Wishing You a Great Holiday Season!
I want to wish all my readers a joyous and safe holiday season, however you celebrate. Remember that the best gift you can give your family and friends is you. The holidays historically involve several tragedies involving GA airplanes either enroute to or returning from visits to families or friends. We all know how to be safe but we must resolve to do it. Please don't let scheduled events or return to work deadlines influence your decisions. Look at the weather, the airplane condition, your proficiency, and your current fitness-to-fly very critically. Please make wise decisions to keep the holidays joyous rather than the season that a family member or friend was lost to a GA crash.
Coming Up in 2026
We will be presenting a series of webinars to help us learn from the misfortune of others. Each webinar will focus on a specific kind of crash and will attempt to find possible root causes beyond what the NTSB states as the "Probable Cause." Upcoming webinars will be posted on VectorsForSafety.com will be announced through the FAA SPANS System.
New Video in Our "Essential Vectors" Series
"All About Flaps" presents, in just 5 minutes, some basic information on different kinds of flaps, the use of flaps, the effects of flaps, and some precautions regarding flap operation and use. Click here to view it on YouTube.
New Edition of "Old Pilot Tips
Episode #37 titled "Now is Not the Time" is now available. In under one minute, see a reminder about when it is appropriate and safe to troubleshoot a problem.. Our "Old Pilot Tips" series is sponsored by Avemco Insurance and is narrated by Gene Benson. Click here to watch Episode #37 on YouTube.
Free Virtual Safety Presentations Available
As you plan your late fall and winter meetings for your pilot group, consider including a virtual guest speaker. We can provide a safety presentation, valid for Wings credits if you choose, free of charge, courtesy of Avemco. For more information or to schedule, contact gene@genebenson.com. Click here to download a copy of our current presentation catalog.
Meta What?
Metacognition sounds like a very complex psychological term that is not within the sphere of interest of most pilots. The truth is that it need not be that complex and it should definitely be of interest to pilots.
Metacognition has been defined as the awareness of one’s own cognitive processes and the ability to understand, control, and manipulate these processes. Let’s open the latches on that and look inside the cowling.
For the first part, we simply need to understand that our senses are sending information to our brains for processing. Our brains are running through much data including our knowledge, experience bases, and our motivations to construct a model of what those sensory inputs mean. That model is what we understand the situation to be and what we expect will follow. Decisions are now made about what actions are needed. We must understand that those decisions may be flawed. External factors, cognitive biases, and heuristics can sway those decisions. To put that in practical terms, we may not see deteriorating weather if the flight is important, such as attending a wedding or business meeting. We may not see the abnormal RPM drop during the magneto check if we have performed the check hundreds of times and never experienced any anomaly.
For the second part, awareness of those processes gives us the ability to rise up and understand, control, and manipulate them. Just knowing that we may not rationally evaluate risks if a flight is important, is a big step. Simply realizing that we may not always see an anomaly because it has been filtered out by our expectations can help us to take a second look at critical information.
Expected and the Unexpected
Any general aviation pilot with total flying time being counted with at least three digits has performed more, and probably many more than, 100 magneto checks during the runup prior to takeoff. As we move the ignition switch from BOTH to RIGHT, back to BOTH, then to LEFT, and then back to BOTH, we have developed an expectation of what will happen with each repositioning of the switch. Most pilots never, or at least very rarely, have experienced anything other than a smooth magneto check with an acceptable RPM drop. Given that experience, the pilot has developed an expectancy that the magneto check will be normal.
The human brain includes a sophisticated and powerful prediction mechanism. It constantly anticipates future events by integrating sensory input with predictions about what is likely to happen. This process affects both perception and action, The brain’s predictions can sharpen neural representations for expected outcomes and suppress responses to unexpected ones, biasing experience toward what is anticipated. Our brains regularly update expectations based on prediction errors—discrepancies between what was expected and what actually occurred. This helps adjust future predictions for better accuracy. But, established expectations can be robust and sometimes persist even when the environment changes dramatically. This is closely related to a cognitive bias called Continuation Bias or Continuation Blindness. I have written about this before and have created a presentation and a course titled, “Combating Mental Inertia.”
Back to our magneto check, given our developed expectancy that the check will be normal, our brain might work to block the perception of a larger RPM drop or a slight engine roughness as we select one of the magnetos.
This obviously extends to many other procedures. Have the control locks and pitot covers been removed and has the towbar been removed and stowed before engine start? Is the airplane accelerating normally during the takeoff roll? Is the visibility improving as forecast? Are the oil pressure and temperature gages showing normal operation? Are the fuel gages showing adequate fuel?
This of course can include larger scope issues. We may have received a weather forecast for clearing skies and improved visibility. But as the flight progresses, evidence to the contrary may be suppressed. Accident reports often list “continued flight into…” as a probable cause. But did the pilot consciously continue into a dangerous condition or was the evidence suppressed until it was too late?
