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Vectors for Safety - February 2021

Safety Initiative Update

Avemco "Pilot Talk" Webinar Series Continues

We appreciate the continued support from the fine folks at Avemco Insurance to make more safety webinars possible. Next up is "Many Happy Returns - Avoiding Runway Excursions and Overruns" coming on February 25. In our quest for continual improvement. the content from webinars in the series will also be used to create an online course. Completion of the course will be valid for the same Wings credit as attending the webinar. When the online course is available, a link will be provided in the "Pilot Talk" section of the Vectors for Safety website. As usual, the webinars will be recorded for later viewing without Wings credit.

For more information and to register, click here. To register directly, click here.

Recordings of Previous Webinars are Still Available with Reference Pages

Most of the previous webinars in the "Avemco Pilot Talk" series were recorded and are available for viewing. (Sorry, no Wings credit for viewing recorded webinars.) Most of the webinars are accompanied by a reference page containing downloads or other information pertinent to the subject. Click here and scroll down the page to see the reference sections which also contain a link to the recording.

New Safety Data Tool Available on the FAA Website

The Dynamic Regulatory System (DRS) combines more than 65 document types from more than a dozen different repositories into a single searchable application. Wondering if your aircraft is the subject of a service bulletin or SAIB? This site can help you find that and much more. Check it out.


Gene's Blog

Things are not Always as They Appear

Two of my favorite illusionists, Siegfried and Roy, both passed away in the past twelve months. I had the pleasure of seeing their show featuring the tigers many years ago in Las Vegas. I have always enjoyed watching illusionists and those two were superb.

The passing of Siegfried in January got me thinking about illusions. What are they? An online dictionary describes an illusion as a thing that is or is likely to be wrongly perceived or interpreted by the senses. An illusion can be fun when it is part of a stage show but not so much fun when we experience one while flying. There are several illusions that can play tricks on our perception while behind the controls. Some are more pronounced at night, some are more likely while flying in reduced visibility, while some are just there all the time.

Various illusions are occasionally included in NTSB accident causal factors but I suspect that they play a larger role and do not receive the credit that they deserve. For example, consider the runway width illusion in which a narrower-than-usual runway can create an illusion that the aircraft is higher than it actually is, leading to a lower approach. If a pilot clips trees during an approach, the accident report will likely state that the pilot failed to maintain a proper glide path to the runway. That is a true statement, but why did the pilot fail to maintain a proper glide path? Perhaps it was because the pilot fell victim to the runway width illusion. Digging deeper into many accidents raises questions about underlying factors that may have adversely affected the pilot.

We all learned about the various illusions that can mess with our perception when we were preparing for the FAA Knowledge Exams. Illusions are probably not something that we think about very much so a review of the subject is a good idea. A concise but thorough explanation of cause and effect for all the major illusions affecting flight can be found in the Pilots Handbook of Aviation Knowledge, Chapter 17. It is available in PDF format as a free download on the FAA website. Click here to download it now.

Accident Analysis

On the night of August 28, 2018, a well-known and respected plastic surgeon was trying to do the right thing. He was flying solo in his Cessna P210 practicing takeoffs and landings at Prescott Regional Airport in Arizona to acquire night currency.

He initially requested clearance from the ground controller to takeoff from runway 21L and stay in the pattern, but the controller told the pilot that the traffic pattern was full. The controller then told the pilot he could depart from and stay in the traffic pattern for 21R, which the pilot accepted.

The requested runway, 21L, is 7,619 feet long and 150 feet wide. The accepted runway, 21R, is 4,846 feet long and 60 feet wide. Runway 21R was equipped with a 2-light precision approach path indicator (PAPI) system with an approach angle of 3.00° located to the left of the runway that provided a threshold crossing height of 48 feet. The runway was equipped with medium intensity edge lights.

The accident occurred at 20:35 local time and the moon had not yet risen. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the visual approach in dark night conditions to judge height above terrain.

