Safety Initiative Survey
Thanks to those of you who participated in the Safety Initiative Survey. The information you provided is valuable as we continue to try and keep the Safety Initiative relative and effective. The survey results provide three key take-aways: include more safety-related articles on the Vectors website, create more safety videos with a duration of about 10 minutes, and conduct more live, on-site safety seminars. We will gradually incorporate those suggestions over the next few months.
Thanks to EAA Chapter 44
I was privileged to present "CFIT-Revisited" to EAA Chapter 44 at Ledgedale Airpark in Brockport, NY on January 16. We had a great turnout, especially considering the temperature was in the low teens. Thanks to Chapter 44 for inviting me and thanks for the warm welcome and the great dinner.
Upcoming Live In-Person Events
On Saturday, February 17, I will be presenting "Just This Once" at Finger Lakes Regional Airport (0G7) in Seneca Falls, NY. Click here for more information and to register. On Saturday, March 23, I will be presenting "Double-D Danger" which addresses delayed decisions at the annual Syracuse Aviation Safety Stand Down. More info on that event will be posted in the March 1 edition of Vectors.
Planning an Aviation Event?
I am updating my presentation equipment and am open to conducting both live, on-site and virtual events. If you have an upcoming event and would like to have me deliver one of my presentations, please contact me at gene@genebenon.com. There is no fee for virtual events. On-site events within a reasonable distance from me also have no fee. More distant venues may require some minimal travel reimbursement. Click here to download my current presentation catalog.
From time to time, I like to share feedback that I receive from readers. I receive many inciteful emails and I appreciate the time that anyone spends communicating with me. The communication that I am sharing below, with the writer's permission, tells a story that nicely validates and illustrates the main point of the January article titled, Mental Exclamation Point.
When I bought my first plane, a Bonanza F33A, although I had over 700 hours that
included only a couple of hours in retractable gear planes. The insurance
company required that I get 10 hours of dual from an appropriate instructor and
I sought out the best qualified I could find. I also was pointed to the
American Bonanza Society as being an invaluable resource in terms of ownership
and information. The instructor I found suggested I take the ABS online training
course for my plane before flying, which I did. While there I signed up for
their flight training with a ABS certified instructor. Torque bolts AND safety
wire them.
The training materials were awesome as were both instructors. I went through
more emergency procedures with those two instructors than I had in all of my
previous training combined.
Just the next week after all of this, after reaching cruise altitude on a night
flight from HPN to BED with my wife, the door popped open. My wife thought that was the end and I couldn't communicate with her as her headphones came off plus I was laser focused on flying the plane. I gave her a thumbs-up, let NY ATC know I needed to land at OXC, landed, shut the door, reassured her everything was fine, took off and resumed the flight. ATC was helpful, accommodating and I even kept the same code for the remainder of the flight.
While it was a startle event, having read about it then practiced it a couple of
times already it was no big deal at all, just another flight maneuver.
Two weeks later, landing at Montauk in gusty conditions, it looked like I was
not set up like I wanted. I executed a go-around, just as I had practiced with
my recent Bonanza instruction and it was no big deal.
This coming spring I plan on doing another BPPP training flight with the same
instructor.
Training and instruction like this is one of the most valuable ways possible to
spend money in aviation. The BPPP training and flight is around $500 so quite a
bargain for what you get.
Beware the Double-D!
This month’s topic cautions pilots to beware of the “Double-D.” No, the caution does not relate to a popular donut shop or a size in a lingerie store. It refers to the delayed decision.
Before we get into that, we will do a very quick review of decision making in general but specifically as it applies to pilots. Deliberative decision making is when we have ample time to consider all options, do research, or ask for advice before we decide. Our flight planning would be an example of that. Rapid decision making is when we have limited time, perhaps a few minutes to decide. Our example there might be having the alternator trip offline while flying in day, VFR conditions. And urgent decision making is when an almost immediate decision is required. That might be experiencing a complete loss of engine power shortly after takeoff.
