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Vectors For Safety - January 2023

Safety Initiative Update

Happy New Year!

I wish all our readers a spectacular 2023 filled with joy, prosperity, and of course safety. My agreement with Avemco Insurance has been renewed for the new year and we have some exciting plans. We will be producing more videos, some with interactivity, more new courses, and much more. Avemco is supporting our efforts to reach more pilots with safety programs by encouraging small group virtual presentations. If you have a group such as a flying club, pilots' association, flight school or anything else, please contact me to arrange a no-cost virtual meeting. Click here to download a copy of my presentation catalog or simply send me an email.

Not Too Late!

It's not too late to enroll in our popular Human Factors Ground School-Live for January 2023. The course consists of three live sessions on three consecutive Thursdays, Jan. 5, Jan. 12, and Jan. 19 with each session beginning at 7:00 Eastern. Missed sessions can be made up via watching the video. Couse completion is valid for all three FAA Wings credits at the basic level. Click here to for more info and to register.

Check It Out!

Our feature this month is on how safer general aviation can reduce the cost of flying for everyone. We are all aware of the rising costs, whether you are an airplane owner, flying club member, or renter. A recent article in Forbes Magazine addressed the issue for GA pilots. Click here to read that article on their website.

And It Continues!

A in "Safety Initiative Update" section of the March issue of Vectors, we featured an item on damage caused by failing to remove tow bars before taxi. Unfortunately, this is one of those of those highly avoidable incidents that drive up the cost of GA for all of us. As we know, a prop strike resulting in damage to the propeller will usually result in a required engine teardown. The problem continues with a report on ASIAS from November 29, 2022 that reads, "AIRCRAFT HAD A PROPELLER STRIKE DUE TO AN UNREMOVED TOW BAR." Click here to visit that issue.

Sara Update!

Granddaughter Sara earned her Instrument Flight Instructor Certification in December. She has now begun the multiengine program which will add a multiengine rating to her commercial pilot certificate and also to her flight instructor certificate. She should be completely finished and on the whatever she chooses to do next by the end of January.

Vectors Navigation Change for Online Courses

In an effort to make our courses more interactive, we have changed platforms which required links to the courses to be changed. All links have been updated on the Online Courses section of the Vectors website. All existing courses are basically unchanged, but new courses will include interactive video.

Avemco Insurance sponsors Gene Benson
Gene's Blog

What is Your Stake?

To be more specific, what is your stake in general aviation? I am not necessarily seeking just your financial stake, however sizeable that may be. Your stake may include your freedom to travel, the benefit of an interesting hobby or socialization through aviation activities. It may also include your livelihood if employed by or have an ownership interest in an aviation business. Or it may simply be an emotional connection going back many years.

General aviation is undergoing changes, but it is not going away anytime soon. But many people with a stake in GA are being pushed out by rising costs in virtually every aspect of GA. I find that very sad. Perhaps it is small of me to be concerned with people who are slipping from their ability to fund their GA activities while many more people are slipping in their ability to fund their basic housing, nutrition, and other life expenses. I do not have the expertise to contribute useful suggestions for solutions to those problems but I do have the knowledge to make a small contribution to the situation in GA.

We have little or no control over some of the things driving up our costs. That list is headed up by fuel. We can shop for the best price but flying 25 miles to an airport with a slightly lower price per gallon might be fun but does not make sense if our only motivation is to save a few bucks. Maintenance and insurance are generally shoppable items but extreme caution is advised. Bargains are not always what they seem to be. Delaying needed maintenance is almost always counterproductive and undervaluing the airplane on the hull insurance can be financially damaging. Some aircraft owners are downsizing to something that consumes fuel and requires less maintenance. That may work for some, but if needed capability is sacrificed, the usefulness of the airplane may be greatly diminished.

We cannot conquer all of aviation’s problems, but we can nibble away at a significant one. That one is accidents and incidents, not just involving us, but in general. We all bear some of the cost of the many accidents and incidents that happen daily in the United States. How so? First and most obvious is insurance. We all know how that works. Our premiums, including the premiums paid by our flying clubs and aircraft rental companies, cover the costs of the accidents. We all contribute a little bit toward that expensive landing gear collapse in somebody’s Bonanza. Moving beyond insurance, accidents decrease the supply and increase the demand for new parts at a time when parts are in short supply. While the used parts supply may have a short-term benefit from an airplane being declared a total loss and being sent to a salvage company, that might take one more of our older airplanes out of the fleet. Eventually, the relatively reasonably priced used airplanes from the 1970s and 1980s will be mostly gone. Then we will be looking at a startling price to replace them with similar performance. Higher hull value may lead to higher hull insurance premium and the cycle begins again.

