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Vectors For Safety - February 2022

Safety Initiative Update

Sleet (and an editorial comment)

What do you do if you fly into an area of sleet? I was asked this question by a pilot recently. When I asked him what he thought he should do, he immediately answered, "climb." When I asked him why he would climb, he replied that he had been doing research into structural icing conditions, and the source he was relying upon said that in a small, general aviation airplane without ice protection, a climb should be initiated at the first sign of encountering icing conditions.

This illustrates a serious deficiency in the ground, or knowledge areas, of a pilot's training. In my opinion, the deficiency is in a lack of a structured and organized curriculum. Simply studying to pass an FAA knowledge exam or reading bits and pieces of information is insufficient and can leave dangerous gaps in knowledge. Call me old school. (I have been called worse.) But I long for the days when local airports provided structured ground school classes, taught by experienced instructors, for the certificates and ratings that they offered. Complete online courses from reputable companies are a viable option, but still lack the personal connection and the opportunity for group discussion.

Back to the sleet question, climbing when sleet is encountered is generally a bad idea. Sleet always has a layer of freezing rain above it. The sleet sounds ominous as it strikes the airplane, but it poses little problem regarding safety-of-flight. Climbing into the layer of freezing rain is likely to bring the flight to an unhappy end in the very near future. Maintaining altitude in the hope that the airplane will pass through the area of sleet is also not advised. The sloping nature of most temperature inversions means that the airplane be might heading into the area of freezing rain at the present altitude. My advice is that if a pilot flies into an area of sleet, an immediate turn to exit the area of sleet is almost always the best option. Obviously, there is more to know about sleet, freezing rain and structural icing.

As for the source telling the pilot to climb, it was not wrong. It was discussing structural icing, which does not include sleet because sleet does not adhere to the airplane's structure. I hope this example illustrates the danger of obtaining aeronautical knowledge piecemeal. 

HFGS-Live was a Success!

Thanks to all who participated in our Human Factors Ground School-Live in January. We had a terrific group for this course with great interacton. I had a terrific time working with all of you!

Baby It's Cold Out There!

It is winter in the Northern Hemisphere. There is more winter in some places than in others. My home is in Western New York State (think about 60 miles east of the stadium in which The Buffalo Bills defeated the New England Patriots in the playoffs). If you watched that game, you know how cold it can get around here. We have had record breaking cold and dangerous wind chill temperatures. We also have some very rural areas. Single engine, GA airplanes are flying in the area day and night. Sometimes I observe the activity in the area online via one of the flight tracking apps. With temperatures near zero degrees Fahrenheit and wind chills in the negative teens, I often wonder if the occupants of those airplanes are prepared to spend a few hours, or more, in the woods or an open field. The largely volunteer rescue organizations will put forth their best effort to reach survivors of a crash or emergency off-airport landing. But it will take time to gather a crew, determine an exact location or define a search area, transport ATVs or snowmobiles over the road to the best position, offload the vehicles, and reach the site.

I always instructed my students to be prepared to spend the night in whatever terrain you are over-flying. That advice applies to any terrain and every season.

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 The Proficiency Killing Virus 

All pilots have several things in common. We all share alove of flying. We have all successfully completed the training and testing required for our various certificates and ratings. We all take satisfaction in concluding a flight that offered challenges. And we all experience a decline in our aeronautical proficiency with a decrease in using our skills and knowledge. 

Since the beginning of the pandemic, many pilots have decreased the amount of flying they are doing or are substituting more local flights for the longer cross countries. We could think of this as a side effect of the COVID 19 virus that eats away at our proficiency. 

But this decline in proficiency only applies to low time pilots who have not yet built a strong experience background, right? Unfortunately, that is not true. There is evidence that it applies to multi-thousand-hour professional pilots also. 

On January 5, 2022, the Sydney Morning Herald broke a story regarding a leaked internal memo from Qantas. The memo was reportedly written by the head of Quantas fleet operations and addresses pilots returning to duty after down time related to the pandemic. That memo says some grounded pilots “have lost recency and experienced a subsequent reduction in cognitive capacity.” It also states, “Combined with reduced flying across the network, we recognise a flow on effect for flight crew’s focus and familiarity with the operation.” 

The memo goes on to say, “Routine items that used to be completed with a minimum of effort now occupy more time and divert attention away from flying the aircraft.” Also, a summary of recent trends from Qantas pilot reports identifies, “errors” while planes were on the ground such as “commencing take-off with park brake set” and “misidentification of altitude as airspeed.” 

Fortunately, the errors stated were detected in simulator sessions and not in actual operations. But unfortunately, most GA pilots do not have the opportunity to take formal recurrent training in a simulator after a break in their flying. In most cases, little or no recurrent training is undertaken. 