A delayed decision is one that was made too late to achieve the desired outcome. This would most likely involve a decision that required a rapid or an urgent response. The probable cause of many aircraft accidents as stated by the NTSB, includes, “The pilot’s delayed decision to…” That is frequently followed by, for landing accidents, “abort the landing” or “initiate a go-around” which I consider to be the same thing. For takeoff accidents, the statement is frequently followed by, “abort the takeoff” or “reject the takeoff,” again considered to be the same. For instructional accidents, the leading statement is often, “The flight instructor’s delayed decision to intervene…” However, I believe the circumstances are somewhat different when discussing instructional accidents, so we will limit our discussion to non-instructional takeoff and landing accidents.
Why do pilots delay making necessary decisions? For starters, aborted takeoffs and landings result in delays, extra cost, and a bit of ego bruising. Our humanness gets involved with at least three cognitive biases. Illusory superiority causes us to believe that we are better pilots than those other folks. Optimism bias tells us that everything will work out fine. And continuation bias provides strong influence to continue a task that has begun.
We can help to mitigate the effects of these influencers by establishing what I call “decision gates” for each critical maneuver. This is a simple process of establishing a “gate” that calls for a decision at a specific point or gate.
On an approach to land, the decision gate might be an altitude. We already do that in instrument flying by complying with Minimum Descent Altitude (MDA) or Decision Altitude (DA) on an approach. For VFR flights, our DGA or decision gate, might be our personal stabilization altitude plus field elevation*.
For each takeoff, the decision gate will be a point down the runway. It might be a runway marking, a taxiway, a bush, or a building. We must consider aircraft performance under existing conditions including wind component, the runway surface and condition, the airport environment, including obstructions, ceiling and visibility, and the aircraft configuration to establish the location of our takeoff decision gate.
We all know that the performance data provided by the aircraft manufacturer may be overly optimistic considering aircraft and engine age as well as pilot technique, so we must be conservative. The FAA recently published some rules of thumb for takeoff distance.
🛩️ Fixed pitch prop, add 15% to your calculated takeoff distance for each 1,000-foot increase in density altitude up to 8,000 feet/12% per 1,000 feet up to 6,000 feet for constant speed prop.
🛩️ When planning takeoff from short, unobstructed runways, establish a landmark at 50% of your calculated takeoff distance.
🛩️ When on the takeoff roll, you should have 70% of your rotation speed at that point. If you don’t, the safest thing to do is to abort the takeoff.
🛩️ If you can’t meet the above requirement, reduce weight or wait for more favorable wind and temperature conditions.
🛩️ If you must clear obstructions on takeoff, you’ll need to have 70% of your rotation speed by the time you’ve traveled 30% of your available takeoff distance.
These might appear to be overly conservative, but through my many hours as a pilot and flight instructor, I can assure you that they are not.
Also, to our discussion of establishing a decision gate for our takeoffs, it is obvious that we want to make an abort decision before it is too late for us to get stopped on the runway remaining. But, running off the end of the runway going 15 or 20 knots is much better than continuing the takeoff and striking obstacles while airborne or stalling while trying to clear obstacles. Pilots have had very serious accidents by changing their mind after initiating an aborted takeoff and then failing to clear obstacles on departure.
Let’s plan our flights and include decision gates for critical maneuvers. The worst decision is no decision. Establishing the decision gates can help force a pilot to make a decision.
*The concept of the stabilized approach sets criteria that must be met to continue descent below a “stabilization altitude.” The stabilization altitude is set by the pilot or operator. For small GA airplanes, the stabilization altitude is perhaps 500 feet AGL for VFR operations and 800 feet AGL for IFR operations. For more information on the stabilized approach, click here to see more on the VectorsForSafety 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.
NTSB Photo
Three people died in the crash of this beech C23 in West Virginia, which occurred in September of 2021. The NTSB report includes the following: "The pilot and two passengers were departing on the return flight following a weekend of camping. Three witnesses watched as the pilot initiated a takeoff from runway 22 (2,950 ft long), then aborted the takeoff. The pilot continued to the end of the runway, turned the airplane around, and initiated a takeoff from runway 04, which he also aborted. The airplane continued to the departure end of runway 04, turned around, and began another takeoff from runway 22."
