Return to site

Vectors For Safety - July 2023

Safety Initiative Update

We Are Only as Good as Our Next Landing

This month's feature blog attempts to address the current epidemic of landing mishaps. We see daily accidents and/or incidents happing during the landing. While business aviation is also experiencing an increase in landing mishaps, we focus mainly on the smaller segment of general aviation airplanes.

New Episode of "Old Pilot Tips"

Our new Episode 9 of "Old Pilot Tips" is now available. The topic of this under one-minute video is the importance of doing an "Airspeed Alive" check early in the takeoff roll. Check it out here.

Planning a Flight to AirVenture?

A search of accidents that occur during July of each year always includes several that occurred either while enroute to, while operating at, or while enroute home from the big show. It is not too early to begin planning the trip. A good early step is to download, read, and study the 2023 EAA AirVenture NOTAM. Click here for the download from the EAA website.

Summer Flying Season is Here!

Our Avemco-sponsored program "Avoiding the Summer Flight Gotchas" has been updated and moved to a new, more interactive platform called Skillfull. Unlike other platforms we have used, Skillfull issues Wings credit immediately after course completion. Even if you have taken this course before, remember that the Wings credits expire after one year, so here is your opportunity to earn one credit for Basic Wings Topic 2 plus one credit for Advanced Wings Topic 2. Click here to visit the course. Also, we would welcome your feedback regarding the new Skillfull platform.

"Just This Once" Live Presentation

I had the pleasure of presenting the live version of the program to fifty pilots at the Canandaigua, NY airport on June 27. It was a true GA event with a spectacular T-hangar graciously provided for our use by Dennis Christiano, Sr. and a great complementary dinner provided by Josef's Artisan Meats and Vector Aviation Services. Webinars are great, but there is nothing like getting out and conversing with the FA community.

It was my Honor and Privilege

My good friend and colleague, David Pepple went west in March as I previously announced. It was my honor and privilege to say a few words at his memorial service in Maine on June 15. During the service, he was posthumously awarded the FAA's Charles Taylor Master Mechanic Award. RIP to a dedicated and knowledgeable aviation professional.

Avemco Insurance sponsors Gene Benson
Gene's Blog

We Are Only as Good as Our Next Landing

Justified or not, pilots are judged by the quality of their landings. A pilot might take off from a very busy airport with a complex departure procedure, navigate through challenging weather conditions, successfully manage an arrival into a congested terminal area at a peak traffic time, but make a hard landing with a bit of a bounce. The passengers will likely judge the pilot as being just marginally qualified to fly based solely on the landing.

Bad landings are forgotten rather quickly, providing no damage is done to the airplane or someone’s property. All past landings, good and not-so-good, are history. The most important landing is our next landing so let’s make it a good one.

Landings bad enough to make it into the NTSB database seem to fall into four categories. Those categories are gear-up, runway excursion off the side, runway excursion off the end, and loss-of-control after landing. Of course, there is some overlap between the categories but let’s look at the root causes of each type and some mitigation strategies.

We must note first that the incident or accident event had its roots some time before the airplane touched the surface. A good, stable, well-planned approach rarely ends in a bad landing.

Gear-up landings are very common. It is a rare day when the daily ASIAS report does not include at least one gear-up landing. Most of these turn out to be caused by failure of the pilot to extend the landing gear while very few result from mechanical failure. Some sort of distraction often precedes these events. Mitigation is to always use a before landing checklist or at least a mnemonic such as GUMPS. As in any landing, maintaining a stabilized approach also minimizes the chance of a gear-up event.

Runway excursions off the side often follow a crosswind landing that exceeds either the airplane’s or the pilot’s capability, most frequently the latter. The insistence on a stabilized approach is critical here since the inability to fly the stabilized approach is a big red flag warning of a bad landing soon to come. This often comes down to degraded pilot proficiency due to a lack of sufficient recent experience. Mitigation is to be as proficient as possible but even more important is to be realistic about proficiency. Landing proficiency can only be accomplished by landing an airplane. Simulation is great for much of what we do as pilots, but the general aviation simulators do not have the fidelity to accurately handle a landing. Planning can also play a role by always having an alternate airport in mind, especially one with multiple runways so that a landing can be made with a lower crosswind component.

