Happy New Year!
To all my subscriber, readers, and followers, I want to sincerely wish a very happy, prosperous, healthy, and safe 2024. I appreciate the emails and comments I receive from you and look forward to more interaction during the new year.
Human Factors Ground School-Live will run in January registration free!
I am sorry, but we have reached our registration limit for the January 2024 sessions. However, you may complete the form anyway so that we can contact you regarding future scheduling of the course. If you complete the form by following the link, below, we will offer you a complimentary enrollment even if the next running of the course is fee-based. I apologize for any inconvenience. Click here for complete information on GeneBenson.com.
New "Just this Once" video on Taxi and Ground Operations
The video illustrates how mishaps can happen not only in flight, but while during taxi or other ground operations when a pilot thinks, "It will be okay just this once." Click here to view the video on YouTube
Beware Structural Icing
It is easy to become complacent about structural icing when you have many hours flying in potential icing conditions without encountering serious icing. I know that because it happened to me. The event happened more than twenty years ago but forever changed my thoughts on flying in icing conditions. I recently posted the article on LinkedIn and here is the link. (You do not need to be registered on LinkedIn to view the article.)
New Online Course
The "Terrible Triad of Stress, Fatigue, and Medications" is now available as a free online course sponsored by Avemco Insurance. Completion of the course and the associated online quiz is valid or one credit, Basic Knowledge Topic 3 in the Wings program. Check it out here.
Safety Initiative Survey
Yes, I know that everybody is asking you to take their survey and I am not comfortable to ask my readers spend more time. But, it is important to keep the Safety Initiative relevant to those of you who do make the effort to be safer, but also to try and reached the unengaged pilots. With that being said, I humbly ask each of you to take take a few minutes and complete this short survey. All responses are anonymous and email addresses are not being collected. Click here to begin the survey.
Live, In-Person Presentation
If you are in range of Brockport, NY, I will be presenting "CFIT-A Fresh Look" to EAA Chapter 44 at Ledgedale Airpark (7G0) on January 16. The event is open to the public and valid for FAA Wings credit. Dinner begins at 6:30 PM EST (small donation requested) and the presentation begins at 7:30 PM EST. Hope to see you there! Click here for more information and to register.
More Live In-Person Events
I am pleased to announce that I will be presenting live at two more events after the January 16 event. On Saturday, February 17, I will be presenting "Just This Once" at Finger Lakes Regional Airport (0G7) in Seneca Falls, NY. and, On Saturday, March 23, I will be presenting "Double-D Danger" which addresses delayed decisions. More details on these events will be included in the February 1 issue of Vectors.
Mental Exclamation Point
When most pilots are asked to recall their most memorable flights, they will verbally paint a picture of a clear sky, smooth air, and great visibility to showcase beautiful scenery or notable landmarks. But the experiences we choose to share might not really reflect the most memorable flights. Any pilot who can count the decades of flying experience with a number greater than one probably has experienced at least one PASS event. Of course, PASS is an acronym for Pants Almost Seriously Soiled. (This would not be an aviation article if it did not include at least one acronym.)
Many PASS events enter our awareness as a mental exclamation point. Sometimes there are multiple mental exclamation points. A glance at an oil pressure gauge reading zero would perhaps be a single exclamation point while a sudden loud noise followed immediately by a spray of engine oil on the windscreen might produce three of four mental exclamation points.
In the world of human factors, those mental exclamation points would be called a startle event. The human brain would immediately begin a chain of events which will be partly determined by our physiology and partly determined by our previous experiences and training.
I will skip the twenty or more paragraphs necessary to explain the physiology involved and just say this. When we are startled, we experience several physiological changes, such as increased heart rate, blood pressure, muscle tension, and a surge of energy and alertness. This happens because our brain activates two systems: the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. The sympathetic nervous system prepares us for action by increasing our heart rate, blood pressure, and breathing. The hypothalamic-pituitary-adrenal axis releases hormones like cortisol and adrenaline that boost our energy and alertness. These responses help us to either fight back or run away from the danger.
Once our body is prepared for action, our previous experiences and training will play a major role in determining the action we will take. The brain must quickly decide whether to attack the problem or run away from it. As the sole pilot in a general aviation airplane, it is difficult to physically flee in most cases. We might have a parachute or the airplane might have a ballistic recovery system. But usually, our most viable option is to attack the problem and that is the almost immediate decision that the brain will make on our behalf.