We must also note that a change in the kind of flying can be as detrimental to proficiency as a total break in flying. With limited availability to visit tourist attractions and other points of interest, many pilots who limited their flying to local operations might see a decline in the skills necessary to operate safely in the cross country environment. This is especially true if instrument flying hours were decreased or replaced with local VFR hours. 

Recognizing that there may be a problem is an important first step. We can all determine a path that leads us back to proficiency. That path might involve a simulator or PC-ATD. It might involve a flight or two with a CFI to review and practice skills that we have not used very much lately.  

As pilots, our proficiency is the marrow of our safety. How good we were five years ago, five months ago, or five hours ago is irrelevant. How good we are on our next flight is all that counts.

 

Click here to see the Sydney Herald Article.

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.

broken image

NTSB Photo

In keeping with our theme of pilot proficiency, the pilot involved in this accident acknowledged that his lack of recent experience was likely a contributing factor. The Piper Arrow was substantially damaged, but  the pilot and his passenger escaped injury.

The accident happened in Minnesota in April of 2019. From the NTSB report, "The private pilot reported that the airplane operated normally during the personal flight. He stated that before touchdown at the destination airport, he applied left rudder and had the right wing down into the wind to counter the crosswinds and maintain the center line of the runway. At touchdown, he held the control yoke to the right and was applying the brakes; however, the airplane veered left and exited the runway. The airplane traveled about 50 ft into the grass, and the right main landing gear collapsed; the right wing struck the ground and sustained substantial damage."

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NTSB Photo

The 368-hour private pilot was landing on Runway 13 at St. Cloud Regional Airport. That runway is listed as 7,500 feet long and 150 feet wide with an asphalt surface. The wind was reported to be from 180 degrees at 13 knots gusting to 20 knots. At the maximum gust speed of 20 knots, the crosswind component is calculated to be 15 knots which is within the 17-knot maximum demonstrated crosswind capability of the Piper Arrow.

The pilot acknowledged his lack of proficiency. He stated, "Looking back, I should have never gone up with crosswinds that high, with little to no practice in crosswinds logged in the last 30, 60, [or] 90 days." 

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Google Earth - annotations by GB

The NTSB Probable Cause: "The pilot's failure to maintain directional control during a crosswind landing. Contributing to the accident was the pilot's decision to land in crosswind conditions given his lack of recent experience in those conditions."

We might look at this as pilots and think that the pilot should have been able to handle a gusty crosswind that, even at peak gusts, was within the published limits for the airplane. But could we? Our humanness tells us that we could. But perhaps we have a bit of illusory superiority working. Maybe optimism bias is whispering in our ear. Maybe we have landed in more severe conditions than this. But how proficient we are at precisely the time of the approach and landing is all that counts. How good we were five years ago, five months ago, five days ago or five hours ago is irrelevant. How good we are on our next flight is all that counts. Let's make sure we do whatever it takes to maintain our proficiency. 

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

broken image

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 is officially characterized as a controlled flight into terrain (CFIT) accident but is actually the result of an error made during a night VFR approach. It occurred in Blairsville, Georgia in December of 2018. The private pilot and two passengers were fatally injured while one passenger survived with serious injuries. The airplane was a Piper PA-28-181 Archer. 

The crash occurred at the conclusion of a local flight to observe Christmas lights in the area. The time of the crash was 1936 local time, so it was well into the dark hours. The runway was lighted, but there was no vertical descent guidance provided, either electronic or visual. The pilot had owned the airplane since 2010 and this was his home airport.

The initial impact point was a stand of 60 to 70-ft-tall trees located about 1/2 mile from the end of the runway at an elevation of about 1,986 ft msl. The airport elevation is published as 1,909 ft. MSL. Though this was a VFR flight, the pilot was instrument rated and should have been aware of the published minimum descent altitude of 2,940 ft. MSL for the RNAV (GPS) approach to the landing runway. That approach was not authorized at night.

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Photo Source: NTSB

The NTSB accident report includes the following: "A witness stated that she was on her front porch when she saw the lights of the airplane approaching the airport. The airplane's engine was running smoothly, but it sounded as if the airplane was "just too low. "The witness heard the airplane impact trees and then the ground."

A GPS device located in the wreckage showed that the airplane had descended to about 1,986 ft. MSL then stopped recording about seven seconds later.

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Google Earth - annotations by GB

The NTSB Probable Cause finding 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."

The NTSB report quotes Chapter 10 of the FAA airplane flying Handbook: A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, orientation is difficult. The runway can seem out of position (down-sloping or up-sloping) and in the worst case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, use the flight instruments to assist in maintaining orientation and a normal approach. Anytime position in relation to the runway or altitude is in doubt, execute a go-around."Bright runway and approach lighting systems, especially where few lights illuminate the surroundingterrain, 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."

