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Vectors For Safety - January 2025

Safety Initiative Update

Q1 2025 to Focus on Landings

Nearly half of all general aviation accidents occur during the landing phase of flight. With that in mind, our focus for the first three months of 2025 will be on making better and safer landings.

New Free Online Course for Wings Credit

In keeping with our focus on landings, we have a new online course, "The Psychology of Approach and Landing" takes a human factors approach to the subject. Course completion, including the quiz, is valid for 1 credit for Basic Knowledge Topic-1 and one credit for Basic Knowledge Topic-3. The course is provided free of charge courtesy of Avemco Insurance. Click here to visit the course.

New Edition of "Old Pilot Tips" is available.

Episode #26 deals with the go-around. Pilots are frequently told to execute a go-around is anything does not look right on the landing approach. But many fatal crashes happen during botched go around attempts. This video, in less than one minute, provides some valuable tips on how to be better prepared for a go-around. The video is sponsored by Avemco Insurance and is narrated by Gene Benson. Click here to view it on YouTube.

Virtual Presentations for any Size Group Available for Free!

Flying Clubs, Pilot Associations, CAP, QB, 99s, FBOs, Flight Schools can all have no-cost virtual presentations courtesy of Avemco. Wings credit is available for all presentations. Virtual presentations can attended by members of your group wherever they may be, can be projected to a group at a central facility, or both simultaneously. Click here to download my updated presentation catalog. Email me at gene@genebenson.com for questions or to discuss scheduling.

Avemco Insurance sponsors Gene Benson
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Memory

Memory can be defined as the brain's ability to retain information and voluntarily recover it when needed. It is what enables us to remember facts, ideas, feelings, and relationships between concepts, along with other stimuli that has happened in the past. While the hippocampus is the main part of the brain related to memory, there are a number of brain areas used in memory. Memory is one of the functions most commonly affected by aging.

Games and activities can help activate and strengthen memory and other important cognitive skills. Activities that stimulate certain neural activation patterns can help strengthen the appropriate neural connections and establish new synapses which may be able to reorganize and/or recover weakened or damaged cognitive functions.

Memory can be thought of as consisting of short term memory, working memory, contextual memory, non-verbal memory, and long term memory.

Memory may not be the first of our cognitive abilities to decline, but it is often the first to be identified. For more information on memory, including details of the different forms of memory, click here to download the free "Aging Pilot Report."

Gene's Blog

We Must Do Better

The number of accidents and incidents that involve general aviation airplanes that occur during the landing phase of flight is nothing short of astounding. The recently released 34th AOPA Air safety Institute Reort (formerly the NALL report) covers the most recent year for which complete data is available which is 2022. The report shows 146 accidents occurred during descent and approach including 33 fatal accidents. It also shows 346 landing accidents of which 8 were fatal. Taking the totals, we see 492 accidents, including 41 fatal accidents, occurring between the time the airplane begins descent and ends the takeoff roll.

Note that this only considers mishaps involving airplane damage or personal injury that meets the threshold of being considered an accident. Most certainly the number of mishaps involving lessor damage and therefore listed as an incident is several times higher. We of course have landing mishaps that involve little or no damage and go unreported. We recognize that whatever these total numbers are, they are a very small percentage of the total number of landings made during the same time period. There is a wide variety of probable causes listed by the NTSB for these accidents, but they mostly involve an operational error or judgement error on the part of the pilot.

The accidents that result in a destroyed or heavily damaged airplane can result in a loss of will north of $100K. When serious injuries or a fatality are involved, settlements can run into the millions, perhaps exceeding insurance limits. Easily overlooked, unless you are the pilot or airplane owner involved, is the cost generated by these mishaps. Many seemingly minor events result in a prop strike. Typically, a prop strike requires a complete engine teardown and inspection, which can cost anywhere from $15,000 to $30,000. Then there is the cost of a prop repair or replacement. A new prop for a Cessna 172 will run in the $8,000 range while a new constant speed prop for a Cessna 210 can tickle $16,000. A very common landing mishap for the retractable gear crowd is the gear-up or gear collapse landing. According to AOPA, each one of those incidents will cost around $70,000. We might not think much of a runway excursion that damages a runway edge light or two, but the pilot or airplane owner will be responsible for having the lights replaced at $1,000 to $2,000 per light plus installation. Take out REILs and expect a bill for around $16,000 plus installation. Sure, insurance will cover the cost minus your deductible, but there might be an unpleasant surprise at policy renewal time. If you do not own the airplane and you didn’t think renter’s insurance would be necessary, get out the checkbook for even a minor mishap. Beyond the out-of-pocket cost is the significant down time for the airplane. Weeks or even months are sometimes the case.