Of the pilots reading this article, I know that 99% of you are doing your part. You make the effort to be safer by reading safety articles, watching video presentations, participating in the Wings program and more. The problem is not with you, but with the portion of the pilot population that for whatever reason, does not work toward being safer. But that does not mean that there is nothing we can do. We can all talk about our efforts at being safer. A mention of that interesting article in an aviation magazine, an invite to attend a safety seminar or to view a webinar together can go a long way. Diplomatically and kindly pointing out a safety discrepancy in a pilot’s procedures and offering a positive suggestion can be effective. The same goes for noticeable issues with a pilot’s airplane. I have frequently asked my readers to become “Safety Evangelists.” That does not mean renting a tent and hosting a revival. It just means to speak up in support of safety and never miss a chance to advocate safer practices. We can all protect our stake in general aviation for being a strong advocate for safety.

broken image

The following article is reprinted from the NASA CALLBACK PUBLICATION #514 of November 2022.

A New Lease on Life

An experienced pilot’s guard and discipline were relaxed during a flight. Results could have been much worse.

■ I was flying home from work, low level over pasture, and failed to see power lines. I did not see the lines until I hit them. There was minor damage to the aircraft, damage to the power lines, and a fire was started from the downed lines. I have no injuries of any kind. I fly this route almost daily, and I think that because it was so familiar, I became complacent in my awareness of power lines when flying low. It was a beautiful, clear day, and I was distracted by the scenery. In the future, maintaining a higher altitude and being more alert of obstacles could eliminate the risk of this happening again.

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.

Most airplane crashes reflect most things having been done right followed by one or two or a brief series things of being done wring. Not so with this accident. The things that were done right compose a very short list with a very long list of errors. My blog this month talks about pilots who need to hear about safety. The individuals directly involved in this crash must be/have been members of the board of that club.

There were two pilot onboard the 1947 Beech 35 Bonanza when it crashed in Texas on March 6, 2020. One of the pilots died as a result of his injuries while the other suffered serious, life changing injuries.


NTSB Photo

The left seat was occupied by a 1300 hour private pilot, age 61 wo was seriously injured. The right seat was occupied by a 1200 hour flight instructor, age 65 who died as a result of his injuries. Neither pilot had an FAA medical certificate and no evidence was found that either had a current flight review. The private pilot had recently purchased the airplane and the CFI, a long-time friend, was asked to come in from New York State to assist in flying the airplane from the point of purchase to his home airport.


NTSB Photo

The NTSB report includes the following: "The airplane was recently purchased by the copilot. The day before the accident, a mechanic performed a pre-buy/annual inspection on the airplane, which had not been inspected in over 8 years, with no issues annotated in the maintenance records. On the day of the accident, the pilot and copilot departed for the cross-country flight of about 200 nautical miles to the
copilot’s home airport. The copilot reported a total of 54 gallons of fuel between the three fuel tanks (17 gallons each in the left and right tanks and 20 gallons in the auxiliary tank) at departure. He also reported that the generator was inoperative, and the flight was made with the retractable landing gear in the extended position. About 43 minutes into the flight, the fuel in the left-wing fuel tank was “depleted,” and the crew switched to the right-wing fuel tank with no issues. The pilot suggested they switch to the auxiliary fuel tank, and when the copilot switched to the auxiliary fuel tank, a total loss of engine power occurred."

Please note that his was a very complex airplane which had not had an annual inspection in more than 8 years. The annual inspection was performed in just one day with no issues noted in the maintenance records. Yet, the generator was known to be inoperative, hence the decision to fly with the landing gear extended.

The photo below from the post-accident examination shows a screwdriver being used to plug a rubber hose inside the engine cowling. Apparently, the mechanic performing the annual inspection did not notice it. I used to jokingly tell my A&P friends, "I don't know why you spend so much money on tools when all you need is ballpoint pen." Maybe that was not as much of a joke as I thought.


NTSB Photo (annotations added by GB)

The NTSB report continues: "The copilot switched the fuel selector to its “opposite position” and then switched it back to the right fuel tank but power was not restored. The crew attempted to restart the engine several times with no success, and the pilot transferred the flight controls to the copilot for a forced
landing. The copilot maneuvered the airplane through a canopy of trees, and the airplane then impacted the ground resulting in substantial damage to both wings and the fuselage."


NTSB Photo

And the NTSB report also includes the following: "During postaccident examination, the required fuel selector placard depicting the four selectable positions (RIGHT TANK, LEFT TANK, AUXILIARY TANK, and OFF) was not observed in the wreckage. The fuel selector was found with the handle between the OFF and LEFT TANK positions; in this position, fuel would not pass through the selector. Detents that
should have been felt at the four selectable positions were not noted as the handle was rotated through the fuel tank positions. The mechanic reported there were no issues noted with the airplane during the annual inspection performed one day before the accident and the mechanic classified the airplane as “complete.”