Runway excursions off the end sometimes happen when a runway is contaminated with water, ice, or snow. Other times they occur due to a lack of planning and are too short for the existing conditions. Most frequently, they follow an unstabilized approach that results in touching down too fast or too far down the runway. Mitigation is again to fly a stabilized approach and execute a go-around if the approach becomes unstabilized. Along with this, reviewing the go-around procedure before beginning the approach is critical. Many fatal accidents happen during botched go-arounds. Mitigation also includes checking actual runway conditions prior to beginning the approach and to have a suitable alternate airport in mind.

Loss of control after landing overlaps somewhat with a runway excursion, but sometimes the airplane ends up damaged on the runway. This may be a ground loop in a taildragger or a roll over in a tricycle gear airplane. The most common denominator here is the crosswind. Mitigation again is flying a stabilized approach and having a suitable alternate airport in mind if the stabilized approach is not working out.

Adhering to these simple mitigation steps can go a long way toward making our next landing a good one.

broken image

Reprinted from NASA "Callback" Issue 521 June 2023

Unverified Assumptions

Although all ended well, this Flight Instructor overlooked a detail that quickly placed the aircraft and crew in jeopardy.

■ That morning, I met [my student], a private pilot to whom I am providing instrument instruction, at ZZZ1 airport. When I arrived, [the student] had already conducted a preflight inspection of the aircraft.… Unfortunately, I did not verify the fuel quantity in the aircraft and relied on the student to do so. The plan for this flight was to do the RNAV…approach into ZZZ2, go missed [approach], and then fly VFR back to ZZZ1. After the missed approach at ZZZ2 and upon reaching 3,500 feet, the engine quit without warning. I took control of the airplane, requested priority with ZZZ2 Approach, and turned toward ZZZ. I was cleared for the runway and landed…without further incident. We could not restart the plane in the air or on the ground.

There is some background needed at this point. Prior to this flight, I was the last person to fly this plane. As part of our standard practice, after the last flight, I requested fuel service from the FBO and asked that the plane be put away for the night. Assuming the FBO would honor my request, I left for the evening. When I arrived at the airport, my student had completed the preflight and confirmed there was fuel in the aircraft. I’ve flown with this student many times and found him to be a very competent pilot.… Accordingly, I did not have reason to think there was not enough fuel in the aircraft. When we started the plane, we reset the fuel totalizer for full fuel, so when the engine quit, I expected there to be nearly 40 gallons of fuel in the plane when it was, indeed, empty.
There are several lessons to learn here. As an instructor, you can never fully trust your student, even if he or she is a certificated pilot, and it’s important to verify all information. Another factor was expectation bias. As part of our standard practice, the aircraft is always put away with full fuel, and the FBO has never failed to honor this request. When I arrived at the airport, I expected the aircraft to have full fuel, and I expected my student to verify this for me. Another factor is that it is impossible to view the fuel gauges from the right seat on the Cessna Cardinal as they are on the left of the pilot side yoke, so I was unable to use them to verify the fuel state. In order to prevent a recurrence, I am going to suggest to the club that we standardize a way to measure the fuel and to make it a requirement to measure fuel before every flight. The aircraft’s fuel quantity is difficult to check visually since there is a spring-loaded cover over the fuel port. At the end of the day, however, I was the Flight Instructor and should have verified the fuel quantity before departing.

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.

ERA22LA190  NTSB Photos

Photo Source: NTSB


This crash involved a Citation 525B and occurred in April 2022 in New Jersey. The business jet ran off the end of 4552 ft. dry runway on a VFR day. There was a 70-degree crosswind at 12 knots gusting to 22 knots. There were no injuries, but the airplane built in 2020 was substantially damaged.

The NTSB accident report includes the following, "The pilot-in-command (PIC) of the business jet described that at the conclusion of the flight the second-in-command (SIC) would conduct the landing. The SIC briefed the approach and the PIC agreed. The tower cleared the airplane for the visual approach to runway 22 (4,552-ftlong), noting winds were 300° at 18 knots, gusting to 26 knots. The PIC told the SIC that if he did not feel comfortable with the approach to landing, he should voice his concern, and initiate a go-around or transfer control of the airplane to the PIC. The PIC also briefed the procedure for taking control of the airplane should any unsafe conditions be observed."