NTSB Photo
The NTSB report continues: "One of the witnesses reported that, “…he was going too fast to stop at the end of the runway but not fast enough to take off.” The airplane lifted off “maybe” 800 ft before the departure end of the runway, cleared trees at the departure end, and flew over a creek which ran below and perpendicular to the runway. The terrain on the opposite bank was higher than the runway and included mature trees. The airplane banked steeply left and disappeared below the trees. A witness estimated the airplane’s bank angle as 45° and said that the engine sound was smooth and continuous from engine start until the sound of impact."
GoogleEarth view of New River Gorge Airport
The NTSB report continues further: "Postaccident examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane had a useful load of about 862 lbs. The airplane’s weight and balance at the time of the accident was calculated using the known weights of the pilot, passengers, and baggage (a total of about 797 lbs) and estimates of the airplane’s fuel state at the time of the accident based on its likely fuel consumption during the 2.5-hour flight to the accident airport. The amount of fuel onboard at the time of the accident could not be determined; however, the airplane’s weight at the time of the accident would have exceeded its maximum gross weight with a center of gravity aft of the aft limit, even with only about 1 hour of fuel onboard."
NTSB Photo showing camping gear that was aboard the accident airplane
The NTSB Probable Cause states: "The pilot’s exceedance of the airplane’s critical angle of attack while maneuvering to avoid trees and terrain after takeoff, which resulted in an aerodynamic stall and loss of control. Also causal was the pilot’s decision to operate the airplane outside of its weight and balance limitations and his decision to continue the takeoff after two previous aborted takeoffs during which the airplane demonstrated reduced performance."
This crash illustrates the importance of doing preflight planning that includes calculating the weight and balance. Beyond that, it illustrates how our cognitive biases can work to influence our decision making.
The following is a transcript from the NTSB accident docket of an interview conducted with the pilot's partner (names redacted by GB). "Ms. (partner) was (pilot's) partner and had flown with (pilot) several times. She and (pilot) had planned a trip for New River Gorge Bridge Day in October and the purpose of this trip was to survey the airport, lodging, etc. He also wanted to survey the runway and the elevation to see how the airplane performed. (pilot) also wanted to log cross-country flight time towards his commercial rating. (pilot) “really wanted to go whitewater rafting.” He had the normal preflight conversations about weight and balance, and he was very careful, very detail-oriented, just like his work. He was an engineer for Cisco. “I told people he was a telephone engineer, but he was more than that, because he designed VOIP systems.” When asked if she had spoken with (pilot) over the weekend, Ms. (partner) said, “He communicated with me Saturday by text with lots of photos and that night about 830 pm” by telephone. She said they had a “normal” conversation about his trip, the weather, and the sights. During the conversation (pilot) said he was concerned that he was taking off from a shorter runway at a higher elevation. He said he planned to depart about 10-1030 the following morning. (partner) described (pilot) as a bright, detail-oriented person. She said he was a planner and plotted detailed drawings and calculations on random pieces of paper. She said that because of this trait, she purchased a journal for him to capture his ideas and plans in one place. Ms. (partner) offered that she was in possession of the airplane’s maintenance records and agreed to a plan that would allow for their examination by investigators."
The crash also illustrates the importance of establishing a decision gate for continuing or aborting the takeoff.
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.
NTSB Photo
This crash of an amateur built Kitfox resulted in the death of the passenger and serious injury to the pilot. The crash occurred in California in June of 2021. The NTSB report includes the following: "Witnesses located near the accident site reported that the pilot attempted to take off from the field on a westerly heading; however, it appeared that the airplane could not attain adequate speed to get off the ground. The witnesses heard the engine sound decrease and watched the pilot turn the airplane 180° and initiate a second takeoff, this time to the east. The airplane became airborne about 20 yards from a canal road and climbed to about 10 to 20 ft above the ground. As the airplane approached the canal, it began to descend and impacted the upper eastern edge of the canal, spun around, and slid down into the water. The pilot had no recollection of the accident sequence."
