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Vectors for Safety - June 2021

Safety Initiative Update

About Our "Most Wanted List"

Last month we began our own MWL for non-commercial, general aviation safety. The first four items were presented and this month we will continue with the remaining four items. These will be found in "Gene's Blog" below.

We want to thank our readers for the many positive comments we received so far. One reader included the following thoughtful comments: "Owners of some older aircraft, like the Ryan, might consider airbags because of the geometry of shoulder restraints. I also think helmets should get more emphasis in GA cockpits. I know a couple who both suffered severe skull injuries when their heads were banged into the sides of the cockpit after an engine failure at low altitude on takeoff from a private strip near West Yellowstone about 10 years ago. Had they worn helmets on that takeoff their injuries would have been far less severe. Other examples exist where helmets prevented side load injuries during off airport landings in rough terrain." I am curious about other readers' thoughts on helmets in small GA airplanes. Please let me know your thoughts on the subject.

Safety Concepts Page has Grown

Last month we introduced a new Safety Concepts page to the Vectors website. We have expanded it considerably during the month. It is necessary to scroll down the page to see the various topics. We hope to make that navigation easier in the near future.

Save the Date - Next Avemco Webinar will be July 13

Our next free webinar in the Avemco "Pilot Talk" series will be on Tuesday, July 13 at 7:00 PM Eastern. The title, Avoiding the Summer Flight "Gotchas," describes the content. We are confident that just about any pilot will learn something new or at least be refreshed on something long forgotten. Complete information, including a registration link, will be in the July 1 issue of "Vectors."

Gene's Blog

Gene's Most Wanted List - Continued from the May 1 issue

In last month's edition of Vectors, I began my Most Wanted List for non-commercial, general aviation safety. I included the first four items on my list and this month I will conclude by listing the remaining four items. If you missed the May edition with the explanation of why I created the list and how I select accidents to analyze, along with the first four items on the list, click here to visit it. Let's look at the remainder of my Most Wanted List.

Five:

All pilots will have a Personal Minimums Checklist or a Flight Risk Assessment Tool (FRAT) and will use it prior to every flight, including local flights, without exception.

Following all applicable regulations is important but it does not guarantee safety. The Personal Minimums Checklist and the FRAT are created or customized by the pilot well in advance of any flight. These tools reflect the realistic limitations of the pilot and of the airplane. These tools must be adjusted periodically to reflect changes in pilot capability. Pilots flying more than one airplane type may need a tool for each type. For more information on these tools, visit our Safety Concepts Section and scroll down as necessary.

Six:

All pilots will have increased awareness regarding airworthines.

Again, we note that the airplane is not a car with roadside assistance readily available. Even a relative minor malfunction can generate a dangerous situation if it happens during a critical phase of flight or creates a distraction. Owner-pilots must ensure that maintenance is not neglected and that all maintenance is performed by competent individuals. Renter pilots must become more knowledgeable in how to critically and independently evaluate an airplane’s airworthiness. All pilots must increase awareness of the need to, the extent possible, verify that recently performed maintenance was done correctly. A related accident is analyzed below.

For more information on this subject, visit our Safety Concepts Section and scroll down as necessary.

Seven:

All pilots will have increased knowledge of how the human decision-making process operates so that the effect of unconscious influences can be recognized and minimized.

Many accidents result due to flawed decision making by the pilot. By becoming aware of how the unconscious mind influences decisions, humans can recognize and mitigate some of the risks of falling prey to these factors. Consider taking our Human Factors Ground School course.

Eight:

All pilots will have increased awareness of techniques to help avoid ramp and taxi accidents.

Ramp and taxi accidents are among the most avoidable kind of accidents. While most of these accidents result only in property damage, some cause life-changing injuries or even death. A few simple techniques and practices can greatly reduce the risk of having a ramp or taxi accident. A related accident is analyzed below. For some useful information on this subject, visit our Safety Concepts Section and scroll down as necessary.

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.

This Beech Bonanza accident happened in Oklahoma in July of 2017. It illustrates the importance of ensuring that aircraft maintenance is done by competent, responsible technicians who comply with manufacturer's procedures and always use the correct parts. though the airplane was substantially damaged, only two minor injuries resulted from the crash.

 

The NTSB accident report includes the following: "The airline transport pilot was conducting a personal, cross-country flight. He reported that, about 10 minutes after takeoff, the oil pressure decreased to 0, and the engine experienced a loss of all power. The pilot conducted a forced landing on a soft field about 1 mile short of an airport, during which the airplane sustained substantial damage to the firewall and lower fuselage.


A review of the airplane's maintenance records revealed that the vacuum pump had been replaced the
day before the accident. Examination of the engine revealed that three connecting rods exhibited thermal
and impact damage, and three rod journals were found dry and exhibited thermal discoloration, indicative of oil starvation. Disassembly indicated that a gasket typically used for carburetors was installed on the vacuum pump. The installed gasket did not completely cover the high-pressure oil orifice on the vacuum pump mounting fixture, which resulted in oil leakage, subsequent oil starvation to the engine, and the loss of engine power."

CEN17LA286 NTSB-1
broken image

The NTSB Probable Cause finding states: "Maintenance personnel's installation of an improper vacuum pump gasket, which resulted in oil starvation to the engine and a subsequent total loss of engine power."

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.

This accident resulted in substantial damage to a Cessna, but the pilot, the only occupant, was not injured. It illustrates that we must focus all of our attention on the task of taxiing.

 

The NTSB accident report includes the following: "The pilot reported that while taxing for takeoff, he observed a skip loader on the immediate left edge of the taxiway and noted there was sufficient clearance to avoid it. However, during the taxi, his attention was distracted by setting up the GPS for the flight, and the airplane drifted left, and subsequently struck the skip loader."

WPR20CA146

The NTSB Probable Cause finding states: "The pilot's diverted attention while taxing which resulted in his failure to maintain clearance from the skip loader during taxi."

In the Pilot-Operator Report submitted to the NTSB by the pilot, He stated: "I landed at Perris Valley Airport (L65) on 5/6/20 because my usual airport, French Valley (L70), was closed for runway repairs. I was not previously familiar with the airport. After my takeoff preflight on 5/7/20 I reviewed the airport diagram on ForeFiight to determine the taxiways. As I was taxing South to runway 33 I noted a skip loader at the immediate edge of the taxiway. There was sufficient room on the taxiway to avoid the skip loader. However, my attention was distracted by setting up the GPS for the flight, and I inadvertently drifted to
the left edge of the taxiway causing the leading edge of the left wing to strike the skip loader."

The pilot's statement in the Owner/Operator Safety Recommendation states: "Avoidance of distractions by maintaining a sterile cockpit at all critical stages of flight, especially taxi, take off, and in the traffic pattern." The pilot's remarks continue as follows: "Subsequently, airport personnel stated that the area where the skip loader was is a service road, not a taxiway. They stated that the procedure for taxiing at the airport is to back taxi on the runway. However, that is not noted anywhere, nor is there any signage. It is depicted as a taxiway on the airport diagram in ForeFlight. If that taxiway is to be used as a service road, it should be posted by signage, and the airport diagram in ForeFlight should be changed. Also, it would be helpful if the back taxi procedure was noted somewhere."

It is true that unfamiliar airports are, actually unfamiliar. Non-standard markings and signage are common. When a change is made to a procedure or to the physical structure, sometimes nobody remembers to report the change so that it can be included in published airport data. A phone call to the airport can sometimes be helpful if someone actually answers the call. The bottom line is simple, While taxiing, we must concentrate on taxi and nothing else.

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

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Books by Gene Benson

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