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Episode #32 in our series reviews the the challenges posed by the runway width illusion. This shorts video is just 57 seconds long. The video is sponsored by @Avemco and is narrated by Gene Benson. Click here to check out "Runway Width Illusion."
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Recommended Video
As I try to read and study every aviation crash reported on the NTSB website, it becomes apparent that cause lies in a faulty decision, not always, but often by the pilot. This month, we are recommending our "Better Decision Making" video. This video, a recording of a live webinar, discusses three kinds of decision making and how we can be better at all three. A featured guest tells a riveting story of an in-flight engine failure. We discuss the decisions he had to make with the information available at the time, from the first indication of trouble through the successful conclusion of the event. Click here check out "Better Decision Making" on YouTube.
Verbal Ability
Verbal ability is the cognitive ability to use and understand language. This ability develops largely as a function of both formal and informal educational opportunities and experiences. An important part of verbal ability is episodic memory. Verbal ability also includes verbal reasoning which is the ability to understand and reason using concepts framed in words.
Verbal ability typically tends to remain strong as people age as compared to other cognitive skills. This fact has caused concern in business aviation as an older captain may be able to offer a viable explanation for an error to a younger and less experienced first officer thus delaying the recognition of decline in other cognitive skills.
Improve Verbal Ability
Overall verbal ability can be improved by being an active learner, learning a new word every day, participating in stimulating conversations, and reading a wide range of material. "Hangar Flying" with other pilots is a valuable tool in supporting verbal ability.
Click here to download the free "Aging Pilot Report."
Smart People Can Do Dumb Things.
Are they really dumb things or are they Human things?
The pilot population mostly consists of smart people. But smart people sometimes do dumb things. Over the past three decades, I have dedicated considerable time to researching the reasons behind this phenomenon. My quest began when a pilot I knew and respected died in a “pilot error” crash. Unfortunately, several more pilot friends and colleagues met their demise in airplanes over the years. Studying NTSB accident reports and finding local news articles covering the same crashes confirmed the belief that smart pilots can do dumb things. But the important question is why?
Before we continue, let’s make a short list of some seemingly “dumb things” that often end very badly. The most common is certainly intentionally flying into IMC when not rated, current, and proficient. Others include flying an airplane with known significant maintenance issues, not knowing the correct go-around procedure for the airplane, succumbing to the influence of external factors, not maintaining engine-out proficiency in a multiengine airplane, flying while fatigued, and a few others.
So back to our important question, “Why?” The overly simplified single answer to that question is that a bad decision was made. That circles us right back to “Why?”
Decision making is a complex process. I like to view it as a very large mixing and filtering funnel with many factors going into the top and one decision coming out the bottom. In theory, the pilot with a fat logbook and pocketful of certificates and ratings has an effective and well-developed mixing filter ensuring that the best decision comes out the bottom.
But theory and reality often diverge. One of my friends and colleagues flew a King Air into a mountain on a night approach to his home airport, resulting in his death and the death of his passenger. He had more certificates and ratings than space here permits, was a DPE, and had logged more than 20,000 flight hours. His flawed decision was to cancel his IFR approach clearance and continue to the airport visually in the dark with snow showers in the area. That decision negated the requirement for a procedure turn and would have saved about six minutes of flight time.
Our mixing filter is highly influenced by our cognitive biases which can lead any of us toward a flawed decision. All humans are generously supplied with these biases. The “Big 3” are illusory superiority. optimism bias, and continuation bias. Here is an overly simplified description. Illusory superiority lets us believe that we have superior knowledge and skills compared to others. Optimism bias assures us that everything will work out just fine. And continuation bias filters out information that a decision we have made may be flawed and influences us to keep moving with our previous decisions.
These cognitive biases are part of the human condition and are largely independent of intelligence. So, the mistakes that experienced pilots make are not dumb mistakes. They are human mistakes.
We cannot and do not want to stop being human. But it would be great if we could make fewer human mistakes. We can decrease the negative influence of our cognitive biases by following a few simple practices. First, we want to move as many of our decisions from the subjective to the objective. For example, the Risk Assessment Matrix asks us to evaluate the likelihood of something bad happening and then compare it to the severity of the event. That requires subjective decisions which are easy targets for out cognitive biases. For example, the use of a Personal Minimums Checklist (PMC) or Flight Risk Assessment Tool (FRAT) mostly removes the subjective decisions and replaces them with objective observations.