NTSB Photo
The NTSB report also includes: "Examination revealed no anomalies with the airframe or engine that would have precluded normal operation, and damage signatures and witness accounts indicated that the engine was producing power at the time of the accident. The departure field, which was about 1,150 ft long, comprised rough terrain with vegetation about 2 to 3 ft in height. The calculated density altitude about the time of the accident was 6,635 ft, with a pressure altitude of 4,297 ft."
Also included in the NTSB report: "The height of the vegetation most likely increased resistance on the tires during the takeoff roll, which reduced the airplane’s acceleration. Coupled with the high-density altitude conditions, it is likely that the airplane’s required takeoff distance exceeded the field length available, which resulted in impact with terrain."
NTSB Photo
The NTSB Probable Cause states: "The pilot’s poor decision making in attempting a takeoff from a field with high vegetation and a high-density altitude, which resulted in decreased takeoff performance and impact with terrain."
Again, we see cognitive biases likely at work influencing the pilot's decisions. And again, the establishment of a decision gate as a go/abort point might have prevented this tragedy.
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 Idaho in June 2021. The two pilots aboard were both seriously injured and their Cessna 182 was destroyed by a post-crash fire.
The NTSB accident report includes the following: "The pilot reported that, while on final approach to land, he was “concerned they had too much speed” to stop in time but elected to continue with the landing. About midfield, as the airplane was floating down the airstrip, the pilot aborted the landing and applied full power. During the climb out, the airplane was unable to out climb rising terrain or maneuver in the narrow canyon to return to the airstrip. The airplane subsequently collided with trees and terrain. A post-accident fire destroyed the airplane."
Google Earth view of the Warren Idaho Airport
The following, copied from the NTSB Pilot-Operator Report, describes the accident sequence in the pilot's own words: "As we turned left for final, we briefly discussed and agreed that it appeared (by the wind sock) to be a little windy and gusty so we agreed to not put a final notch of flap in and maintained 20 degrees of flat and continued our approach. We made the final approach radio call. We descended down to the airfield with airspeed approximately 75 knots at the threshold. We became concerned that we had too much speed to be able to stop in time, but agreed to continue the landing. Approximately mid-field as the airplane was floating down the airstrip, I knew we could not stop in time and immediately put full power in to halt our descent and climb out. As the airplane climbed out, the landing gear was struck by the top of a tree, without damage. We reduced the flap to zero and continued our climb in rising terrain. We agreed to turn around and we could not get over the top. We had just a few seconds. I looked over at John (redacted) and told him we were going to crash. I slowed the airplane down as much as I could (without stalling), pulled a high angle of attack, and looked quickly for a spot of trees and flew directly into them. We crashed through (sic) the trees, wings were ripped off, and we fell mostly intact on the forest floor with minor injuries (I had a broken ankle and finger). Our seatbelts had held us in place. It was within seconds that the airplane filled with gas and sparked a fire inside the cockpit. We struggled to get free. We eventually released our seatbelts opened the pilot-side door and both exited the left side together. Very shortly after, the airplane exploded and burned down to ash."
Google Earth view of runway departure end
The NTSB probable cause finding states, "The pilot's decision to continue the approach for landing with excess airspeed, which resulted in an aborted landing and subsequent collision with trees."
Actual accident airplane
The pilots' decision to use just 20 degrees of flap for the landing due to a gusty wind is questionable, but not necessarily incorrect for the 2,765-foot runway with an elevation of 5902 feet with an ambient temperature of 82 degrees Fahrenheit. But the issue here is the delayed decision to continue the approach as the pilot described. (See sentence highlighted in red above.) If we have to discuss whether an approach will turn into a successful landing, it is time to execute a go-around and try again, perhaps with a different airplane configuration and or airspeed.
Click here to download the accident report from the NTSB website.
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