ERA19FA070

The NTSB concluded that the pilot's lack of recent experience flying at night contributed to the accident. A pilot's lack of recent experience is only part of being proficient. The truly proficient pilot has the knowledge and awareness of the potential problem areas regarding the upcoming flight. A pilot who had 25 hours of recent night experience at airports offering VASI, PAPI, or an electronic glide slope might have still had this accident if unaware of the material quoted from the Airplane Flying Handbook. When planning a flight, it is helpful to think about what might be encountered on this flight that has not been encountered before or at least not encountered recently. Information on just about any aspect of flying is available instantly via our electronic devices. All we need to do is to look it up.

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.

How can an instrument rated private pilot with more than 3,000 hours including 400 hours in the make and model of airplane die in a loss-of-control-inflight (LOC-I) crash? The simple answer is it can happen from a lack of proficiency in one or more skills that are essential for the flight. It is impossible to assign a numerical value to the status of a pilot's proficiency, so the FAA substitutes recent experience in their regulatory requirements. The accident pilot had logged 527 actual instrument hours and 18 actual instrument approaches in the 19 months prior to the accident. But we must remember that how proficient we were a few months ago is irelevant. All that counts is how proficient we are for our next flight. Of all that time logged within the 19 months prior to the accident, the pilot had only logged 18 actual instrument hours, including 8 actual instrument approaches in the 22 months leading up to the accident flight. His last logbook entry was nearly 3 months prior to the date of the accident. The NTSB report states that the pilot did not meet FAA recency requirements to act as pilot in command under IFR or weather conditions less than the minimums prescribed for visual flight rules.

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NTSB Photo

The crash happened in Florida in November of 2018. The private pilot was alone in the airplane and was fatally injured. The airplane was a Mooney M20C. From the NTSB accident report: "A friend of the private pilot accompanied him on the flight leg before the accident flight; she stated that,while approaching to land, the weather became "very turbulent" and that, after they landed, it was "very windy and raining very hard." The pilot stated that he needed to continue his flight in order to attend a family event, and the passenger suggested that he wait for the weather to improve. During this time, the pilot requested fuel for his airplane from line personnel at the airport's fixed base operator (FBO), who asked if the pilot could wait to receive fuel due to the adverse weather. The pilot stated that he needed fuel "now" and requested that the line personnel wipe his fuel caps with a towel and use an umbrella to prevent rainwater from entering the fuel tanks. After waiting about 45 minutes for the weather to improve, the pilot stated to FBO personnel that he was "heading out"; when asked if he had found a break in the weather, the pilot said he was "gonna go for it." Based on the pilot's comments to his passenger and FBO personnel, he was likely experiencing self-induced pressure to complete the flight despite the poor weather conditions in order to attend the family event."

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NTSB Photo

Regarding the weather conditions, the NTSB report states: "Review of weather radar information showed light to moderate intensity echoes over the route of flight and the accident site consistent with rain showers, and soundings depicted a high probability of moderate or greater low-level turbulence in the area. Conditions about the time of the accident at a nearby airport included 1-1/4 mile visibility in heavy rain and a broken cloud ceiling at 100 ft. above ground level. Although the pilot contacted flight service to file his IFR flight plan, he did not request a weather briefing at that time, and what, if any, weather information he obtained before the flight could not be determined."

The NTSB Probable Cause finding states: "The pilot's loss of control due to spatial disorientation while maneuvering in instrument meteorological conditions. Contributing was the pilot's lack of instrument currency and his self-induced pressure to complete the flight. The pilot's failure to obtain an updated weather briefing before the flight and his subsequent loss of airplane control due to spatial disorientation while maneuvering in instrument meteorological conditions during a diversion to an alternate airport after encountering forecast icing conditions."

CEN18FA144 NTSB Photo

NTSB Photo

This pilot was likely hit by a deluge of several human factors which led him down a dark path. The human error chain perhaps began with the strong, self-induced, external factors. He was determined to attend a family event. His confidence was likely bolstered by some illusory superiority fueled by his previous experience in instrument flying. Optimism bias is rather universal and perhaps it led him to believe that a good outcome was more likely than not. Finally, since he had committed to attend the family event and he was at an airport with an airplane that had been fueled, continuation bias probably exerted its influence.

We can go a long way in overcoming these human factors that want to lead us astray by using a Personal Minimums Checklist or Flight Risk Assessment Tool. More information on these tools can be found on our Safety Concepts page. Click here and scroll down to "Decision Tools."

 

A brief description of the human factors mentioned here can be seen in my video, The Bias Bundle Bomb." Click here to view it on my YouTube channel.

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

Books by Gene Benson

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