Here is an interesting note from the accident report: "None of the three fuel tanks contained observable fuel levels on scene. There was no evidence of fuel spillage, smell, or vegetation blighting at the accident site. The right-wing and auxiliary tanks were not breached. The left-wing bladder was punctured by a fracture in the inboard wing rib that likely occurred during impact."


NTSB Photo

Another interesting note from the accident report states: "Although the copilot reported that the fuel selector placard was installed, review of his cell phone records indicated that during the flight, he sent a text message to the previous airplane owner asking what position on the fuel selector was for the auxiliary fuel tank. Therefore, it is likely the fuel selector placard was not installed in the airplane. The text message also indicates the flight crew lacked an understanding of how to properly operate the fuel selector."

The NTSB Probable Cause finding states: "A total loss of engine power due to the flight crew incorrectly placing the fuel selector between fuel tank detents, which resulted in fuel starvation. Contributing to the accident was the lack of a placard on the fuel selector, the lack of obvious fuel tank detents in the fuel selector, and the flight crew’s lack of understanding of proper fuel selector operation."

This was a needless tragedy. A pilot lost his life and the family lost a valued member. Another pilot suffered life-altering injuries. A GoFundMe page posted by his wife asks for assistance with medical bills and states that he will no longer be able to operate his business. She also indicates that she will not be able to work since her husband requires 24-hour care. Reports also indicate that there was no insurance on the airplane and that it was purchased on a 7-installment plan. Someone will suffer a significant financial loss.

What lessons can we learn? It would take pages to list them all, but here are just a few. Beware bargain or too-fast annual inspections. Do not fly an airplane with a known discrepancy. Look inside the cowling yourself after an inspection; even us dumb pilots know that a screwdriver plugging a hose is not good. Know the fuel system on any complex airplane you fly. Do not fly an airplane that only has lap belts and not shoulder harnesses. A look at the photos above show that the cabin area is mostly intact. Perhaps had these two pilots been secured with shoulder harnesses, the severity of the injuries would have been much less.


Do you know any pilots who do not appear to prioritize safety? Please reach out to them with a gentle nudge. There is no need to be confrontational or accusing. Just find a way to work the issue into a conversation. Sometimes a simple question, "Are you sure you are comfortable with that?" can open a door to a discussion.

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.


NTSB Photo

The 48-year-old private pilot died in the crash of his American Aviation AA 5 on August 1, 2020 in Dunnellon, Florida. The NTSB report includes the following: "The pilot, who was not a certified airframe and powerplant mechanic, had recently reassembled the airplane, which had been in storage for 14 years. He told people that he was having problems with the fuel system and had an engine failure on a previous test flight. On the day of the accident, the pilot told his girlfriend that he was going to fly around the airport’s traffic pattern a few times but never returned. The airplane was located the following day about 1 mile west of the airport in heavily wooded terrain.


Graphic Source: NTSB Map showing accident location in relation to the airport

Postaccident examination of the engine revealed the engine-driven fuel pump was heavily corroded, and water was found in the carburetor. Debris was found in the fuel line that connected the auxiliary fuel pump and the engine driven fuel pump. Rubber debris was also noted in the hose, consistent with damage to the rubber hose lining during fitting installation. The auxiliary fuel pump switch was found in the ON position at the accident site, which was consistent with normal takeoff and landing operations. The pilot had purchased 23 gallons of fuel about 1 month and a half before the accident and, according to the tachometer, had flown only 1.55 hours since the last annual inspection. The fuel burn rate for the engine was about 5.2 gallons per hour, thus giving the pilot about 14 gallons or more than 2 hours of fuel on
board at the time he departed.


NTSB Photo

A review of maintenance records revealed that the airplane had not had an annual inspection—
as required by Federal Aviation Administration regulations—in almost 19 years prior to the
accident. The engine had not had an annual inspection for almost 23 years or been overhauled
in 23 years prior to the accident.

Though the pilot was mechanically inclined, he had no experience maintaining aircraft and was
not certified to do so. As a result, critical components that provided fuel to the engine were not
properly installed or inspected. This lack of maintenance resulted in operating with water in
the carburetor, corrosion on the engine driven fuel pump, and debris in the fuel system which impeded proper fuel flow to the engine and resulted in a loss of engine power while operating
at a low altitude in the traffic pattern."