Not to push anyone toward becoming a pessimist but try to make a conscious effort to look for anomalies. This is rising above our normal mode of operation, which is not easy but worth the effort. Find a method that works for you. Personally, I like the pause method borrowed from medical practice. Set a pause-point at a few non-critical times during the flight. At each pause point be alert for any unusual vibrations or sounds, any slight variation in an engine instrument reading, any variation in the weather from the forecast, etc. Also, consider pilot and passenger health and condition. If the extra alertness at a pause point detects anything unusual or unexplained, take appropriate action. Remember that your brain will work hard to convince you that everything is fine, but don’t be fooled.
Awareness of how our brains can deceive us in this way can help us to notice and consciously evaluate anomalies or conditions ahead and help us make better in-flight decisions.
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 of a Beech B36TC happened in Alaska in August of 2023. The 2200-hour 59-year-old instrument rated private pilot and his passenger died in the crash.
Beech B36TC (Not the Accident Airplane)
The NTSB accident report begins: "The instrument-rated pilot and passenger departed on a cross-country flight over mountainous terrain. The airplane departed an airstrip near the pilot’s residence about 0850 with a planned stop in Ketchikan, Alaska, before continuing to Washington state. The pilot established contact with an Anchorage Air Route Traffic Control Center controller when the flight was at 12,000 ft mean sea level (msl) about 25 minutes after departure. The controller advised the pilot he would need to climb to a higher altitude due to terrain and weather. The pilot responded that the airplane was turbocharged and that a higher altitude would not be a problem. The controller instructed the pilot to climb to 14,000 ft and advised him that, due to the remoteness and terrain, he might lose contact with the controller and issued backup frequencies. At 0953 the controller approved the pilot’s request to climb to 15,000 ft; there was no further communication from the pilot."
NTSB Graphic
The NTSB report continues: "The next day, a search and rescue crew located the wreckage, but terrain and poor weather conditions precluded reaching the site. The National Park Service overflew and photographed the site and concluded that, due to the unique challenges posed by the accident location, neither the occupants nor the wreckage would be recovered."
NTSB Graphic
The NTSB report continues: "The pilot obtained three preflight weather self-briefings from ForeFlight with a planned cruising altitude of 13,000 ft. Between the second and final briefing, the pilot requested the maximum icing severity image, icing potential for 11,000 ft and 12-hour icing forecast, and the 18,000 ft winds aloft forecast. Archived versions of the icing product viewed by the pilot were not available in the ForeFlight database or available from the NWS and the products the pilot requested were only available for the contiguous United States and were not created for the Alaska region.
Weather soundings, forecasts, and experimental weather images depicted a greater than 70% probability of moderate to heavy icing above 12,000 ft through 15,000 ft. Data also indicated Page 2 of 13 ANC23LA065 that the icing threat increased as the accident airplane climbed from 14,000 ft to 15,000 ft. Based on the weather data, the airplane likely encountered supercooled large droplet (SLD) conditions during the last minutes of the flight that degraded the airplane’s performance and resulted in a loss of control. According to the airplane pilot’s operating handbook (POH), flight into known icing conditions was prohibited. The National Weather Service (NWS) had issued advisories for instrument flight rules (IFR) and mountain obscuration conditions over the area; low clouds and precipitation were also present. The NWS area forecast and Alaska Aviation Weather Unit (AAWU) graphic icing forecasts were for isolated moderate icing in clouds between 17,000 ft and 22,000 ft, with the freezing level identified at 14,000 ft. However, the NWS underestimated the area and intensity of the icing conditions over the region and did not have in-flight advisories in effect around the time of the accident for all altitudes affected by icing.
The pilot completed his instrument rating in the contiguous United States about two months before the accident, where the graphic map display of current and forecast icing products would have been available to him during his training. It’s likely he was looking for these images in ForeFlight, but they were not available for Alaska. Although the icing information was available to the pilot in a vertical cross-section chart, the graphic map that displayed areas of icing along his route of flight would have been familiar to him and visually consistent with other popular weather mapping products. Access to the icing information in this format would have given him the best opportunity to select a different route. Additionally, although the graphic icing information in Alaska was not available to the public or pilots, it was available to Alaska Flight Service weather briefers; however, the pilot did not obtain a formal weather briefing. Due to the expansive mountainous terrain in the area of the accident, there were no options for the pilot to exit icing conditions once he entered them. The pilot was unable to access icing products that were familiar to him, his airplane was not equipped for flight in icing conditions, yet he selected the riskier route over the mountains. After inadvertent flight into icing conditions, he did not notify air traffic control of his situation or initiate a 180° turn to exit icing conditions."
NTSB Graphic
The NTSB probable cause finding states, "The pilot’s continued flight into moderate to severe icing conditions, including supercooled large droplets, over mountainous terrain, which resulted in a loss of control and impact with terrain. Contributing to the accident was the National Weather Service forecast that underestimated the area and intensity of the icing conditions and the lack of Alaska-specific icing graphics readily accessible to the pilot for preflight planning."
We do not know the pilot's thoughts during the time leading up to the crash, but we must consider that when he initially inadvertently entered icing conditions, his brain filtered out evidence that contradicted his decision to begin the flight. Perhaps he saw what he expected to see rather than the reality of the situation.
