Yet Another New "Essential Vectors" Video
Our newest "Essential Vectors" video focuses on the importance of the Stabilized Approach. In addition to high-profile fatal crashes, many landing accidents and incidents, especially runway excursions off the side or off the end of the runway, result from a pilot continuing an unstabilized approach. This less than five-minute video reviews the elements of the stabilized approach and reviews a related fatal crash. The “Essential Vectors” Series is sponsored by Avemco Insurance . Click here to view the video on YouTube.
New Video from FAA Recommended
Operating at a busy airport with an operating control tower can be stressful, especially for pilots who do not do it very often. Sometimes pilots get confused by unfamiliar terminology and make serious errors. The FAA has released a very good and highly animated video regarding the 'Line up and Wait" instruction from ATC. Click here to see it on YouTube.
Check Out Our Wide Library of Videos!
Did you know that we have 65 aviation safety videos on YouTube? They are sorted into three categories, with the longer videos first, followed by our "Essential Vectors" series of streamlined videos running usually between 10 to 15 minutes, and then our "Old Pilot Tips" series that reinforces important points in less than one minute. Click here to view the video offerings on our website with links to each one on YouTube..
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. Click here to download my updated presentation catalog. Email me at gene@genebenson.com to discuss scheduling.
Estimation
This month I want to feature a cognitive skill that is part of our Performance Group. Estimation is a critical cognitive skill for everyone, and especially for pilots. We depend on our ability to estimate speed, distance, or time. to predict the future location of an object based on its current speed, distance, and time. The brain processes the information that our eyes receive and determines what will happen and how to react quickly and when necessary.
The most obvious need for good estimation skill for pilots is obstacle avoidance during ground operations and collision avoidance while airborne. But it goes well beyond that. We estimate when and how much to flare during landing. We estimate when to initiate our level off from a climb or descent. We estimate when to begin the rollout from a turn. The list goes on and on.
This cognitive skill is learned through our experiences. Young children beginning to walk bump into things until their level of estimation is improved through trial and error. A new student pilot may not know when to flare for a landing until they learn through demonstration and practice. When we check out in air airplane of significantly different performance characteristics, we automatically apply what we know from our previous experience. This might not be successful in the different airplane and we go about learning to estimate in the new airplane. Shortly, our brain has learned the differences and applies accurate estimation to whichever airplane we are flying.
Estimation processing is done in the brain’s frontal lobe. The processing can be adversely affected by cranial trauma, brain tumor, aneurysm, MS, and more. Anxiety and depression have also been linked to degradation of the ability to accurately estimate. Also, alcohol, cannabis, and other drugs may affect our ability to correctly estimate speed, time, and distance.
We can work to improve our estimation skills using appropriate cognitive stimulation exercises. Dancing is an excellent activity since it uses and therefore provides learning regarding estimation of speed, distance, and time. Playing action video games and using a desktop flight simulator program can be helpful. To get outdoors, horseshoes, cornhole, tennis, badminton, pickleball, and golf can also be beneficial.
Aviation Disease?
We always see postings this time of year from health professionals warning us of an uptick in diseases spread through airborne or aerosol transmission. These include the flu, pertussis, RSV, and of course the dreaded COVID. But as the holiday season approaches, there is another disease that seems to primarily affect pilots. This disease is not likely to be found in medical journals but is frequently mentioned in aviation publications. The disease is commonly referred to as “get-there-itis.”
While the aforementioned diseases are generally caused by either a virus or bacteria, “get-there-itis” primarily originates from our cognitive biases. I have written before and have created a video on what I call the “Bias Bundle Bomb.” The “Bomb” is three of our cognitive biases working together, but not in our best interest. Illusory superiority causes us to all believe that we are a bit better, because we are more knowledgeable, more skilled, or just smarter than other people. Optimism bias tells us that bad things happen to other people and will not happen to us. Continuation bias filters out information that is contrary to what we want to believe, convincing us that we should continue a task once it has begun. We should note that in the case of continuation bias, the task is the flight and it begins when we commit to making the trip, not when we make a takeoff.
