Save it!
The date that is. Choose either June 28 at 7 PM Eastern or July 12 at 3 PM Eastern. I will be presenting, "Getting Together Uneventfully," an Avemco sponsored webinar. See more details plus registration links on the Vectors for Safety" Events Page.
Stop it!
The engine that is. Never ever - let me say that again louder - NEVER EVER allow or direct anyone to exit or enter the airplane with the engine or engines running. Doing so is dangerous, careless, and reckless. When a flight instructor does it I would add a few more choice words. When a flight instructor directs a 16-year-old student on a first flight lesson to get out and remove a chock, albeit a distant chock, with the engine running, and that student walks into the prop, I have no words. (That is a lie but using those words would probably get me kicked off social media and my mother would rise from the grave and wash my mouth out with soap.) Fortunately, local news reports show that the young student has recovered well and continues to make progress.
Click here to read the full accident report on the NTSB website.
Click here to access the accident docket which includes the instructor's statement
Apply it!
Carburetor heat that is. We continue to have accidents resulting from power loss due to carburetor ice. My experience has shown me that carb ice can happen even when the conditions do not meet the published criteria for carburetor ice. I have also learned, courtesy of an adrenalin rush, that even airplanes that do not recommend the use of carburetor heat in most situations, can develop carburetor ice. And do not think that carb ice is only a problem when landing. Any prolonged ground delay with the engine running can result in ice accumulation, resulting in an unpleasant surprise when cleared for takeoff. Just be sure to turn off the carb heat just prior to takeoff.
Yes, applying carburetor heat results in some power loss and bypasses the air filter allowing contaminants into the engine, but I know that I have avoided many power loss incidents by applying carburetor heat whenever the power comes back below the cruise setting.
Click here to download the an example carb ice accident report from the NTSB website.
Extend it!
We continue to see almost daily, and sometimes multiple incidents daily, of retractile gear airplanes landing gear-up. System malfunctions account for very few of these. While most do not result in personal injury, the aircraft damage is often substantial. