Vectors For Safety - January 2022

Happy New Year!!

I wish everyone a safe, happy, healthy, and prosperous 2022. A great resolution for the New Year is to improve aviation skill or knowledge by adding a certificate or rating, completing the next phase of Wings, or just participating in more aviation activities such as online courses, instructional videos, or webinars. For 2022, please fly like your life depends on it!

A New Distraction?

It is a rare day when the daily ASIAS report does not include an accident or incident in which a pilot taxied an airplane into something. It seems reasonable to assume that there are also many similar incidents that go unreported.

These events usually do not result in personal injury, but often involve more than a few thousand dollars combined damage to the taxiing airplane and to whatever was struck. These mishaps are often caused by a distraction. The usual culprits include distractions caused by tuning avionics, programming a GPS, running a checklist, or chatting with a passenger. A new member of the gang may have emerged.

The internet offers many aviation videos, some helpful and some not so much. As a flight instructor and safety advocate, I sometimes cringe at some of the procedures I see. I hope that the younger, more impressionable pilot do not view this as "How the cool pilots operate."

I just watched a prime example of how not to taxi and the distraction was our new gang member, the action camera. This pilot had three cameras mounted in the cockpit. One was behind him looking over his shoulder at the instrument panel. The second one was mounted on the glare shield, looking out the windshield. The third was mounted on the right side of the glare shield looking at the pilot's face. He also had a camera mounted on the left wing strut.

He began the recording as he began his taxi to the runway. Throughout the taxi, he made several camera adjustments and very often looked into the camera aimed at his face and provided narration. Given that his eyes were directed toward the camera lens, there was no way he was watching where he was going. Whenever his edited video cut to the outside view, he was never on the taxiway centerline.

Call me old school, but taxiing is a critical operation and it deserves our undivided attention. I have no objection to action cameras being used to record a flight, but the operation of the aircraft must be our primary concern.

Weather Briefings Optional?

I am passionate to learn more about human behavior. I am fascinated to learn more about why people do what they do. Particularly intriguing is why people sometimes take actions that are clearly and flagrantly not in their best interest.

A current topic of discussion in aviation safety circles is "Safety Drift." This is a new name for a well-known source of human error. It is related to complacency. Safety Drift occurs when a person, over time, "drifts" away from an adherence to an established safety practice.

An example that is increasingly being listed as a part of the probable cause in airplane crashes is the pilot’s failure to obtain a thorough aviation weather briefing before beginning a cross country flight. The regulations, backed up by accident data and common sense require pilots to have knowledge present and forecast weather conditions. “14 CFR 91.103 -- Preflight action” includes: Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include - (a) For a flight under IFR or a flight not in the vicinity of an airport, weather reports and forecasts, fuel requirements, alternatives available if the planned flight cannot be completed, and any known traffic delays of which the pilot in command has been advised by ATC.

That seems clear that a weather briefing is required for a cross country flight. Regulations aside, why would a pilot not invest a few minutes to learn what the weather has in store for the flight? The answer lies in the fact that we are human beings first and pilots second. Our brains do not always lead us down the best path. An anti-authority attitude may cause us to forego the weather briefing because it is an example of someone trying to tell us what to do. External factors might lead us to believe that the flight is so important, that it must happen regardless of weather. Impairment, even slight, from OTC drugs, prescription medications, alcohol, or illegal substances may interfere with good decision making. Optimism bias may tell us that everything will be fine. Illusory superiority may lead us to believe that we have better skills than others and we can handle whatever comes up. Complacency may convince us that the weather has always been manageable before so it will be again.

Each time a pilot completes a flight successfully without obtaining a weather briefing that pilot is reinforced in the behavior of not receiving a briefing and becomes less likely to seek a weather briefing in the future. Eventually, the task of getting the briefing is removed from the pilot’s routine.

No pilot is immune from this, but I see it more frequently in older pilots. Being one of those older pilots myself, I recall the days when obtaining a weather briefing was more difficult and much less user-friendly. The present technology provides us with the opportunity to easily obtain all the information we need, all the time we need to study it, and even tools to help us visualize the big picture. Even pilots who are not particularly tech savvy probably have at least a smart phone. The website 1800wxbrief.com makes the task relatively easy. User guides and videos are available. It is completely free to use courtesy of the FAA. Create a free account to make future visits quicker. If you visit the site on a mobile device, it prompts you to go to the mobile friendly website. A little time learning how to use these tools can be a valuable investment in safety.

Most of you reading this are probably already familiar with how to obtain a thorough weather briefing. Why not offer to mentor another pilot, perhaps an older one, who may need a nudge in the right direction?

The accidents analyzed in the Accident Analysis sections below illustrate the decision to skip the weather briefing resulted in loss of life.