Now comes the tricky part. The brain has decided that we will attack the problem, but it must reference all of our past experiences and training to decide the immediate course of action. In the absence of a definitive action recalled, the brain will rely on general experiences and an incorrect action might be called up. For example, numerous pilots have had very serious accidents following a cabin door popping open shortly after takeoff. The open door generally will not have a significant effect on the airplane’s flying characteristics nor on its performance. But there will be loud wind noise, perhaps a blast of very cold air, and maybe a passenger or two screaming. In the absence of specific training, the brain might decide that the immediate action should be to shut the door. Bad things can happen very quickly if the pilot attends to shutting the door rather than flying the airplane in this critical phase of flight. However, if the pilot has received training on the need to focus on flying the airplane during critical phases of flight and to ignore distractions, the brain will have access to better information on how to handle the situation.
Airline, business aviation, and military pilots spend many, many hours in very expensive simulators being trained in just about any emergency that could present itself. This is done to provide experience from which the brain can draw to initiate the most effective response in a very short amount of time. A diverse and strong experience background is built in a safe environment with extremely little risk.
Most pilots of small, general aviation airplanes do not have access to this level of training. These pilots face three main obstacles. The first obstacle is access. Though simulators representing small GA airplanes have had exponential improvement over the last two decades, there is still not widespread availability. The second obstacle is time. Since flying small GA airplanes is not usually a full-time job, devoting the many hours required to match the training the career pilots receive is not realistic. The third obstacle is cost. Training is costly whether done in a simulator or in an airplane. Most pilots of small GA airplanes do not have an unlimited budget to spend on flying and related expenses. If an owner-pilot is supporting an airplane’s cost of maintenance, hangar expense, fuel, insurance, and all the other things that go with that, there might not be much left over for training. With recent increases in the cost of all things aviation, even the pilot involved in an airplane partnership or flying club might not be able to commit a few thousand more dollars to training.
We need to find creative ways to enhance the pilot’s experience background while still leaving enough financial resources to actually do some flying. We need to discover methods that require minimal time and reasonable cost.
While nothing will match the value of experiencing startle events in a simulator, reading articles, watching videos, and taking online courses does require some time, but has little or no cost. The caveat here is that the activities chosen must be carefully selected. Remember the old joke, “If it’s on the internet it must be true.” The creators should be researched to make sure they are credible before participating in the activities. Reading or watching something that contains erroneous information adds that information to the experience background just as readily as does correct information.
The next step up is to use any sort of accurate simulation available. Even the most basic simulator apps for a PC can be valuable if used correctly. The ATDs and free-standing simulators add a level of realism, but also add another level of expense. Obviously, instruction from a skilled CFI in the simulator is optimum, but much can be gained by working in a small group of conscientious pilots. It can be fun and provide valuable experience background building.
So, in summary, a large experience background filled with pertinent and correct information is extremely valuable in following a startle event. That experience background can be enhanced by reading authoritative articles, viewing videos produced by credible sources, and training via simulation, either solo or in a small group. The greater our experience background, the more likely we are to keep the “ALMOST” in our future PASS events.
Reprinted from NASA "Callback" Issue 526 November 2023
Part 91 – Communication, Command, and Control
An unsuspecting Cherokee pilot experienced a dangerous control issue during the landing rollout. A classic, but preventable human factor contributed to the circumstances.
■ I was the pilot flying (sole manipulator of the controls) in the left seat. In the right seat was the acting Pilot in Command (PIC), as I was not current for passengers. I kept a slightly higher airspeed on short final due to wind conditions. Upon landing in winds that, at the surface, were reported as 12 knots, gusting to 17 with a 10-degree right crosswind, I found the aircraft to be difficult to control. It swerved a bit left and right. As I attempted to gain control, I found it nearly impossible to add left rudder when needed. Then, suddenly, the left rudder freed itself, and the plane swerved severely left, entering the grass momentarily before I turned back onto the runway. No damage was done. The acting PIC asked me, “What do you suppose happened there?” I answered that I believed we were both on the rudder pedals. He replied that he did, in fact, have right rudder applied. I suspect when he released right rudder pressure, the left rudder became free, and since I was applying significant pressure on it, this caused the [excursion]. I had [briefed] with the PIC before the flight, indicating if he said, “My controls,” that I would relinquish them immediately. However, he had not indicated to me that he was planning to use the rudder during our landing, nor did he inform me he was on the rudder. I have learned that if I have an acting PIC with me and I am the pilot flying, I must be more specific about communication and use of the controls.
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
Four people died in this crash of a Piper Saratoga in Houston Texas. The private pilot experienced a startle event when the forward baggage door open shortly after the airplane rotated for liftoff near midfield. The airplane climbed to about 100 feet above ground level and began a left turn. The airspeed decreased from 84 knots to 1 knot as the airplane entered a stall/spin.