Decision making is an extremely complex process. We do not necessarily need to thoroughly understand it, but we do need to recognize some of the traps that can lead us to those flawed human decisions. I strongly encourage all pilots to review some resources regarding decision making. Here are a few recommendations:
Better Decision Making for Pilots Video
Decision Tools in Vectors “Safety Concepts” Includes information on PMC and FRAT
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 happened in Texas on Thanksgiving weekend in 2023. The airplane was a Piper PA28-180. The 36-year-old, non-instrument rated private pilot, his 35-year-old wife, and their 10-year-old daughter died in the crash. The pilot had logged 94.7 flight hours, all in this make and model.
Photo Source: NTSB
The NTSB report begins with the following: "The non-instrument-rated pilot departed on a visual flight rules (VFR) cross-country flight while marginal VFR and instrument meteorological conditions (IMC) were present along the route. Following a planned en route fuel stop, the pilot deviated from the planned flight route and altitude. Automatic dependent surveillance-broadcast (ADS-B) data showed that for the next six hours the pilot maneuvered around adverse weather conditions at low altitudes and made two stops at airports not listed on the flight plan. Before the first stop, one of the passengers sent a text message telling the pilot’s parents that they had to turn back because the weather was not good. The text message included a photograph depicting the airplane operating in an area with a low cloud layer and visible moisture. The pilot delayed his departure from the second unplanned airport stop for about two and a half hours for unknown reasons. After departing at night, the pilot continued to maneuver at a low altitude, and not directly toward his original destination. It is likely that the combination of low cloud ceilings, dark conditions, and the pilot’s limited experience with instrument flight, resulted in the pilot not maintaining sufficient altitude to clear the hilly terrain while trying to maintain VFR flight."
Phot Source: NTSB. Photo sent via text message to the pilot's parents
The NTSB report continues: "The ADS-B data, impact trajectory, and the wreckage distribution were consistent with spatial disorientation. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures with the airframe or engine that would have precluded normal operation. The continuation of the cross-country flight at night with forecast IMC is consistent with the pilot’s overconfidence in his flying abilities."
Graphic Source: NTSB Google Earth image with the accident flight route depicted.
The NTSB probable cause states: "The non-instrument-rated pilot’s continued visual flight into night instrument meteorological conditions, which resulted in spatial disorientation and subsequent loss of control. Contributing to the accident was the pilot’s overconfidence."
We must assume that the pilot was a relatively smart individual. By the age of 36 he had earned a private pilot certificate and owned an airplane. But he had not yet reached 100 hours of flight time. He had logged just 4.5 hours of night flying time and just 3.1 hours of simulated instrument flight time. Yet, he departed on this flight after receiving a weather briefing that was not favorable for VFR flight.
The NTSB report includes the following: "The pilot filed a VFR flight plan from LRU to 1T7 and obtained a weather briefing from a third-party flight and weather planning service that reported current marginal VFR conditions along most of the flight route, including overcast cloud conditions less than 3,000 ft above ground level (agl). Multiple AIRMETs were included in the brief that forecasted IFR conditions along a portion of the route of flight. The AIRMETs were active when the airplane flew through Mertzon, Texas."
But this smart person made a mistake. Not a dumb mistake but a human mistake. The NTSB listed overconfidence as a contributing factor. The overconfidence could have been produced by our "Bias Bundle Bomb" of the cognitive biases, illusory superiority, optimism bias, and continuation bias.
External factors likely played a role. The flight was to return home after a holiday weekend. Perhaps there were work obligations for one or both parents and school for the daughter.
We can only speculate on these factors, but hopefully we can learn a valuable lesson that we must be realistic about our capabilities. Using tools that help us make objective decisions, such as a Personal Minimums Checklist or Flight Risk Assessment Tool can be a huge step in the right direction.
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.
This crash Involved a Cessna 310D and happened in Texas in May 2023. The 19-year-old multi-engine rated private pilot and his pilot rated passenger were seriously injured. A rear seat passenger was fatally injured.
NTSB Photo
The NTSB report includes the following: "The pilot-rated front seat passenger reported that the pilot chose to perform a go-around while on final approach for runway 16 at Ennis Municipal Airport (F41), Ennis, Texas. However, the passenger reported she was not sure why the go-around was initiated. During the go-around, the airplane veered to the right and rolled. A statement from the pilot was not received due to the pilot’s injuries."