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 accident happened in Ohio in June of 2019. The airplane was a Beech A36 Bonanza. The 65-year-old pilot and his 50-year-old passenger died in the crash. The following is an excerpt from the NTSB accident report. "The noninstrument-rated private pilot and passenger departed on the cross-county flight under visual flight rules (VFR) in visual meteorological conditions and proceeded on course at an altitude of about 9,000 ft mean sea level (msl). As the flight progressed, the weather conditions deteriorated, and about halfway through the flight, the pilot appeared to deviate before resuming flight toward the destination and descended to about 2,000 ft msl over about 30 minutes. Within 20 miles of the accident site, the pilot executed multiple course changes, including two 360° turns. The airplane then entered a right turn from a southeasterly course to a southwesterly course, and about 1 minute before the accident, the airplane re-entered the right turn, which progressed into a right graveyard spiral that continued until
impact.
Weather observations and satellite imagery indicated that instrument meteorological conditions (IMC)
prevailed in the vicinity of where the pilot began making the multiple course changes and at the accident
site. It is likely that the pilot encountered rain, and possibly heavy rain, during the final portion of the
flight. There was no record of the pilot obtaining a preflight weather briefing from an official source.
Examinations of the airframe and engine did not reveal any anomalies consistent with a preimpact
failure or malfunction.
Toxicology testing of the pilot revealed the presence of carboxy-delta-9-tetrahydrocannabinol (THC), an
inactive metabolite of THC. The low-level presence of the inactive THC metabolite suggests that the
pilot was not under the influence of THC at the time of the flight, and therefore, it is unlikely that any
effects from the pilot's prior use contributed to the accident. The testing also revealed the presence of
diphenhydramine; however, it did not provide a blood level. Therefore, whether the pilot might have
been impaired from the diphenhydramine at the time of the accident or whether his prior use contributed
to the accident could not be determined.
The restricted visibility conditions present in the area were conducive to the development of spatial
disorientation, and the airplane's maneuvering and spiraling descent are consistent with the known
effects of spatial disorientation. It is likely that the pilot experienced spatial disorientation during an
encounter with instrument meteorological conditions, which resulted in a loss of control."

NTSB Photo

The NTSB Probable Cause finding states: "The noninstrument-rated pilot's decision to continue visual flight rules flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing was the pilot not obtaining a weather briefing prior to the flight."

NTSB Photo

Why did this non-instrument rated pilot fail to obtain a weather briefing and why did he continue into the instrument weather conditions rather than divert? We cannot know for sure. The pilot had more than 1,600 hours total flight time, a current flight review, and was medically qualified to fly. Had he ventured into instrument conditions before and been reinforced by a successful outcome? Again, we cannot know.

The toxicology report detected THC at a low level indicating that the pilot was not under the impaired at the time of the flight but showing evidence of prior use. Diphenhydramine, an extremely impairing ingredient in several OTC medications was also detected. A blood level of the drug was not provided by the test. No impairment level for diphenhydramine has been established, but it is possible that the drug influenced the pilot's decisions.

The lesson to be learned from this is that we must always do our flight planning, including obtaining a thorough weather briefing. We must be ready to divert or return to our destination if weather beyond the capability of the airplane or beyond our own limitations is encountered.

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 accident happened in California's Tehachapi Mountains and involved a Beech D55 Baron. The 74-year-old pilot and his two passengers, ages 53 and 38, died in the crash. The crash occurred in February of 2019.

There is no record of the pilot receiving a weather briefing, no flight plan was filed, and there was no communication with ATC. At the time of the crash, the pilot was 41 miles to the left of the straight-line course from his departure point to his destination. The airplane initially impacted trees and left a wreckage distribution path392 feet long which is consistent with controlled flight into terrain (CFIT).

Graphic Source: NTSB

The NTSB accident report includes the following: "The pilot’s son reported that a family friend had asked the pilot to fly two passengers to see a client but that the flight was not for compensation or hire. The airplane departed San Luis County Regional Airport (SBP), San Luis Obispo, California, about 1600, on the cross-country flight destined for Whiteman Airport (WHP), Los Angeles, California, but did not arrive. There was no contact with air traffic control."

Also included in the NTSB accident report is the following sentence: "Had the pilot obtained a weather briefing for his planned route of flight, he would have been aware of the weather hazards, and alternate routing may have allowed for safe operations in visual conditions."

Photo Source: NTSB

The NTSB Probable Cause finding states: "The pilot’s continued visual flight into instrument meteorological conditions associated with mountain obscuration conditions, which resulted in controlled flight into rising terrain. Contributing to the accident was the pilot’s failure to obtain a weather briefing."

The pilot was properly certified and rated to fly the multiengine high-performance airplane. He held a Commercial Pilot Certificate with Multiengine Land and Instrument Ratings. He also held a Flight Instructor Certificate with ratings for Airplane Single and Multiengine and Instrument Airplane. There was no available information on the status of a flight review. The pilot had 4012 hours total flight time including 100 hours in this make and model and 38 hours in the last 90 days.

So how does an accident like this happen with an accomplished, experienced pilot? News reports indicate that the passengers he was asked to carry on behalf of a family friend were attorneys on the way to see a client. Did this cause pressure from external factors? If so, was the pressure sufficient to cause the pilot to skip obtaining a weather briefing? Why did the pilot not contact ATC for flight following?

