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Vectors For Safety - December 2021

Safety Initiative Update

Holiday Wishes!

I want to wish all of my followers and subscriber a joyous, happy, and safe holiday season regardless of how you celebrate it. A few years ago, I wrote an article titled, "The Best gift." I proposed that the best gift we could give our families and loved ones is for us to be safe in everything, but especially in our flying. I still believe that is true. I would encourage everyone who plans to fly a general aviation aircraft this holiday season to be diligent in flight planning and to be realistic regarding the present state of flying proficiency along with aircraft capability and airworthiness. Always remember, fly like your life depends on it.

Invest Three Hours to Make Better Decisions!

Most accidents, aviation and others, result from a flawed decision of some kind. Invest three hours in our Human Factors Ground School and be on your way to making better decisions in everything. Beginning in January 2022, I will be offering the course via Zoom Meeting, not webinar, to a small group (maximum 35 attendees). Discussion and interaction will abound. The course will consist of three live sessions (recorded if someone misses one), of about one hour each. Completion of the course is valid for all three Wings credits at the basic level.

Click here to watch a short video trailer related to the course on YouTube.

The half-price early registration offer is available through December 10, so don't delay. Also, for groups such as partnerships or flying clubs, there is a special offer to pay for four registrations and receive two more free.

NEW! Complete the course and receive digital credentials which includes a certificate plus a verifiable digital badge for your social media!

Click here for complete details and to register on

Know the Systems

We all become accustomed to our aircraft systems working as they should and we develop an expectancy that they will always work as commanded. Mechanical things sometimes fail and, according to Murphy's Law, will fail at the most inopportune time. We should be prepared for that and periodically review emergency procedures and mentally run through scenarios in which those procedures may need to be executed.

Having a good working knowledge of the systems of any aircraft that we fly is important and that goes double for any newly acquired airplane. If the aircraft is older and no longer in production, manuals and checklists may be lacking or even missing. Finding someone who is familiar with the aircraft may also be difficult. Owner or pilot organizations specializing in that make or model might be helpful. Though we cannot trust everything we see on the internet, YouTube can sometimes be a valuable resource.

This came to mind due to a recent fatal accident. Only preliminary information is available on the NTSB website, but it is a reasonable possibility that the crash resulted from loss-of-control as the pilot spoke via mobile phone with a mechanic. The pilot of the newly acquired Twin Comanche was seeking assistance in the operation of the emergency landing gear extension system. He was flying single-pilot in VFR night conditions in an unfamiliar high-performance airplane. We cannot make assumptions without complete knowledge of the situation and the NTSB will sort it all out in time. In any case, knowledge of the systems of any aircraft we fly will give us an advantage when things do not work as they should.

Holiday Travel Hazards Video Available

About a year ago, on behalf of Avemco Insurance, I conducted a webinar and published a video on the same material. The subject was related to safe holiday travel in general aviation airplanes. If you are planning any holiday travel this year, I would encourage you to watch the video. Click here for the YouTube video. Sorry, no Wings credit for watching the video.

Gene's Blog

Managing Trust

Trust is a human trait. In psychology, trust is believing that the person who is trusted will do what is expected of them. Trust means that you rely on someone else to do the right thing. You believe in the person's integrity, knowledge, and skill, to the extent that you are willing accept some risk to yourself, for the other person’s actions. Trust is more like a variable knob than an on/off switch. We trust some people more than others and that degree of trust will vary depending upon task involved. I highly trust the person who cuts my hair to do a decent job with this thinning grey mess and not remove my ear in the process. I would not trust her to repair the brakes on my car. I highly trust my auto mechanic with my brakes, but there is no way he is getting me into a barber chair.

But even the most trusted person can make an error. It is not always possible to check the work done by a trusted person, but, especially in critical operations we make our best effort at verifying the work has been done correctly. After a haircut, I instinctively glance in the mirror before leaving. After brake work on my car, I always test the brakes before I go very far or get to a high speed.

Bringing this discussion around to aviation, do you trust your aircraft maintenance provider? I assume everyone answers that question in the affirmative or a different maintenance provider would have been chosen. But what is the extent of your trust? Do you have complete, unequivocal trust? I hope not. Trust but verify whenever possible.

Humans make errors. The consulting work that I do mostly focuses on error reduction. Please note that we call it “error reduction” not “error elimination.” We will never completely eliminate human error and our maintenance providers are human. Maybe someday we will have a vaccine to prevent human error with three shots required to be fully vaccinated. But for now, we must accept the fact that even our most trusted maintenance provider is capable of error.

Our mantra must be “trust but verify.” At least verify what we can. After an engine overhaul we cannot easily verify that the engine through-bolts were torqued to the correct value. We cannot easily check to make sure that other bolts ere tightened or that cotter pins were installed as required. But we can check to make sure oil as added as part of an oil change. We can check to make sure that the control surfaces are moving in the correct direction after work on the cables. We can check to make sure that newly installed or newly repaired avionics are working prior to departure. In fact, we should do all these things as part of every preflight inspection, not just after maintenance work.

In the following section, we will detail three accidents in which the maintenance error should have been detected during the preflight inspection.

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.

How many pilots are not familiar with the phrase, "free and correct" regarding operation of the primary flight controls? I would guess that nearly every pilot has heard that phrase near the beginning of every flight from their flight instructor and that most pilots have assimilated the phrase into their own preflight and/or pre-takeoff practices. I cannot think of anything that is more important before taking off than to be certain that our control surfaces are free to move and that they move in the direction we command them to move.