NTSB Photo
The NTSB report continues: "The airplane impacted cedar trees and terrain about 1/4 mile southwest of the runway. A postimpact fire ensued and destroyed the airplane. According to the pilot’s logbook, he passed his private pilot multi-engine check ride on January 12, 2023. The pilot had accumulated a total of 13.9 hours of multi-engine flight time, all of which were in the accident airplane make and model."
NTSB Photo
The NTSB report also states: "The airplane was purchased by a family member in June 2021. According to logbook records, the first annual inspection performed after purchase was in August 2022. The airframe annual inspection was noted by a mechanic as unairworthy. However, the engines were found to be airworthy, and the annual inspection was signed off for the engines. A list of airframe deficiencies was given to the airplane owner. The owner took the airplane to another mechanic, and the deficient airframe items were addressed. The airplane was approved for return to service by the second mechanic in January 2023.
In February 2020, Continental Aerospace Technologies Service Bulletin (SB20-01) was issued for IO-470-D engines. This SB calls for the fuel plug and screen assembly on the fuel injection control assembly to be removed and cleaned during every annual inspection. An engine logbook entry from the mechanic who signed off the annual inspection on the engines revealed that all fuel injector components were cleaned on both engines, and all engine airworthiness directives were complied with. However, the mechanic stated that their records do not indicate whether SB20-01 was performed.
Before the August 2022 and January 2023 annual inspections, the airplane had not had an annual inspection since June 2013. Additionally, the engine logbooks indicated that both engines were overhauled in November 2001. When the engines were overhauled, all rubber flexible fluid-carrying hoses were replaced. A review of the airframe and engine maintenance logbooks revealed no record of the hoses having been replaced since the November 2001 overhaul. The airplane was equipped with two Continental IO-470-D engines. Continental recommends hoses be replaced as needed upon a conditional inspection or at engine overhaul. Continental also recommends that the IO-470-D be overhauled at 1,500 hours or every 12 years, whichever occurs first due to the possible deterioration of rubber that could affect the airworthiness of the engine and engine-mounted components and accessories. At the time of the August 2022 and January 2023 annual inspections, the recorded Hobbs time in the maintenance records was 1,526.4. The airplane had avionics maintenance performed on May 2, 2023, and the recorded Hobbs time was 1,532.7. A search of ADS-B data revealed that the last recorded flight was April 28, 2023, so between the time the airplane was signed off as airworthy in January 2023 and the accident flight, the airplane accumulated about 6 hours of flight time."
NTSB Photo - Fuel plug and screen assembly from right engine
The NTSB report also includes this: "Examination of the right engine revealed soot deposits, debris, and impact damage. Compression and suction were obtained on all cylinders. The right engine was run in a test cell and initially ran roughly. The fuel plug and screen assembly from the fuel injection control assembly housing was removed. It was obstructed with black debris, small string-like fibers, and metallic fragments. The fuel plug and screen were replaced with a new exemplar component. During the second engine run, the engine started without hesitation and ran smoothly. The original fuel screen was sent to the National Transportation Safety Board (NTSB) Materials Laboratory for analysis along with a sample of the right fuel bladder. The NTSB materials laboratory tested the black debris and metallic particles found on the right engine fuel plug and screen assembly. The black debris was a match for polyurethane. The metallic particles consisted of brass (copper and zinc) and aluminum The flexible fluid-carrying hoses are made of polyurethane. However, due to post-impact fire damage, a sample of the hoses was unable to be retained for analysis to determine a match. According to Continental Motors, the polyurethane and string-like fibers were consistent with a flexible fluid-carrying hose."
NTSB Photo - Magnified image of fuel plug and screen assembly from right engine
The NTSB probable cause states: "The partial loss of right engine power due to reduced fuel flow as a result of the contamination of the fuel screen."
NTSB Photo
The obvious lesson here hammers home once again the importance of good maintenance, including compliance with non-mandatory Service Bulletins. Since the airplane had only flown about six hours since the annual inspection sign-off, it seems unlikely that the fuel system had been serviced according to the engine and airframe manufacturers' instructions. We do not know precisely what the circumstances were regarding this airplane, but generally speaking, bargain maintenance is no bargain.
