Completely New Program
Our feature this month is "Just this Once." It is a preview of a completely new program that we are rolling out soon. The live presentation will be premiered at the Syracuse NY safety stand down on March 25. I will have more information on that event in the March edition of "Vectors." We will also be adding a video and online course for Wings credit in the near future. We thank Avemco Insurance for their support of this project.
Check It Out!
If you have not seen any of our "YouTube Shorts" videos yet, check them out. Click here to visit the playlist on YouTube.
Checklists are Critical!
We continue to see reports of many accidents and incidents that could have been easily avoided if a checklist had been used correctly. Our free online program, "Checklists Micro-Course" provides a great refresher on the subject and completion is valid for 1 credit, Advanced Knowledge-2 in the FAA Wings program. Click here to visit the course.
Sara Update!
Granddaughter Sara has been slowed a bit in her progress by delays in getting checkrides scheduled or rescheduled when there is a weather cancellation. But, she has now added a multiengine rating to her Commercial Pilot Certificate. She has begun the final phase of building the required PIC time and adding multiengine to her Flight Instructor Certificate.
Just This Once
How many times have any of us realized that what we were about to do was not aligned with established procedures, a regulation, or simply good practice? If we are being honest, the answer is probably many times. We often know better but rationalize that it will be fine just this once.
I saw a perfect example of this in my own family. A close relative who is an auto mechanic was using an impact wrench to tighten a lug nut on a wheel. He was in a hurry and his safety glasses were on a bench across the shop. He knew he should take the time to get the glasses but thought that it will be okay just this once. Sure enough, a piece of metal flew off and went into his eye. He eventually regained full vision in the eye, but endured a surgery, lost a week of work, and had discomfort for several months.
Part of our humanness is something called continuation bias. This gives us the mental inertia to complete a task once it has begun. The task might be completing a project at work or at home. Our brains consider the task to have begun when the first steps are taken, and that can include mental preparation.
The issuance of a pilot certificate does not vaccinate us against continuation bias. How many pilots have abbreviated a preflight inspection, skipped taking a fuel sample or verifying fuel quantity, continued VFR flight into IFR conditions, engaged in scud running, or skipped a before landing checklist when traffic pattern is busy? The answer is certainly a large number and likely includes all of us on at least one occasion.
Unfortunately, our humanness also provides positive reinforcement when we succumb to just this once and have a successful outcome, encouraging us to repeat the action in the future.
The accidents analyzed below all involve an omission by a pilot. We cannot know for sure, but that omission may have been preceded by the pilot believing that it will be fine just this once.
The following article is reprinted from the NASA CALLBACK PUBLICATION #409 of August 2021.
■ I departed the airport for a pleasure flight. The flight was estimated to be two hours, and I topped off with fuel for a four-hour endurance. No flight plan was filed. I fly over this area frequently and navigate by ground reference. I first flew northwest to the western edge of a mountain range, then traveled east along the southern face of these mountains. My plan was to continue to fly along the mountain range to the east, and then south to land. While transitioning between the two ranges, I switched fuel tanks, and the engine immediately quit running. I switched back to the previous tank, turned on the boost pump, and increased the mixture. The propeller was windmilling. I waited for a few seconds for the engine to restart. When it did not restart, I pumped the throttle a few times. This was not successful, and the propeller stopped. I initiated my forced landing procedure at this point while turning over the engine with the key for another 20 seconds or so. I decided on the freeway. The landing was uneventful. The plane was [towed] from the freeway by a flatbed truck. The engine was restarted and a number of tests were done to isolate the cause of failure, but none could be found. I used a stretch of open road to take off and return. My Mechanic told me that I should always turn on the boost pump when switching tanks in a low wing [aircraft]. I am making this part of my normal procedure and only switching tanks when within gliding [distance] of an airport, whenever possible.
Note from Gene: For a one-minute summary of recommended procedures for switching fuel tanks in flight, check out my YouTube video.
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.
Gear-up landings are quite common. It is a rare day when the daily ASIAS report from the FAA does not include at least one incidence of a retractable gear airplane landing with the tires safely tucked away from that nasty pavement. The unfortunate part of this common event is that it is potentially dangerous and very expensive.
This accident involved a Piper Aerostar 601P, occurred in July of 2022, and apparently happened in Oregon, though the NTSB report lists Washington as the state. The sole occupant of the airplane, the pilot, was not injured.
No level of pilot certification or experience makes a pilot immune from making this noisy, embarrassing, and pricy arrival. In the case of our example accident, the 54-year-old commercial pilot had about 2,300 hours total flight time and was rated for Single-engine land; Single-engine sea; Multi-engine land; and Multi-engine sea. His had a current medical certificate and current flight review which was accomplished in a Cessna Citation.
According to the NTSB accident report, "The pilot reported that, he was a little behind the airplane because of the short duration of the flight and he did not use a prelanding checklist to verify that the landing gear was extended before touchdown. The bottom of the fuselage was substantially damaged during the gear up landing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation."