A planned holiday trip provides plenty of fuel to support our bias bundle. The northern hemisphere, especially north of about 35° N latitude, has an arsenal of weather-related problems it can hurl at us. We might venture into weather that may exceed the capabilities of our airplane or ourselves. We might fudge our weight and balance calculations to fit that extra passenger, heavy winter clothing, or that big sack of gifts. Or, we might cut our fuel reserve to make our weight and balance calculations work. We might stretch our proficiency or overlook necessary aircraft maintenance.
The holiday season can produce anxiety, stress, and fatigue. For some, spending extra time with in-laws, small children, or somebody else’s ill-behaved or slobbery dog can raise anxiety, stress, and fatigue levels. In some cases, a few days with family can convert that get-there-it is to get-out-of-there-itis. The flight home can be subject to the same bias bundle, but with the added risk factors of stress, anxiety, and fatigue.
How can we take steps to be safer during our holiday travel, other than leaving the airplane in the hangar and booking an exotic vacation to some tropical destination? Trip planning in addition to flight planning can go a long way. Avoid trying to cram too much into a short amount of time. Allow for some alone time to settle down the anxiety and stress. Insist on getting adequate sleep to reduce fatigue. Be cautious of medications intended to reduce stress or aid sleep. While these may be effective, some can have impairing properties that can last many hours after the final dose. Carefully research any such meds, whether they are prescribed or available over the counter. Plan the return trip so that a couple of extra days to wait out weather or an unanticipated maintenance issue will not cause significant problems at work or at school for you or for anyone traveling with you.
We all know how difficult it is to disappoint family or friends and canceling or postponing a planned holiday trip goes right to the top of that list. But bad decisions about beginning or continuing a trip result in several serious crashes each year during the holiday season. One way to help mitigate the pressure is to use a personal minimums checklist or flight risk assessment tool (FRAT). Either of these goes a long way toward moving the decision-making process from the subjective to the objective and minimizing the influence of our cognitive biases. And share whichever tool you use with pilots and non-pilots alike who will potentially be affected by a delay or cancellation. By sharing the guidelines in advance, family and friends, whether travelling with you or anticipating your visit, you can raise their awareness of the limitations posed by traveling via general aviation.
The crashes discussed this month all occurred during the holiday travel season. It is impossible to know for sure if or how the pilot’s decisions were influenced by the events of the season, but we cannot dismiss the possibility that the pilots involved may have fallen victim to the “bias bundle bomb,” fatigue, stress, or anxiety.
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 70-year-old instrument rated private pilot, his two daughters, a son-in-law and a family friend were killed in the crash of a Cessna 340 on Christmas Eve 2017 in Florida. The pilot's two daughters, along with the son-in-law were in their 20s. The older, married daughter was a public school teacher. The 32-year-old family friend, was also public school teacher and the mother of two, who will likely always remember Christmas Eve as the day their mother died.
NTSB Photo
The NTSB Report includes the following, "The instrument-rated private pilot and four passengers boarded the multiengine airplane inside a hangar. The pilot then requested that the airplane be towed from the hangar to the ramp, since he did not want to hit anything on the ramp while taxiing in the dense fog. Witnesses heard the pre-takeoff engine run-up toward the end of the runway but could not see the airplane as it departed; the engines sounded normal during the run-up and takeoff. A witness video recorded the takeoff but the airplane was not visible due to the dense fog. During the takeoff roll the airplane's tires chirped, which is consistent with the wheels touching down on the runway with a side load. The video ended before the accident occurred. The witnesses stated that the takeoff continued and then they heard the airplane impact the ground and saw an explosion. The weather conditions at the time of the accident included visibility less than 1/4 mile in fog and an overcast ceiling at 300 ft above ground level. The airplane's weight at the time of the accident was about 105 lbs over the maximum takeoff weight, which exceeded the center of gravity moment envelope. The excess weight would have likely extended the takeoff roll, decreased the climb rate, and increased the amount of elevator pressure required to lift off of the runway."
NTSB Graphic - Taxi Video Screenshot
The NTSB report continues, "A majority of the airplane was consumed by postcrash fire. The ground impact marks and wreckage distribution were consistent with the airplane rolling left over the departure end of the runway and impacting the ground inverted in a nearly vertical, nose-low attitude. Examination of the engines revealed operating signatures consistent with takeoff power at the time of impact."
CNN Photo
The NTSB probable cause finding states: "The pilot's loss of control due to spatial disorientation during takeoff in instrument meteorological conditions."
