop-and-goes. Yes, there are exceptions such as an old military base with a 10,000 foot runway while we are in Cessna 152.

Of course reducing the number of touch-and-goes and stop-and-goes will increase the cost of obtaining a pilot certificate. The simple fact is that flying is expensive but safety is priceless.

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

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 happened in Georgia in April of 2021 and involved a Piper PA-32R-300 (Lance). The two pilots, one Commercial/CFI the other ATP/Commercial and the non-pilot passenger escaped without injury. The Piper PA-32R-300 Lance was destroyed by a post crash fire.

The NTSB accident report includes the following: "According to the owner of the airplane, who was the non-flying pilot seated in the right seat, prior to takeoff an engine runup was completed with no anomalies observed, and in addition, the wind sock indicated a calm wind. The owner reported that he and the pilot flying briefed the procedures for a short-field takeoff, back taxied to the end of the runway, and applied the brakes. The pilot flying increased the engine power, released the brakes, and began the takeoff roll. He attempted to rotate; however, the stall warning sounded, and he lowered the nose to accelerate more. The pilot flying again attempted to rotate, the stall warning horn sounded, and at this point the owner took the controls, calling for an aborted takeoff. The owner reduced engine power and applied the brakes; however, the airplane continued off the end of the runway and struck a ditch. A postaccident fire ensued, and the pilots and passenger egressed the airplane without injury. During the accident sequence, the airplane incurred substantial damage to the wings and fuselage. The owner reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. According to the airplane’s pilot operating handbook, the flaps should be set to the second notch, or 25° for a short field takeoff. After the accident, a Federal Aviation Administration inspector examined the airplane and noted that the flaps were in the first notch, or 10° position. Further, the owner acknowledged that, “…it is possible that the flaps were not set correctly on takeoff.” Given this information, it is likely that the pilot did not properly configure the airplane, which is why the airplane was unable to become airborne during the short field takeoff attempt."


NTSB Photo

The NTSB probable cause finding states: "The flying pilot’s failure to configure the flaps for a short field takeoff and delayed decision to abort the takeoff, which resulted in a runway overrun."


NTSB Photo - View of flap handle

I must admit that this accident caused me to have some confusion. I have some experience with the make and model airplane and having difficulty taking off from a 3,000 ft. runway seemed odd. Given the information presented regarding the airplane weight, ambient temperature, altimeter setting, and wind, plus an internet search for the takeoff performance graph the the airplane, I determined that the distance to clear a 50 ft. obstacle was less than 1,900 feet. Even with the flaps set at 10 degrees rather then 25 degrees, something seemed off.

The pilots did not have accurate information regarding the wind. The pilot stated that the wind was calm in his report to the NTSB. The NTSB report stated that the wind at about the time of the crash, measured at a station 300 feet higher than the airport and 14 nautical miles away, was 190 degrees at 6 knots. That raises the question of what was the actual speed and direction at the departure airport? The departure was from Runway 29 so there may have been a slight tailwind on takeoff. A little tailwind can make a big difference on the takeoff distance. What if the actual wind had been 10 knots from 110 degrees? The obstacle clearance takeoff distance would now be closer to 2,500 feet. That is not a great safety margin, but when we consider that the flaps were at 10 degrees rather than the recommended 25 degrees the whole thing makes more sense.

Of course, the safety lesson to be learned is to make sure the flaps are set correctly for whatever we are going to do. Also, with two qualified pilots aboard, we should designate a flying pilot and a monitoring pilot. Under this system, the monitoring pilot should catch an error in flap configuration.

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

Books by Gene Benson

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