Elected to S.A.F.E. Board
I am honored to announce that I have been elected the the board of Directors of S.A.F.E. (safepilots.org). I am looking forward to helping lead this great organization as it continues to grow and make important contributions to aviation safety.
Episode 21 of "Old Pilot Tips" is Available!
Episode 21 of "Old Pilot Tips " provides a reminder of the importance of the stabilized approach and shows where to learn more about this critical concept. Click here to view Episode 21 on YouTube. The "Old Pilot Tips" series is sponsored by Avemco.
New Episode in the Essential Vectors" series!
The next episode of our "Essential Vectors" series, sponsored by Avemco, has been released. "Windshear Essentials" In this nine-minute video, we take a brief overview of low-level windshear. We look at the dangers associated with this phenomenon as well as common windshear producers. We also see some examples of the effects of windshear, and some strategies to avoid, recognize, and remediate windshear effects. Click here to watch the video on Youtube.
Thanks to Two Great Audiences!
I had the pleasure of conducting two live seminars in June. On June 1, I presented "Combatting Mental Inertia" to the NY-NJ Section of the International 99s in Binghamton, NY. They were excellent hosts and the lively discussions during and following the presentation were great. On June 13, I presented "Help! My Brain is trying to Kill Me" the the Shelby County Aviation Association in Alabama. That one was a virtual presentation to the group gathered in a large hangar. They had excellent AV equipment to project onto a 20 foot screen and provide great sound quality. They even had a camera set up allowing me to see the audience. A wireless microphone was taken to attendees to who wanted to participate in live discussion. Thanks to both groups for inviting me into your organizations!
Flying to AirVenture?
If so, enjoy this epic aviation event but please take all reasonable safety precautions. Every year, there are several crashes involving pilots either enroute to, operating at, or returning from Oshkosh. Please conduct due diligence regarding becoming familiar with the unique traffic procedures, weather, aircraft performance, and fuel. A good refresher on summer operations might our free, online course, "Avoiding the Summertime Gotchas." Click here to visit the course.
Planning an Aviation Event?
I have updated my presentation equipment and am open to conducting both live, on-site and virtual events. If you have an upcoming event and would like to have me deliver one of my presentations, please contact me at gene@genebenon.com. Click here to download my current presentation catalog.
The following is reprinted from the August 2021 Issue 499 of the NASA CALLBACK series.
Anatomy of an Unstable Approach
This private pilot chronicles an inadvertent oversight and subsequent efforts to compensate for it. Results were an unstable approach and aircraft damage.
■ Due to the proximity of trees on the downwind leg of the traffic pattern, I inadvertently stayed above standard traffic pattern and approach altitudes. [During the] final turn, my altitude remained higher than a stable approach required. In an attempt to descend quickly, I deployed the speedbrake to increase rate of descent on short final, which steepened the descent and increased the airspeed.… Sink rate and airspeed remained higher than required for a stabilized approach, resulting in a hard landing involving both main gear and the nose gear contacting the runway and a subsequent bounce. On the second contact with the runway, the nose gear collapsed, and the aircraft slid down the runway center.
Miscellany
I read most of the NTSB accident reports. Now that 2024 is half over, I thought it might be a good idea to take another look at the accidents for 2023, especially looking for any that I had missed. I searched the NTSB database for accidents involving airplanes that were engaged in Part 91 general aviation operations. Setting the search to include only accidents with completed investigations that resulted in fatalities and found six. I followed that those with completed investigations that resulted in serious injuries and found forty-eight. We must note that many accident investigations require nearly two years to be completed so the most serious or most complex investigations are still “in work” as the NTSB puts it. The calendar year 2023 shows that, as of this writing, 187 in work fatal accidents and 77 in work accidents that resulted in serious injury.
The following are a few of the 2023 accidents with completed investigations that I believe are noteworthy. If you are a regular reader of "Vectors," you will recall that each of these kinds of accidents has been previously discussed. All of the information provided is taken from the respective NTSB accident report.
Another Seat Latch Related Crash WPR23LA337
In New Mexico on August 25, 2023 the pilot of a Cessna 195 apparently failed to secure the seat's position prior to beginning takeoff. The seat slid aft on the seat rails, and the pilot could not reach the rudder pedals. He reduced engine power and stretched to reach the brakes, however, he no longer had forward visibility. The airplane drifted to the right, and then to the left of the runway. The pilot braked hard, and the airplane nosed over resulting in serious injury to the pilot and substantial damage to the airplane. Click here to download the accident report from the NTSB website.