NTSB Photo
The pilot had a current medical certificate, but his personal logbooks were apparently aboard the airplane and were consumed by the fire, so recent experience, flight review, or instrument proficiency checks could not be determined.
According to news reports, the purpose of the flight was to spend the day at Key West. The departure in the low visibility condition was legal since the pilot was operating under Part 91 which does not specify minimum visibility for taking off under an IFR flight plan. But as we all know, legal, smart, and safe do not always coincide.
Plenty of preparation had certainly gone into getting these five people together for a day, especially the day before Christmas. That provided plenty of fuel for the pilot's cognitive biases to operate. The pilot, an attorney and community leader, perhaps had, as we all do, a bit of illusory superiority. Optimism bias probably provided assurance that everything would be fine. Bad things happen to other people. And continuation bias would have begun when the date was set for the outing and grew stronger as the day approached and the passengers arrived at the airport.
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 occurred in Arkansas on December 26, 2021. The 57-year-old, 379-hour pilot and his 52-year-old passenger died in the crash of the pilot's Cessna 172E. The couple had been visiting the pilot's family for Christmas. The accident flight was to return home after the holiday. The NTSB report begins as follows: "The non-instrument-rated private pilot was conducting a visual flight rules cross-country flight over mountainous terrain with a passenger in an airplane that was not equipped for instrument flight. There is no evidence that the pilot received a preflight weather briefing before the flight and the amount of fuel onboard the airplane at takeoff is unknown."
NTSB Photo
The NTSB report continues: "While en route, the pilot contacted air traffic control and requested the weather at his destination airport along with the weather at additional airports. When queried, he stated he was over his destination airport. Instrument meteorological conditions prevailed at the destination airport at the time. The pilot reported that he wanted to land because he had less than a quarter tank of fuel left, and he was going to continue flying west. Weather conditions further to the west were showing visual meteorological conditions at the time. The pilot informed air traffic control that he was setting up to land at an alternate airport when radar contact was lost."
NTSB Photo
And the NTSB report continues: "Radar data showed the airplane was at an altitude of about 4,000 ft, about 2.5 nautical miles (nm) from the airport, when it turned right, descended slowly, and flew a track consistent with an attempt to make an approach. The airplane then entered a tight left turn and traveled to the north. During this time there were abrupt changes in ground speed, altitude, and the direction of flight. The airplane executed at least one sharp counterclockwise 360° turn before the data was lost."
NTSB Photo
The NTSB report continues further with this bit of analysis: "A review of meteorological data showed that low cloud ceilings, low visibility, and low-level windshear prevailed at the accident site. Based on the weather conditions and the flight track data, it is likely that the pilot encountered low cloud ceilings and low visibility conditions. The flight track data was consistent with the known effects of spatial disorientation. It is likely there were no outside visual references, the pilot had an increase in workload due to spatial disorientation, and he was unable to recover the airplane from its descent. The airplane impacted trees and terrain with a near-vertical descent angle. The airplane was destroyed.
Perhaps very significant, the report also includes this fact: One text message that the passenger sent to a family member while in flight stated, “ran into weather can’t see anything” and another text message later stated, “out of gas in air.”
NTSB Photo
The NTSB probable cause states: "The non-instrument rated pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing to the accident was a loss of engine power due to fuel exhaustion."
The NTSB stated the probable cause of the crash, but perhaps the real cause was "get-there-itis." Or, in psychological terms, continuation bias. In 2021 Christmas day fell on a Saturday. The accident flight was made on the following day, a Sunday. It is likely that the pilot or his passenger or both had commitments on Monday, necessitating the return on Sunday. The flight had originated at Geneseo, Illinois with an intended destination of Walnut Ridge, Arkansas. The straight line distance, according to Google Maps, is 411 statute miles and the driving distance is 458 miles with a driving time of a little more than 7 hours. Perhaps renting a car and driving would have been an inconvenient, but viable option. Interview reports include in the NTSB accident docket tell that the pilot, rather than purchase the more expensive avgas for the return trip, borrowed several cans from his mother and used them to transport the less expensive auto gas from a local gas station to the airplane since the airplane had an STC for using auto gas. Perhaps this is evidence of frugality which may have may have been a factor in the decision to not rent a car. We cannot know all the circumstances involved, but missing work, extra expense, nor anything else can justify the risks taken by this pilot.