We can and we must do better. It is no surprise to see soaring costs associated with general aviation flying. The landing accidents, among others, are quietly driving up the cost of flying and making it unattractive or completely unaffordable for many. As insurance companies pay these claims, they recover their costs through our premiums. As the older and more affordable GA airplanes are damaged beyond realistic cost to repair, they leave the fleet short of one more affordable airplanes.

All that being said, we will focus primarily on landings at least through the first quarter of 2025. Watch the Vectors website for articles, videos, and more to help pilots make better and safer landings.

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.

Anyone who has followed my writings (or rants) over the years knows that I am I am staunchly opposed to taking off or landing with a tailwind unless it is absolutely necessary. This mishap involved just minor injuries to the pilot but substantially damaged the Maule MX7 that he was flying. Airplane damage was significant enough to classify the mishap as an accident. It occurred at the Bozeman Yellowstone International Airport on July 4, 2023.

The image below is an excerpt from the Form 6120 Pilot/Operator Report submitted to the NTSB.

WPR23LA254 Pilot/Operator-Report Excerpt

The NTSB Report includes the following, "The pilot of the tailwheel equipped airplane reported that during landing, the airplane’s tail swung to the right and the airplane veered to the left. The airplane struck a runway edge cone, then exited the turf runway and nosed over. The left wing, both wing struts, the vertical stabilizer, and the rudder were substantially damaged. The pilot said there was a 6-10 kt left quartering tailwind when he exited the airplane. He reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation."

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NTSB Photo

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NTSB Photo.

The NTSB probable cause finding states, "The pilot’s failure to maintain directional control during landing with a quartering tailwind, which resulted in a runway excursion and nose over." Far too many accidents, some of them fatal, have occurred during both takeoffs and landings with a tailwind. My strong recommendation is to always avoid tailwind takeoffs and landings unless they are absolutely necessary.

The pilot supplied the following information (shown in graphic below) in the NTSB 6120 form in the Safety Recommendation section.

WPR23LA254 Pilot/Operator-Report Excerpt

Wind direction relative to the landing runway is always important, but in a tailwheel equipped airplane it is critical. The pilot's comment regarding the tower not informing him that the wind had switched should be a reminder to all of us to always give the airport wind indicator a good look when in the pattern and again while on final approach.

KBZN Approach end of paved and turf runways

KBZN Approach end of paved and turf runways (Google Earth)

The 67-year-old private pilot reported having 3,250 total flight time including 57 hours in this make and model. He had both single-engine and multiengine ratings as well as an instrument rating. Unusual for a private pilot, he reported having type ratings in the CE510S and EMB500 and training to operate the MU2B-20. He had a current class 3 medical certificate and current flight review.

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

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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 occurred in Pennsylvania in May of 2021 and involved a Cessna T210. The NTSB accident report includes the following, "The pilot reported that during an aerial observation flight he finished the survey block and decided to land at an airport nearby to use the restroom and get fuel. He reported that he had never been to the airport, so he chose to enter the traffic pattern “a little high” as he noticed terrain around the airport. On final approach, the pilot executed a forward slip maneuver to reduce “excess airspeed and altitude” and once over the runway, he entered the landing flare, and the airplane floated down the runway about 500 ft. Subsequently, the airplane touched down nose first and entered a porpoise, which resulted in the collapse of the nose landing gear and a runway excursion through the end of the runway. The airplane sustained substantial damage to the fuselage and left wing."

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NTSB Photo

The NTSB report continues: "The passenger on-board, who was the sensor operator, reported that while on short final approach, he observed the airspeed to be 125 knots, with a descent rate of 1,250 feet per minute, and the airplane subsequently touched down ”halfway down” the runway. He then described that the airplane began to porpoise, and the pilot retracted the landing gear and applied full power, however the airplane ”hit the ground” again and slid off the runway."