Another Cabin Door Unlatched ERA23LA314
This accident involved a Mooney M20R. In Tennessee on July 26, 2023, the pilot and the flight instructor were climbing out after departing from the airport when the cabin door suddenly opened. The flight instructor tried to close the door but could not get it closed properly. The pilot subsequently returned to the airport to land. During the landing approach, the pilot was distracted, flew too low, and the airplane contacted several approach lights short of the runway threshold. Both the pilot and the CFI were seriously injured. Click here to download the accident report from the NTSB website.
Another Passenger into a Prop WPR23LA207
The pilot of the Cessna 182Q reported that on a night landing the airplane touched down smoothly on the main landing gear. During the landing roll, when the nose gear touched down, the airplane’s roll out became rough and bumpy. When the airplane came to a stop, the pilot and passenger discussed that they probably had a flat nose wheel tire. Subsequently, the passenger exited the airplane to examine the nose wheel tire and observed it to be flat. The pilot told the passenger to keep clear and then attempted to taxi clear of the runway. However, at a high-power setting, the airplane only moved a few feet, and the pilot elected to discontinue the taxi. The pilot was deciding what his next move would be when the passenger approached the airplane from the front. The pilot tried to warn the passenger but subsequently, the propeller struck the passenger and resulted in a serious injury. Click here to download the accident report from the NTSB website.
Another Pilot into a Prop CEN23LA186
This accident happened on May 6, 2023 in Oklahoma. The pilot of a Beech F33A stated that after he started the airplane engine, he realized that the wheel chocks were still in place on the nose landing gear tire. He set the parking brake and exited the airplane with the engine still running. As the pilot removed the chocks, they inadvertently hit the propeller and pulled his arm into the propeller arc. The pilot sustained a serious injury to his right arm. Click here to download the accident report from the NTSB website.
Low Flying (Again) WPR23LA259
This accident happened on June 24, 2023 near Las Vegas, Nevada. The pilot of the AVIAT A-1B reported that he intended to land on a dry lakebed behind a model that was being photographed and create a ‘wall of dust’ using the airplane for a photograph. During the landing roll, the pilot stated he was moving too fast to stop before reaching the model and elected to execute a go-around. He then returned to the lakebed and landed, where he saw that the model had been seriously injured. According to the photographer, he and his model had been approached by the pilot, who offered his airplane as a backdrop for the photo shoot. After taking several photographs near the airplane, the pilot offered to overfly the model for additional photographs. The pilot flew over the model twice, and on the third flyover, the airplane was lower than the previous passes and the airplane’s left wing struck the model in the back of the head causing serous injury. Click here to download the accident report from the NTSB website.
Flight into a Canyon (Again) CEN23LA263
This accident involved a Cessna 182G and resulted in serious injury to the pilot and three passengers. It happened in Colorado on June 23, 2023. The pilot reported that she had been checked out in the accident airplane that morning and this was only her second flight in the same type. She stated that she and three passengers were sightseeing in a canyon that began to narrow. As the flight progressed, she was unable to climb out of the canyon and stalled the airplane. During the stall recovery, the airplane impacted trees and terrain; a postcrash fire ensued and the airplane was destroyed. 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.
It is not uncommon to read a report in which a pilot entered IFR conditions, suffered spatial disorientation, lost control of the airplane, and crashed. Many of these crashes involve a pilot who was instrument rated but had a level of proficiency that was not adequate for the conditions. On occasion, we find a report of a non-instrument rated pilot deciding to embark on a flight in instrument conditions and experience a bad ending. In this accident, a non-instrument rated pilot allowed external factors to produce a fatal decision. That decision was to depart into instrument conditions that included precipitation and convective weather.
NTSB Photo
The crash occurred in January 2023 in Georgia. The non-instrument rated, 203-hour, 43-year-old private pilot died in the crash of a Piper PA-28-180. The NTSB accident report includes the following. "According to fixed base-operator (FBO) personnel at CNI, about 1600 on the day of the accident the pilot arrived at the airport via rental car and requested that his airplane be fueled. The FBO personnel were unable to do so at that time due to heavy rain and lightning nearby."