The NTSB Probable Cause finding states: "The pilot’s failure to extend the landing gear before landing. Contributing to the accident was the pilot’s failure to utilize a prelanding checklist."
Photo source: NTSB
The following excerpt is from the Pilot-Operator Report submitted by the pilot to the NTSB.
This raises at least two important reminders. First, the approach was not stabilized there was some confusion as to the significance of the horn. That should indicate the need for an immediate go-around to get properly established on final and to sort out the reason for a warning horn. Second, unexpected excess airspeed when flying an airplane with retractable landing gear should immediately raise the question of whether or not the landing gear is down.
The pilot made some good points in the Recommendation Section of the Pilot-Operator Report as shown below.
Photo source: NTSB
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, involving a Piper PA32-260 (Cherokee Six), happened in September of 2021 In Minnesota. The 57-year-old private pilot and sole occupant received only minor injuries. The NTSB accident report includes the following: "The pilot reported that before he departed for a cross country flight, he asked the fuel servicing personnel to fill the left fuel tank. While enroute and burning fuel only from the left tank, the airplane lost all engine power and the pilot executed a forced landing into a field, which resulted in substantial damage to the right wing and fuselage."
The NTSB accident report continues: "During a post-accident inspection, the left fuel tank was found to be empty. The pilot stated that he assumed all of his fuel tanks were full at the time of departure but did not confirm the fuel level by looking in the tanks or at the fuel gauges. He also stated that his failure to verify the fuel quantity resulted in a fuel exhaustion event when the 6.6 gallons of fuel in the left main tank were consumed. He did not use fuel from the right tank during the flight."
Photo source: NTSB
The NTSB probable cause finding states: "A total loss of engine power as a result of fuel starvation. Contributing to the accident was the pilot’s failure to properly manage the fuel on board the airplane and his failure to perform an adequate preflight inspection."
Photo source: NTSB
We can learn several lessons from this accident. First, we can see from the accident scene photos that the airplane made a rather sudden stop. The pilot received just minor injuries. In the Pilot-Operator Report submitted to the NTSB shows that a 4-point harness was being worn. Had just a lap belt been used, the pilots injuries might have been much more severe. I take this opportunity to repeat my plea that airplane owners, rather individual, flight schools, or airplane rental companies, equip their airplanes with harnesses if they are not already installed.
Our second lesson is "trust but verify." Always personally observe the airplane fueling if at all possible and always visually verify the fuel quantity in each tank. We must wonder if the pilot knew that he should visually check fuel but thought that it would be okay just this once?
Our third lesson is to know and practice emergency procedures. The power loss occurred when the left fuel tank ran dry but there was fuel remaining in the right tank. The pilot stated in the Pilot-Operator Report that he did not follow the appropriate procedures for an engine restart.
The pilot acknowledged his errors in this regard and included the following recommendations in his Pilot-Operator Report:
- Do not assume anything - check & double check
- Comply with all checklists & procedures for every flight
- Make complete instrument scans each and every time
- Take corrective action to avoid/minimize distractions
- Memorize and practice emergency procedures
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.
Nether the pilot nor the Commercial Pilot/CFI passenger/airplane owner aboard this Bellanca 14-19-3 escaped injury in a crash that happened in Montana in August of 2021. The NTSB accident report includes the following: "The pilot reported that, at the request of the airplane owner, he was going to reposition the airplane to another airport for an annual inspection. As a precaution, the pilot wanted to fly around the airport traffic pattern to refamiliarize himself with the airplane. The pilot reported that when he arrived at the hangar, the owner stated that the airplane was “ready to go” and that 25 gallons of fuel had been added to the right fuel tank. They departed for a flight around the pattern and were on the crosswind leg when the engine lost power; he adjusted the throttle, mixture, and engaged the boost pump, and the engine started. They continued with the landing sequence, and on the base leg, the engine lost power again. The pilot did not believe the airplane was going to make the runway and elected to land straight ahead in a grassy field. During the landing roll out, the airplane impacted a dirt berm and slid sideways before it came to rest upright. After they exited the airplane, the pilot checked the right fuel tank and noted it was empty."
Actual accident airplane
The NTSB report continues: "The airplane was inspected at the accident site by the Federal Aviation Administration (FAA) inspector, and it was determined that the right fuel tank was empty, and the left fuel tank was nearly full. The airplane sustained substantial damage to the right wing."
Photo source: NTSB
The NTSB probable cause finding states: "The airplane was inspected at the accident site by the Federal Aviation Administration (FAA) inspector, and it was determined that the right fuel tank was empty, and the left fuel tank was nearly full. The airplane sustained substantial damage to the right wing."
Again, we must wonder if the pilot knew he should visually check the fuel and thought that it would be okay just this once.
In the Pilot-Operator Report submitted by the pilot, he made the following recommendation: "Never allow anyone (even a pilot with several thousand more hours than you) to do the preflight. Its the pilot's job for good reason." The Pilot-Operator Report includes a complete narrative of the flight written by the pilot. You can download the report by clicking here. Click here to download the accident report from the NTSB website.
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