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Photo Source: Justin Strawser/

This accident happened October 2013 in Selinsgrove, Pennsylvania. The pilot and passenger in the Piper Pacer were seriously injured when the airplane impacted the runway immediately after takeoff. The NTSB accident report includes the following: "According to the pilot, he completed the before takeoff checklist, which included a flight control check of the tailwheel equipped airplane; however, he could not see the elevator from the pilot seat. He taxied the airplane onto the runway, applied full throttle, and when the airplane began to gain airspeed, he pushed the yoke forward in order to bring the tailwheel off the runway. The airplane departed the runway, the pilot pushed the yoke forward again, but the airplane continued to climb at a "low airspeed." The pilot decreased the engine power, the nose of the airplane lowered, and the pilot pulled back on the yoke to arrest the descent. The airplane responded by descending at a higher rate, the pilot applied nose-up trim; however, the airplane impacted the runway. The pilot did not recall any events after the airplane impacted the runway."

The accident report continues, "According to a witness, he saw the airplane taxiing on the parallel taxiway, then enter the runway without stopping, and begin the takeoff roll. Immediately after the main landing gear departed the runway, the airplane "went into a vertical climb." Then, above the runway, the nose of the airplane dropped, and it descended vertically in a slight left turn. The airplane impacted the runway, which resulted in substantial damage to the wings and fuselage."

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Photo Source: Eric Scicchitano/

Also included in the accident report is the following: "In an interview with the mechanics that performed the annual maintenance, they stated that during the annual inspection the mechanics decided to replace the elevator cables since they were frayed. The mechanics routed the new cables in with the part tags attached and a second mechanic confirmed the cable installation. Then, they performed a flight control check utilizing the control column to confirm the correct installation of the elevator cables. Once checking the airplane, one of the mechanics noticed that a bolt was too short, removed, one cable, replaced the bolt with a longer bolt, and reattached the elevator cable. When asked if they verified the cable rigging, both mechanics stated that they confirmed the correct routing from the elevator cables to the control yoke. In addition, they stated there was no maintenance manual for the airplane and they used the illustrated parts catalog in order to install the cables."

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Photo Source: NTSB

And the accident report continues, "Examination of the airplane by a Federal Aviation Administration inspector revealed that the elevator control cables moved the opposite direction as commanded. When the elevator control cable was operated that corresponded to the yoke being pushed forward, the elevator control surface moved in the upward direction or positioned the airplane in a nose up attitude. When the elevator control cable was operated that corresponded to the yoke being pull aft, the elevator control surface moved downward or positioned the airplane in a nose down attitude."

In the operating instructions for the airplane, under the section labeled "Preflight," it stated that "upon entering the plane, the pilot should ascertain that all controls operate normally and are in proper position and that the door is closed and latched."

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Photo Source: NTSB

The NTSB Probable Cause finding states: The incorrect (reverse) rigging of the elevator cables by maintenance personnel and their subsequent failure to verify that the rigging was correct during postmaintenance checks and the pilot's inadequate preflight check."


The pilot stated that he could not see the elevator from the pilot's seat. A control check could have been accomplished from outside the airplane as part of a preflight inspection. This was clearly a human factors error. Several common human factors were probably involved. Optimism bias tells us that things will be fine. Expectancy and familiarity combine to create complacency. Trust but verify.

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

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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 Cortland, New York in July of 2020 and again resulted from incorrect rigging of the flight controls. Fortunately, neither the pilot nor the mechanic who was accompanying were seriously injured. The airplane was a Piper PA22 Tri-Pacer. The NTSB Accident report includes the following, "The pilot was performing a post-maintenance test flight after a "lengthy restoration" of the airplane had been completed by a mechanic, who accompanied him on the flight. After takeoff, the airplane did not respond in accordance with the pilot’s control inputs, so he elected to immediately land the airplane. The airplane impacted the ground off the departure end of the runway, which resulted in substantial damage to the wings and fuselage. Post-accident examination of the airplane revealed that the aileron control cables had been rigged opposite of the proper orientation prescribed in the airplane’s illustrated parts catalog. Both the pilot and the mechanic stated that when they conducted flight control checks prior to the flight, they confirmed deflection of the ailerons, but that they each failed to confirm that the aileron deflection corresponded correctly to the input at the control yoke."

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Photo Source: NTSB

The NTSB Probable Cause finding states, "The mechanic’s incorrect rigging of the aileron control cables, which resulted in a reversal of aileron control inputs applied by the pilot during the takeoff. Also causal was the mechanic’s inadequate post-maintenance inspection and the pilot's inadequate preflight inspection and before takeoff check, which failed to detect the misrigging."

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Photo Source: NTSB

Again, we see an accident that could have been easily prevented. In checking the control movement, the "free" part was confirmed, but the "correct" part was not verified. When it comes to the operation of our flight controls, we must verify everything and assume nothing. We are all very capable of making this kind of error based on our humanness. We are all susceptible to complacency, optimism bias and many more factors. By learning more about our humanness, we are better able to manage it.

Though the accident was preventable, it could have also been fatal if the emergency had not been handled properly. We must commend the pilot on his decision making. When he realized something was wrong, he immediately decided to land the airplane. That comes under the category of urgent decision making. The pilot had only seconds to make a decision and he made one that most likely saved the lives of both occupants.

Another element that likely prevented serious injury or death is the fact that the airplane was equipped with shoulder harnesses and both occupants were using them. The airplane was manufactured in the 1950s and was not originally equipped with these restraints. The NTSB has statistics on the overwhelming safety benefit of having these restraints.

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

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Publications by Gene Benson

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