NTSB Photo
The NTSB report continues, "FBO personnel reported that they had a discussion with the pilot on his plan to take off in poor weather and fly at night. The pilot stated that “after the rain passes it should be fine right?” The pilot further stated that he had an international flight scheduled to Europe the following day from the Washington, DC, area and wanted to leave as soon as possible. The staff reported that after further discussion, the pilot agreed for them to book him a hotel in the area. The staff also provided the code to the airport gate should he want to arrive in the morning before the FBO opened. The pilot subsequently left the airport in the rental car. Fuel records showed that, later in the evening at 1954, the pilot returned to the airport after the FBO had closed and, via self-service, added 27 gallons of 100-low lead aviation fuel to his airplane."
NTSB Photo
The NTSB report continues: "Furthermore, the pilot told the airport staff that he needed to return home the evening of the accident, because the next day he was scheduled to take an international flight to Europe. Despite leaving the airport after he had arrived for the flight and having a hotel room booked for him by the airport staff, he returned later in the evening after the staff had departed, refueled the airplane himself, and took off. The pilot’s aeronautical decision making to depart was likely influenced by his stated desire to get home and make an international flight the next day. According to the FAA Airplane Flying Handbook, this type of influence on decision making can be characterized as “get-home-itis” and is a common external pressure pilots are trained to be cognizant of during preflight."
Also included in the NTSB report: "According to Federal Aviation Administration (FAA) ADS-B flight track data, at 2005 the airplane departed runway 23 at CNI. The airplane flew on varying headings towards the eastnortheast and continued to climb for about 10 minutes, reaching a peak altitude of about 7,200 ft mean sea level (msl). In the final two minutes of the flight, the airplane began to descend followed by a series of tight turns before the airplane entered a rapidly descending spiral turn. The airplane’s final position was recorded at 2017:32, about 0.15-mile south of the accident site at an altitude of about 2,000 ft msl."
NTSB Graphic
The NTSB probable cause finding states: "The pilot’s decision to initiate a visual flight rules flight into night instrument meteorological conditions, resulting in a loss of control in-flight due to spatial disorientation. Contributing to the accident was the pilot’s lack of qualifications and experience in night instrument meteorological conditions."
External factors can be powerful. When something such as catching an international airline flight or anything else that is very important is involved, it is a good idea to always have a plan "B" to remove the pressure to go. In this case, the pilot had a rental car. The internet says that the driving time from the pilot's location at the Concord, NC airport to the Atlanta Airport, presumably the departure point for his international flight, would be about four hours. The report stated that he arrived at the Concord, NC airport around 4:00 PM. A check of the weather would have shown that VFR flight was not prudent, but ample time was available to drive to home or to the Atlanta airport to make the next day departure. Had he chosen driving as his Plan "B," the crash might have been avoided.
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.
We have all heard the old saying about assuming. but when it comes to our flying, it can do much more than to make us seem like that animal that rhymes with "pass." The pilot/owner of a Piper PA28-140 made an assumption about maintenance being completed and it cost the life of himself and his passenger. The crash happened in Virginia in January of 2023.
NTSB Photo
The NTSB accident report includes the following: "Six days before the accident, the pilot brought his airplane to a mechanic, as it had an excessive engine rpm drop during a run-up magneto check. The mechanic changed some spark plugs but did not have a chance to run the engine. Three days before the accident, the pilot arrived at the mechanic’s hangar and performed a ground run of the engine on the ramp area near the mechanic’s hangar so the mechanic could listen to the engine. As soon as the pilot ran the engine, the mechanic knew that the new spark plugs did not correct the problem as the engine was “skipping.” The pilot shut down the engine and the mechanic informed the pilot that the airplane was not to be flown until he could investigate further, and he would most likely be able to do it the following week. The mechanic later moved the pilot’s airplane from the ramp in front of his hangar, into the pilot’s hangar, as bad weather was forecast. The mechanic added that he had not completed the maintenance on the airplane and that the pilot did not contact him before departing on the accident flight to see if the maintenance had been completed."
NTSB Photo
The NTSB accident report also states: "Postaccident Examination of the wreckage revealed that the hold-down nuts on both magnetos were only finger tight. Some rotational damage was noted on both propeller blades. No other preimpact mechanical malfunctions were identified. Due to the combination of black smoke that the witness observed trailing the airplane, the limited rotational damage signatures that were observed on the propeller blades, and the only finger tight magneto hold-down nuts that were found during the postaccident engine examination, it is likely that the loose magnetos detrimentally affected ignition, which resulted in a partial loss of engine power. Given that there was a known, unresolved maintenance issue that existed prior to the flight, had the pilot positively affirmed the airplane’s airworthy condition with the mechanic prior to the flight, it is likely the accident would not have occurred. Additionally, the witness description of the airplane’s final descent, the airplane’s calculated speed during it’s final maneuvering, and the lack of a horizontal debris field observed at the accident site suggested that the airplane entered an aerodynamic stall before it impacted the ground."