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.
The 70-year-old, non-instrument rated, 675-hour private pilot died in the crash of a Cessna 150K in New Hampshire. The crash occurred in September of 2023. The NTSB report begins, "The pilot was completing a cross-country flight at night and had arrived in the area of the destination airport. After entering an extended downwind leg of the traffic pattern, he was flying over a lake when the accident occurred. The airplane entered a left base-to-final turn that developed into a steep, spiral dive to the right, and continued until the airplane impacted the lake. The airplane lacked an autopilot; therefore, it was being manually flown by the pilot. No preimpact malfunctions of the airplane were identified during a postaccident examination of the recovered wreckage."
NTSB Photo
The NTSB report continues: "The pilot was not instrument-rated and had no recent experience flying at night. Witnesses indicated visibility in the area was reduced by wildfire smoke. Surveillance video confirmed that the sky was obscured and that the airplane was flying through low clouds immediately before the loss of control occurred. Few ground lights or other visual references were available in the vicinity of the lake that could have helped the pilot maintain orientation or aid in recovery after he lost control of the airplane. Loss of outside visual references during a visual flight rules (VFR) flight creates a high risk of spatial disorientation and loss of control for pilots who are not instrument-rated and current/proficient. Several risk factors for spatial disorientation were present in this case: reduced visibility, manual control, and maneuvering flight. Therefore, the pilot likely experienced spatial disorientation followed by a loss of control in flight."
NTSB Photo
The NTSB report also includes the following: "The pilot was advised by a flight instructor before departing on the accident flight that meteorological information indicated visibility might be diminished by the time he arrived at the destination airport, but he decided to depart anyway. According to the instructor, who was a friend of the pilot, the pilot had experienced multiple delays returning the accident airplane to his home and had plans with a friend that evening. Thus, the pilot appears to have disregarded Page 2 of 9 ERA23FA384 information that the flight might have been unsafe to operate under VFR, and he likely did not divert because he was motivated to avoid further delays and attend to a social obligation."
NTSB Graphic
The NTSB probable cause states "The pilot’s loss of control during visual flight rules flight in night instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot’s motivation to depart on the flight despite being made aware that conditions might be unsafe and his continuation of the flight as weather conditions deteriorated."
This crash is clearly and example of the powerful influence of external factors. But perhaps there is more. Was the pilot so determined to continue the flight that important information regarding deteriorating visibility was filtered out preventing him from correctly analyzing the situation? We cannot know, but we should always be aware of our brain's ability to trick us.
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 happened in November of 2020 in Western New York State. The airplane was a Grumman G7, a light, multiengine airplane similar to the Beech Duchess. The 65-year-old 1,082-hour instrument rated commercial pilot and his two passengers were killed. The NTSB accident report begins as follows: "The pilot rented the airplane and completed a long cross-country flight 4 days before the accident. Before the return (accident) flight, the pilot discussed weather decisions and avoiding icing conditions with his flight instructor via telephone. The instructor subsequently checked a commercial website and realized that the pilot had departed on the return flight. He hoped that the pilot would divert due to the poor weather conditions and sent him a text message to that effect."
Actual accident airplane - FlighAware
NTSB Photo
The NTSB report also includes: "Review of the last 1 minute of data revealed an approximate 500 ft-per-minute descent, consistent with the pilot’s descent on the instrument approach. A witness who lived near the airport reported that he could not see well due to wind and snow and did not initially hear the airplane. He then heard loud engine noise for 10 to 15 seconds followed by silence. The wreckage was located the following day about 1/2 mile from the runway threshold. The wreckage path was consistent with a gradual descent into trees."
NTSB Photo
The NTSB report also includes: "The pilot’s logbook was not recovered, and neither his total time nor his recent instrument flight rules experience could be determined. The circumstances of the accident are consistent with the pilot’s continued descent below the minimum descent altitude while conducting an instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain."
NTSB/FAA Photo
The NTSB probable cause states: "The pilot’s logbook was not recovered, and neither his total time nor his recent instrument flight rules experience could be determined. The circumstances of the accident are consistent with the pilot’s continued descent below the minimum descent altitude while conducting an instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain."
The pilot's communications with his flight instructor show a determination to complete the flight. Something went horribly wrong in the final few seconds of the flight, and we cannot know exactly what that was. We do not know the level of the pilot's proficiency in instrument flying, but we must consider that his expectation of breaking out into visual conditions may have caused him to continue descent without visual reference until colliding with terrain. On an instrument approach, always know a firm MSL altitude below which you will not descend without the runway in-sight.
Click here to download the accident report from the NTSB website.
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Looking for a holiday gift for a pilot? Check out my publications on Amazon. "Fifty Years of Flying Insights" is available in Paperback, Kindle, or Audio books. The three editions of "Thoughts on Being a Better, Safer Pilot" are available as Kindle or Audio books. Click the image above to visit my Author Page on Amazon.