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NTSB Photo

And the NTSB probable cause states,: "The pilot’s unstable approach and delayed go-around attempt, which resulted in a porpoised landing, a nose landing gear collapse, and runway excursion."

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NTSB Photo

We always like to look a bit deeper into the causal factors of crashes. The 21 year-old commercial pilot with 867 hours has done a reasonably good job of sorting that out for us. The next three graphics show what he had to say in the NTSB Form 6120.

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It is refreshing to see this young pilot actively evaluating the circumstances and possible underlying causes of this crash. He accepts responsibility for his part and points out what changes might be made to help prevent future crashes.

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.

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NTSB Photo

This gear-up landing occurred in Fort Worth, Texas on January 7, 2024. Since there was substantial damage to the airplane, it is classified as an accident. Neither the private pilot undergoing instruction nor the flight instructor was injured. The NTSB accident report includes the following, "The flight instructor reported that he and the private pilot receiving instruction had just completed their seventh landing of the morning. The private pilot reduced the throttle on downwind and the landing gear warning horn sounded so he increased the throttle and continued in the traffic pattern. The flight instructor prompted him to extend the flaps and the student stated that he would extend the landing gear. They “confirmed 3 green,” which would indicate that the landing gear was down and locked. During the landing flare, “no gear warning horn was alarming,” but as they got closer to the ground the instructor observed sparks out of the left window. The airplane slid on the runway, came to rest upright, and sustained substantial damage to the lower fuselage longerons."

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NTSB Photo

The NTSB accident report continues, "The Federal Aviation Administration (FAA) inspector completed an extensive examination and functional testing of the landing gear system. With the airplane on jacks, he cycled the landing gear at least six times and determined the landing gear, warning annunciations and aural alerts operated per the procedures in the airplane’s maintenance manual and there were no anomalies found."

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NTSB Photo

The private pilot under instruction held single-engine land and multi-engine land ratings. The 19-year-old reported having 142.8 total flight time including 7.6 hours in the preceding 24 hours. The 31-year-old flight instructor held a commercial pilot certificate with ratings for single-engine and multi-engine land and a flight instructor certificate also valid for single-engine and multi-engine airplanes. He reported having 1081.8 total flight hours including 121.7 hours in this make and model. He reported having flown 7.9 hours in the preceding 24 hours.

The NTSB probable cause states, "The pilot’s failure to extend the landing gear and the flight instructor’s lack of recognition and inadequate remedial action, which resulted in a gear up landing."

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NTSB Photo

The private pilot under instruction and the flight instructor both stated that the gear was verified to be down yet it apparently was not. The damage to the underside of the airplane indicates that the gear was fully retracted during the landing. The FAA's thorough test of the landing gear and its indication and warning systems showed correct operation post-accident. The FAA reached the logical conclusion that the crew failed to extend the gear prior to landing.

Looking at this through a human factors filter, several factors might have been involved. We must first consider fatigue. This was a night conditions instructional flight that began earlier than 5:00 AM local time with both individuals having flown nearly eight hours in the previous 24 hours. Taking and receiving flight instruction is demanding on the human body and mind. This was reported to be the eighth landing of the instruction session.

Fatigue can increase vulnerability to other factors including complacency. Information submitted to the NTSB by the flight instructor, the gear-up landing occurred on the eighth landing of ten planned landings. Complacency is composed of familiarity and expectancy. Both pilots had flown the PA44 enough to become familiar with it, including the fact that when the landing gear was selected down, the system worked as it should and the gear would extend and lock. That familiarity breeds expectancy that each time the landing gear is selected down, it will extend and lock. A plan to conduct ten consecutive landings in the same traffic pattern at the same airport probably was an open invitation for complacency.

Perhaps some fatigue and some level of complacency ushered in continuation bias. This cognitive bias tells us to complete a task once it has begun and it can cause the brain to filter out evidence that indicates the task should be abandoned. In this case, with both pilots feeling some fatigue and perhaps wanting the session to end, it could have caused both pilots to see indications incorrectly and not perceive the gear warning.

I realize this scenario may seem like a stretch and that many will conclude that the crew simply forgot to extend the gear and then tried to blame their error on a mechanical failure. Maybe, but my experience in studying the psychology involved leans toward believing that they fell victim to these human factors and really thought that they had extended the landing gear.

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

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