NTSB Photo
The NTSB accident report includes the following: "The postaccident investigation determined that the forward baggage compartment door separated during the airplane's impact with terrain. The door latch mechanism was found unlatched, and its corresponding key-lock assembly was unlocked. No anomalies were found with the forward baggage door latch mechanism, key-lock, or door frame latch catch/receptacle that would have precluded the door from being properly secured before the flight. Based on the witness descriptions and the physical evidence, it is likely that the pilot failed to ensure that the forward baggage compartment door was closed, latched, and properly secured during his preflight inspection. The pilot likely became distracted by the open baggage door and, as a result, did not maintain adequate airspeed while on the downwind leg, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall at a low altitude."
NTSB Photo
The NTSB probable cause finding states: "The pilot's failure to maintain adequate airspeed after becoming distracted by the open baggage door while operating in the airport traffic pattern, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall at a low altitude. Contributing to the accident was the pilot's failure to ensure that the forward baggage compartment door was closed, latched, and properly secured during his preflight inspection."
A startle event often requires urgent decision making. The likelihood of making a good urgent decision can be increased by building a strong experience background in how to react to certain events. The pilot's reaction to a door of any kind opening unexpectedly can be easily simulated during training, either in-flight or in a simulator. Even reading scenarios such as this one can help build that experience base.
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.
Actual Accident Airplane-Photo Source Unknown
The builder/private pilot of this kit-built SQ 2000 died in the crash which occurred in Pierre, South Dakota. The left gull-wing door popped open shortly after takeoff likely producing a startle event for the pilot resulting in a loss of control. The NTSB accident report includes the following: "During the airplane’s initial takeoff climb, two ground witnesses observed the left “gull-wing” entrance door to be open. They reported that when the airplane was about 50 feet above the ground, it entered a series of approximately four pitch oscillations. During the last pitch-down oscillation, the airplane impacted the runway at a steep descent angle and then skidded forward about 500 feet, coming to a stop near the right side of the runway. A postimpact fire ensued."
NTSB Photo
The NTSB probable cause states, "The airplane's entry into a pilot-induced oscillation and the pilot’s loss of airplane control during the takeoff initial climb. Contributing to the accident was the left entrance door opening in flight for undetermined reasons."
Again, a startle event leads to a preventable accident. As described in the previous listed accident, developing a solid experience background can go a long way in preparing the pilot to handle a sudden and unexpected situation.
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.
The 56-year-old pilot received minor injuries and the passenger was seriously injured in the crash of a Piper Turbo Lance in Idaho. The accident sequence began with a startle event, loss of visual reference during a night takeoff in mountainous terrain.
The NTSB accident report includes the following: "During takeoff from an airport in a narrow valley on a dark night, the pilot lost sight of the lights around the runway environment while he attempted to engage the autopilot to assist in his navigation of the pre-programmed route. When he determined that his first attempt to engage the autopilot had not been successful, the pilot repeated the steps of the autopilot engagement process. As the pilot was completing his second attempt to engage the autopilot, the tower air traffic controller asked him if he was making a turn to the downwind leg. About the same time, the terrain warning signal on one of the airplane’s global positioning system units began to sound. The pilot then realized that while he was trying to engage the autopilot, the airplane’s heading had drifted and the airplane was headed toward rapidly rising terrain. Because it appeared to the pilot that he would not be able to avoid that terrain, he slowed the airplane and performed an emergency landing on “rough and comparatively level” snow-covered ground."
Photo Source: KPVI.com
The NTSB probable cause finding states, "The pilot's failure to maintain course heading and terrain clearance because he was distracted by efforts to engage the autopilot shortly after takeoff on a dark night in mountainous terrain."
Graphic Source: NTSB
The NTSB accident report also includes the following: "When the pilot completed the RECOMMENDATIONS section of the NTSB Form 6120.1 (Pilot/Operator Aircraft Accident/Incident Report), he made the following two recommendations: 1. Do not depart an airport in mountainous areas when single pilot and mountainous terrain is within 5 nautical miles of the airport; 2. Do not troubleshoot discrepancies within 5 nautical miles of the terrain, instead treat any discrepancy as an inoperable item."
Perhaps a simpler and more direct to state the pilot's #2 recommendation is to make flying the airplane the main priority regardless of what else is happening.
We all need to be spring loaded that in the first couple of seconds after a startle event, we direct our attention to airplane attitude, altitude, and airspeed. We should immediately follow that by an evaluation of heading as it relates to obstacles or terrain in the vicinity. Once the airplane is under control and there is no immediate threat of collision with obstacles or terrain, we can attend to addressing whatever problems are present.
Click here to download the accident report from the NTSB website.
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