NTSB Photo
The NTSB probable cause finding states: "The pilot’s decision to fly the airplane without confirming it had been released from maintenance, which resulted in a partial loss of engine power due to loose magnetos. Contributing to the outcome was the pilot’s failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall."
We should remember three things whenever the airplane undergoes maintenance. First, always verify that the work has been completed and signed off in the aircraft logbooks. Second, complete a thorough preflight inspection and before takeoff checklist, including engine run-up before departing. Third, after takeoff, spend a few minutes in close vicinity to the airport to facilitate a safe return if something seems amiss.
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.
Accident Airplane
This crash of a Beech M35 Bonanza happened in Arkansas in January of 2023. The 43 year-old commercial pilot with 1765 total flight hours including 377 hours in this make and model, died in the crash.
NTSB Photo
The NTSB accident report includes the following: "The pilot departed on the first leg of the trip with the airplane fully fueled and two passengers onboard. After about an hour flight, the pilot landed at the destination airport and dropped off both passengers. The airplane was not fueled at that time. The pilot departed as the sole occupant to return to the initial airport. About 18 miles from the destination airport, the airplane entered a gradual descent as it remained on course. About 6 minutes later, the airplane entered a descending left turn that continued until the available position data ended. The airplane impacted trees and terrain about 3 miles from the airport. The accident site was in a wooded area adjoining an open field."
NTSB Photo
The NTSB report continues: "A witness heard the airplane as it approached and recalled that the engine sounded as if it was going to lose power but then “revved up really high.” This cycle occurred 3 or 4 times over a span of 10 – 15 seconds. The engine then seemed to stop; however, he was unsure if the airplane had descended behind a ridgeline. He did not hear the impact nor was he able to see the airplane."
NTSB Photo
The NTSB report continues: "The airplane was equipped with 2 25-gallon main fuel tanks and 2 10-gallon auxiliary fuel tanks. The fuel selector valve had settings for the left main tank, the right main tank, and the auxiliary tanks. The main fuel tanks were selected individually. Both auxiliary tanks fed simultaneously when selected. Excess (unburned) fuel from the engine was returned to the selected main fuel tank or, if the auxiliary tanks were selected, to the left main fuel tank.
The fuel tank caps were securely installed, and each tank appeared to be intact. About 15 gallons and 10 gallons of fuel were recovered from the left and right main fuel tanks, respectively. Both the left and right auxiliary fuel tanks contained minimal fuel. Data recovered from an onboard electronic engine display unit revealed that the pilot departed on the initial leg of the trip with the left fuel main fuel tank selected. About midflight, the pilot changed to the auxiliary fuel tanks. Upon departure on the accident flight, the pilot had the right main fuel tank selected. About 14 minutes before the accident, the pilot selected the auxiliary fuel tanks to supply the engine. About 2 minutes before the accident, the useable fuel contained in the auxiliary tanks was exhausted, and the engine lost power due to fuel starvation. The pilot most likely selected the left main fuel tank in an effort to restore engine power. Useable fuel was available in both the left and right main fuel tanks when the engine lost power. The pilot was likely maneuvering toward an open field for a forced landing under a clear night sky and rising full moon. However, the airplane did not have sufficient altitude to reach the field. It could not be determined whether the night lighting conditions hindered the pilot’s attempted forced landing."
NTSB Photo
The NTSB probable cause finding states: "The pilot’s mismanagement of the airplane’s fuel system, which resulted in fuel starvation and a loss of engine power."
The fuel system in this airplane was less complex than some, but more complex than most. It is generally not a good idea to run a fuel tank dry and it is a really bad idea to run a tank dry if it is feeding a fuel injected engine. We do not know what steps the pilot took to restore engine power other tank switching to a tank containing fuel. The conditions were ripe for the IO-470 engine to experience vapor lock once the fuel flow was interrupted. It is likely that the pilot realized this and directed his efforts to executing the off-airport landing. Unfortunately, it was dark and finding a suitable landing site was problematic.
The lesson here is that having sufficient fuel is important but that managing the fuel onboard is critical.
Click here to download the accident report from the NTSB website.
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