Once airborne, the pilot did not fly a traffic pattern that paralleled runway 21R on downwind and he overshot the final approach course on his base-to-final turn. The pilot subsequently corrected his track and became aligned for runway 21R, but airplane collided with desert terrain about 1,900 feet short of the destination runway, impacting in a near level-pitch attitude with the landing gear down. The airplane impacted a berm and shortly thereafter, was destroyed by a postcrash fire. The pilot died in the crash.

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Accident Airplane - Photo Source:

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Photo Source:

The NTSB accident report states the probable cause as follows: "The pilot's misjudgment of distance and altitude from the runway and his subsequent failure to maintain an approach path that provided clearance from the terrain due to a visual illusion in dark night conditions."

The NTSB accident report also includes the following: "The pilot’s collision with terrain short of
the runway suggests that he was experiencing the runway width illusion in which the sight picture to a
narrow runway during a nighttime approach can lead pilots to believe their approach path is too high and
they descend in an attempt to correct. The runway had a precision approach path indicator (PAPI)
system to help pilots maintain a safe glidepath at night. The pilot’s competing visual task demands
including traffic and runway alignment and recency of nighttime experience may have contributed to his
failure to heed this information."

The reference to night recent experience results from the pilot's most recent night flight was about nine months prior to the accident. We should note that since the pilot was not carrying passengers, he was not required to meet night recent experience requirements. The pilot, age 71, held ATP, Commercial, and flight Instructor certificates. He was rated in helicopters as well as in airplanes. He also held a current Class 2 FAA Medical Certificate. The NTSB accident report does not state whether he had a current flight review. He had 2,480 hours total flight time, including 32 hours total in the same make and model.

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

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This accident happened in Georgia in December of 2018. The private pilot and two passengers were killed and one passenger survived with serious injuries. The airplane was a Piper PA-28-181, commonly known as an Archer.

From the NTSB accident report, "The private pilot was approaching the airport for landing following a local personal flight in night visual meteorological conditions when the airplane impacted 60 to 70-ft-tall trees about 1/2 mile from the end of the runway. Although the runway lights were illuminated at the time of the accident, the runway was not equipped with a precision approach path indicator (PAPI) or visual approach slope indicator (VASI) light system." The accident report also states, "It is likely that, in the absence of a PAPI or VASI system by which to judge the airplane's approach path, the sparsely-lit terrain off the approach end of the runway may have created an illusion that resulted in the pilot's descent into terrain short of the runway."

Also from the NTSB accident report, "According to the passenger, who was seated in the front right seat, the takeoff from Blairsville Airport (DZJ) was normal, and they flew around the local area to look at Christmas lights before returning to the airport. As they got closer to the airport, the passenger could see the lighted runway in front of them. During the approach, the pilot described to the passenger that he needed to hit "markers" on the GPS he was using for navigation as the airplane approached the runway. She said that the pilot was relaxed and didn't seem to have any concerns about the flight. The airplane's engine was running fine and there were no unusual noises in the cockpit. Everything appeared normal. The next thing the passenger remembered was seeing rescue personnel."

A review of the pilot's logbook revealed that the pilot had not flown at night in just over four months preceding the accident. Therefore, the pilot was not in compliance with recent experience requirements regarding carrying passengers at night.

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Photo Source: NTSB

The NTSB probable cause states: "The pilot's failure to maintain clearance from trees during a visual approach for landing in night visual meteorological conditions. Contributing to the accident was the pilot's lack of recent experience flying at night."

Though the possible impact of illusions is not mentioned in the probable cause finding, the Additional Information section of the accident report includes the following: "Bright runway and approach lighting systems, especially where few lights illuminate the surrounding terrain, may create the illusion of being lower or having less distance to the runway. In this situation, the tendency is to fly a higher approach. Also, flying over terrain with only a few lights makes the runway recede or appear farther away. With this situation, the tendency is to fly a lower-than-normal approach. If the runway has a city in the distance on higher terrain, the tendency is to fly a lower-than-normal approach. A good review of the airfield layout and boundaries before initiating any approach helps maintain a safe approach angle."

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

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