Photo Source: NTSB

The NTSB accident report continues, "The PIC further described that after turning final, the landing checklist was completed, and the airplane was established on a stabilized approach. The SIC noted that he would fly at a slightly higher speed due to varying winds and gusts. Just before touchdown, the airplane “encountered a gust of wind that resulted in a ground effect float.” The airplane then touched down “at Ref speed” and on what the PIC perceived to be the first third of the runway. Due to the float and wind gust upon touchdown, the PIC called for the controls with the intent to initiate a go-around or to bring the airplane to a stop. The PIC then decided not to commence a go-around due to the limited amount of remaining runway available, low airspeed, and time to initiate takeoff power. The PIC realized that the airplane would not come to a stop on the remaining runway, even with maximum braking applied, and the airplane overran the runway and came to a stop in a brook beyond the departure end. The forward portion of the fuselage was substantially damaged during the runway excursion. The PIC reported that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation. Review of airport surveillance camera footage showed that the airplane touched down beyond the midpoint of the runway."


Photo Source: NTSB

The NTSB Probable Cause states, "The flight crew’s failure to attain a proper touchdown point during landing, which resulted in an overrun of the runway and collision with terrain."

ERA22LA190 Excerpt from NTSB Pilot Operator Report

Excerpt from NTSB Pilot Operator Report

ERA22LA190 Excerpt from NTSB Pilot Operator Report

Excerpt from NTSB Pilot Operator Report

Regardless of statements made by the crew and the operator, airport surveillance video shows the airplane touching down with only about 1/4 of the runway remaining. The first video shows the airplane approaching the runway from the right and touching down. The second video shows the airplane attempting to stop with very little runway remaining, running off the end and being damaged. Click here to view the combined videos.

The operator's recommendations are valid for this class of airplane. The recommendation of using a personal minimums checklist is a good one for all pilots. But the obviously neglected point here comes from pre-solo flight training. If the airplane is not on the ground in the first third of the runway it is time to go around. The crew stated a belief that the airplane had touched down in the first third which is obviously not correct based on the video evidence. Once on the ground, the decision not to go around was probably the best option available at that point. If the airplane could not successfully execute a go-around from that point, an unsuccessful attempted go-around could have been catastrophic. But how did the pilot not realize how far down the runway they had floated before touching down? A common cognitive bias, part of the Bias Bundle Bomb, is called continuation bias. We are programmed to complete a task once it is begun. A decision to make a landing had been made. The brain filters out information that contradicts the decision. In this case, the brain may have filtered out the fact that the airplane had already passed the runway midpoint and was still airborne.

The lesson to be learned is to study airport diagrams to find an easily identifiable point along the runway, such as a taxiway, which is a good indicator of how far down the runway the airplane has travelled.

broken image

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.


ERA21LA268 Photo Source: NTSB

Photo Source: NTSB


This crash happened in Pennsylvania in May of 2021. The Cessna T210 was substantially damaged and neither the pilot nor the passenger received serious injury. In the pilot's own words, this was a textbook accident.

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."


Photo Source: NTSB

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."

The docket for this accident contains airport surveillance video of the crash. Click here to view the video.


Phot source: NTSB

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."

ERA21LA268 Pilot Narrative

Narrative from NTSB Pilot-Operator Report

ERA21LA268 POR-recommendation

Recommendation from NTSB Pilot-Operator Report

ERA21LA268 POR Additional Information

Additional Information from NTSB Pilot-Operator Report

The pilot, in his statements contained in the NTSB Pilot-Operator Report, shows an understanding of the issues that contributed to this crash.

The need to use the restroom is a likely causal factor in more accidents than we know. Many pilots have been strongly influenced to continue an approach or take other action that is contrary to safety due to this biological need. However, many pilots would be reluctant to admit that it influenced their decision. We all must follow what we have been taught and resist the temptation to deviate from what we know is safe "Just this once."

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

Not subscribed to Vectors for Safety yet? Click here to subscribe for free!