Clearly, the pilot made bad decisions regarding this flight. His deliberative decision making was flawed in his failure to obtain an aviation weather briefing. His rapid decision making was flawed in his decision to continue into instrument flight conditions while VFR and without the altitude protections provided by IFR routing.

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 loss-of-control accident happened in Pennsylvania in April of 2018. The 65-year-old instrument rated private pilot and his 65-year-old non-instrument rated passenger died in the crash. the airplane was a Cirrus SR22. They departed on an instrument flight plan from Lancaster, PA to South Bend, IN. After encountering structural icing, the pilot requested to divert to Johnstown, PA. However, when he was advised that the ceiling was only 200 feet AGL at Johnstown, he requested vectors to Altoona, PA where the ceiling was 500 feet AGL. After the controller provided the vectors, the pilot requested to descend to 4,000 feet MSL, but the controller cleared him to 4,500 feet MSL, which was the lowest altitude
he could clear the airplane to descend to in that geographical area. Figure 1 shows a Google Earth
overlay of the airplane's radar track in red, the AOO approach localizer path in white.

Figure 1 NTSB Graphic

About 0842, the controller advised the pilot that the airplane had passed through the localizer for the ILS
approach to runway 21 at AOO, and the pilot stated that he still wanted to land at AOO and requested vectors to intercept the localizer. The controller issued additional vectors for the pilot to make a box pattern to intercept the localizer; the airplane then turned left turn toward the north. At 0842:33, the airplane began a left standard rate turn and remained about 4,000 feet MSL. At 0843:12, the airplane started to descend, and the airspeed increased. At 0843:38, the airplane descended through 2,525 feet MSL and continued in a tight, left spiral turn. The final radar point was recorded at 0843:52 at 1,850 feet MSL, at which point the airplane was still in a tight, left spiraling turn. Subsequently, radar contact was lost, and no additional communications were received from the pilot. See figure 2 for a radar track showing the initial left turn followed by the spiraling left turns. Before the final left turn and descending spiral, the flight path and altitudes were normal with no erratic maneuvers or anomalies noted.

Figure 2 NTSB Graphic

The NTSB Probable Cause finding states: "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."

NTSB Photo

The NTSB accident report includes the following: "Before the flight, a forecast icing potential (FIP) indicated that light-to-moderate intensity icing existed near the accident site, and a current icing potential product indicated that SLD existed near the accident site; this information would have been available to the pilot before the accident flight departed.

The pilot received a weather briefing via the ForeFlight application on his mobile device about 10 hours
before the accident flight. At that time, the forecast showed cloud cover, snow showers, and instrument
flight rules conditions. Since the AIRMET received in the weather briefing expired at 0500 the pilot
should have requested an updated briefing with the valid AIRMET. In the time between the weather
briefing and the accident, an AIRMET was issued for moderate icing, IFR/mountain obscuration, and
low-level turbulence, and was valid until 1100. An updated AIRMET advisory was recorded via the
flight plan identification number less than 2 hours before departure. No records were found indicating
whether the pilot retrieved any other weather information before or during the flight. Therefore, although the pilot had sufficient weather forecast information available to him before departure to have known about the existing icing conditions along the flight route, the investigation could not determine whether he received all of the pertinent information before the flight.

Although the pilot reported that the airplane had accumulated ice, the investigation could not determine
if the airplane was significantly affected by structural icing during the approach. The airplane was not
equipped with an anti-icing or deicing system, which prohibited the pilot from flying into known icing conditions."

NTSB Photo Undeployed ballistic parachute

NTSB Photo showing CAPS handle with safety pin still installed

Regarding the pilot's proficiency, the NTSB report includes the following: "The pilot's flight instructor stated that he had flown with the pilot six times in the 6 months before the accident. Four of the flights were conducted for the purpose of maintaining instrument currency and proficiency. Their most recent flight was on November 30, 2017, during which the pilot completed ILS and GPS approaches in simulated IMC.
The pilot's logbooks showed that he had completed the recent instrument experience requirements in
accordance with 14 CFR Section 61.57, "Recent flight experience: Pilot in command."

The NTSB report also includes: "The toxicology testing also detected two impairing psychoactive substances, diphenhydramine and clonazepam, in tissue specimens. These drugs alone or in combination could have affected the pilot's decision-making and/or slowed his detection of potential hazards and his reaction to them. However, antemortem levels of these two drugs could have been low enough to not have affected him, but, because antemortem levels cannot be calculated from tissue levels, it could not be determined whether effects from the pilot's use of diphenhydramine and clonazepam contributed to the accident."

This accident illustrates the importance of making good decisions regarding our flying. This pilot made several unfortunate decisions. He did not obtain an updated weather briefing, he did not remove the safety pin from the ballistic parachute system, and he flew an airplane with diphenhydramine in his system. Possibly another bad decision was to not engage the autopilot for his instrument approach. However, there may be valid reasons why he did not.

We have seen before the terrible results of diphenhydramine and similar psychoactive impairing drugs. The NTSB cannot say that the pilot was impaired by these drugs because of testing limitations. However, we have a pilot who had demonstrated instrument competency but made some unfortunate decisions and then lost control of the airplane.

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

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