NTSB Photo

The NTSB Probable Cause states: "A total loss of engine power due to fuel starvation as a result of improper installation and inspection of the airplane’s fuel system. Contributing to the accident was the pilot’s lack of certification and knowledge in aircraft maintenance."

The NTSB probable cause finding states: "The pilot’s loss of directional control during landing in gusting crosswind conditions that exceeded the airplane’s capability and his decision to attempt to takeoff from a field, which resulted in collision with a power pole/line and terrain."

"We don't know what we don't know" is a common expression but very true. This pilot, though generally recognized as being mechanically inclined, apparently did not know that he did not posses the knowledge to safely rebuild this airplane. I find similar problems often in my human factors work. A person highly skilled and knowledgeable in one area attempts to undertake a task in an unfamiliar area and it does not end well. Lesson to be learned, we should all do what we know but seek the counsel of experts for what we do not know.

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.

It's a clear but dark night and you are landing at an airport after the control tower has closed. You touch down normally and suddenly become aware that another airplane has also touched down, but on the opposite end of the runway and is closing rapidly at high speed. I cannot speak for the two pilots involved, but I would have experienced a PASS moment. (PASS=Pants Almost Seriously Soiled)

Each pilot swerved, fortunately in opposite directions, to avoid a head-on collision. A wing of each airplane made contact as the airplanes passed resulting in some damage but avoiding injury to either pilot. The airplanes involved were a Cessna 172 and an Aero Commander 500.


Annotations by GB

The NTSB accident report includes the following: "The private pilot of the Cessna was landing while the airline transport pilot of the Aero Commander was landing on the opposite runway during night visual meteorological conditions, after the airport control tower had closed. The Cessna pilot activated the runway approach lighting system and mistakenly believed that the green threshold lights indicated the direction for landing on the active runway. The pilot-controlled lighting system used a separate radio frequency from the common traffic advisory frequency (CTAF) at this airport. The Cessna pilot stated that he then “switched radio channels” and made “routine calls.” The Aero Commander pilot made radio announcements on the CTAF during each leg of the traffic pattern, announcing his location and intentions."

Warren Idaho Airport

Photo Source: NTSB showing Cessna 172 right wingtip damage.


Photo Source: NTSB Showing Underside of Right Wing

The NTSB accident report continues: "Contrary to the Cessna pilot’s belief that the green lights he observed indicated the active runway (and the one on which he intended to land), they denoted the location of the (displaced) runway threshold of the adjacent runway. During landing rollout, the right-wing tip of the Cessna contacted the underside of the right wing of the Aero Commander, which had landed on the opposite runway, resulting in substantial damage to the Cessna’s right wing."


Photo Source: NTSB Showing Underside of Right Flap and Aileron (view from rear) of Aero Commander

The NTSB accident report continues further: "The Cessna pilot reported that he did not hear any radio transmission from other aircraft operating at the time, and the pilot of the Aero Commander did not hear any radio transmissions from the Cessna pilot. Audio recordings of the CTAF frequency captured the radio transmissions made by the Aero Commander pilot (and other traffic) but did not capture any transmissions from the Cessna pilot. It is therefore likely that the Cessna pilot kept his single communications radio tuned to the pilot-controlled lighting frequency rather than change it to the CTAF as indicated in the airport/facility directory, which resulted in his communications not being heard by other pilots in the vicinity and his lack of awareness of the Aero Commander pilot’s position."

Cessna 182P Rate-of-Climb Table

Figure 1 Graphic Source: NTSB

Also included in the NTSB accident report is this: "A review of Federal Aviation Administration (FAA) automatic dependent surveillance broadcast (ADS-B) tracking data (see figure 1) revealed that the

The NTSB probable cause finding states: "The Cessna pilot’s failure to tune his radio to the common traffic advisory frequency, which resulted in a lack of awareness of the other aircraft operating at the airport. Contributing to the accident was the Cessna pilot’s lack of understanding of the airport lighting system."

I want to note here that two of the common accident causal factors are mentioned in the NTSB Probable Cause. They are lack of awareness and lack of understanding. Flying is serious business and cross country flying is very serious business. All pilots owe it to themselves, their families and all the rest of us stakeholders in GA to be diligent in our maintaining our aeronautical knowledge and our preparation for any and all flights. This accident is minor as aircraft accidents go, but tragedy was avoided by literally a few inches.

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

The Memorandum for Record submitted to the NTSB by the Cessna pilot makes for interesting reading. Click here to download it from the NTSB website.

There is a brief YouTube video that includes surveillance video of the actual collision. Click here to watch it on YouTube.

Books by Gene Benson

Check out publications by Gene Benson on All proceeds from book sales are used to help support the Safety Initiative. Click here to visit Gene's author page on Amazon.

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