Then we must address the pilot's proficiency. A Cessna 310D will not struggle to climb with loss of power, either full or partial, on either engine as long as correct procedures are followed. Regardless of the reason for the go-around, it appears that the pilot allowed the airspeed to decrease to less than Vmc. A multiengine airplane must always be flown such that the airspeed remains at or above Vmc. If flying slower than Vmc, loss of power on either engine will result in an uncontrollable roll toward an engine not producing power. This fact is usually taught, and then demonstrated, and then reviewed until it is etched into the pilot's brain during multiengine flight training. Why was this pilot, not that far out of multiengine training, unable to handle the partial power loss of the right engine?
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.
Our humanness can exert tremendous influence on our decision making. Once an initial decision to fly to a destination is made, continuation bias can cause our brains to filter out evidence that does not reinforce that initial decision. In this crash, the non-instrument rated, 675 hour, 70-year-old private pilot had decided to fly from Providence, Rhode Island to Laconia New Hampshire to have a "special dinner" with his girlfriend.
The NTSB accident report includes the following, "The pilot was completing a cross-country flight at night and had arrived in the area of the destination airport. After entering an extended downwind leg of the traffic pattern, he was flying over a lake when the accident occurred. The airplane entered a left base-to-final turn that developed into a steep, spiral dive to the right, and continued until the airplane impacted the lake."
NTSB Photo
The NTSB report also contains the following, "The pilot was not instrument-rated and had no recent experience flying at night. Witnesses indicated visibility in the area was reduced by wildfire smoke. Surveillance video confirmed that the sky was obscured and that the airplane was flying through low clouds immediately before the loss of control occurred. Few ground lights or other visual references were available in the vicinity of the lake that could have helped the pilot maintain orientation or aid in recovery after he lost control of the airplane. Loss of outside visual references during a visual flight rules (VFR) flight creates a high risk of spatial disorientation and loss of control for pilots who are not instrument-rated and current/proficient. Several risk factors for spatial disorientation were present in this case: reduced visibility, manual control, and maneuvering flight. Therefore, the pilot likely experienced spatial disorientation followed by a loss of control in flight."
NTSB Photo
The NTSB report continues, "The pilot was advised by a flight instructor before departing on the accident flight that meteorological information indicated visibility might be diminished by the time he arrived at the destination airport, but he decided to depart anyway. According to the instructor, who was a friend of the pilot, the pilot had experienced multiple delays returning the accident airplane to his home and had plans with a friend that evening. Thus, the pilot appears to have disregarded information that the flight might have been unsafe to operate under VFR, and he likely did not divert because he was motivated to avoid further delays and attend to a social obligation."
NTSB Photo - Photo sent via text message to the pilot's friend/flight instructor during the flight
And the NTSB report also includes: "The pilot’s friend said he sent a text message to the pilot about 1849 to ask how the flight was going and the pilot replied by sending him a photo of the instrument panel of his airplane. This photo showed his iPad fastened to the yoke and presenting a primary flight display as well as a navigation display with a VFR sectional chart overlay. The cockpit was illuminated by a red overhead light and traditional “round dial” flight instruments were visible behind the iPad. A lower portion of the windscreen was included in the photo, but no horizon or ground lights could be seen. The pilot’s friend sent several additional text messages between 1916 and 1917 warning the pilot that instrument meteorological conditions (IMC) were present at LCI and urging him to divert to another airport. The pilot did not respond. The pilot’s friend said he believed the pilot’s decision making was degraded by “get-there-itis.” The friend was watching the flight via FlightAware and observed the airplane enter the traffic pattern, turn downwind, and then continue out over the lake. He said the pilot could have turned sooner on to the base leg, and he was not sure why the pilot extended the downwind over the lake."
NTSB Photo
The NTSB probable cause states, "The pilot’s loss of control during visual flight rules flight in night instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot’s motivation to depart on the flight despite being made aware that conditions might be unsafe and his continuation of the flight as weather conditions deteriorated."
Our theme this month is that smart people can make bad decisions based on their humanness. This pilot was a retired aerospace engineer who made a bad decision and then continued down a fatal path perhaps due to our "Bias Bundle Bomb" of illusory superiority, optimism bias, and continuation bias.
The accident docket includes a professionally prepared "Human Performance Factual Study." Click here to download it from the NTSB website.
Click here to download the accident report from the NTSB website.
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