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.
Photo Credit - Detroit Free Press
This crash is yet another example of a holiday trip that ended in tragedy and probably an example of what "get-there-itis" can cause. The crash of the Piper Comanche occurred in Michigan on January 2, 2021 and resulted in the death of a family of three. It also resulted in the destruction of a home in which the family of three was home but escaped. That family's cat perished in the fire. The family of three who were onboard the airplane consisted of the 60-year-old pilot, a successful homebuilder, his 55-year-old wife, and their 19-year-old son who was a college freshman.
The non-instrument rated private pilot had 1.190 total flight hours, including 41.5 hours of simulated instrument time but only 15.2 of those hours was with an instructor and no mention of a safety pilot is in the pilot's logbook. He had also logged 99.6 hours of actual instrument time, but only 4.8 of those hours was with an instructor. This perhaps indicates that the pilot had been flying under IFR conditions for some time without earning an instrument rating.
On the accident flight, the pilot had requested and received an IFR clearance for an approach into his destination airport since the ceiling was 600 feet. Also, there is no record of the pilot receiving a weather briefing for the flight from Canton, Georgia.
Photo Credit - Detroit Free Press
The NTSB accident report includes the following: "As the airplane approached the destination, the pilot requested VFR (visual flight rules) flight following and was issued a discrete beacon code. He asked if there were any pilot reports (PIREPs) for icing in the area and was told there had not been any in the last hour. The pilot then requested the VOR-A approach into Y47. The pilot stated that if he missed the approach, he would divert to another airport. The pilot was vectored to intercept the VOR-A final approach course and was given a pilot report from a pilot who landed at a nearby airport who reported the cloud base to be 300 ft with no ice descending through the layers. The accident pilot said he would “give it (the approach) a shot.”
Photo Credit - Hometown Life
The NTSB report continues, "Automatic Dependent Surveillance-Broadcast (ADS-B) data showed the airplane approach the airport at an altitude of about 2,000 ft and 100 knots (kts). It passed over the airport and began to decelerate in a left descending turn to 1,475 ft and 85 kts. The airplane entered a second tighter turn and descended to 1,150 ft and 60 kts. Track data was lost at 1541:20. The last recorded altitude and airspeed were 975 ft and 71 kts. near the accident location."
Security Camera Video from NTSB Docket (Edited by GB)
The report also includes the following: "A residential security camera captured the accident. The sound of an aircraft engine is audible on the recording. The sound goes away and returns, but is louder. Once again, the sound disappears and is heard again with the airplane coming into view in a left wing low, nose low descent. The wings and nose level off just before the airplane impacts the ground in a flat attitude. The airplane slides across the ground, impacts a house, and a fire erupts. The airplane was destroyed during the postimpact fire."
CFII Statement from NTSB Docket
The NTSB probable cause states, "The pilot’s failure to maintain proper airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall. Contributing to the accident was the pilot’s lack of an instrument rating and the low visibility at the time of the accident."
Why would a pilot put his family at risk by knowingly accepting an instrument clearance and entering IMC without an instrument rating? There are many possible answers and the perhaps several of them combined to steer the pilot's decision-making process. This month's edition is highlighting "get-there-itis" which was probably involved here. The accident flight was a return home after the New Year's holiday. The pilot and and/or his wife likely had commitments the following day and there was a perceived importance get home. I have an ongoing series of presentations called "Just This Once." The premise is that if we violate a rule or established procedure thinking that it will be fine just this once, we are much more likely to violate the same rule or procedure in the future. As we do that more, it becomes part of our established behavior and we begin to consider it normal. This pilot, with his logging of actual instrument hours with no instructor endorsement nor mention of a safety pilot, perhaps had gone down that path and considered flying in IMC without an instrument rating normal. Then we have the possibility of illusory superiority being involved. The successful businessman perhaps began to believe that he was smarter than others and did not need more instrument training or the instrument rating.
As tragic as this crash was, it could have been much worse if the three occupants of the house that was struck had not been able to escape. As pilots we must realize that our decisions not only affect ourselves, but our families, our passengers, their families, the people beneath our flight paths, and their families.
Click here to download the accident report from the NTSB website.
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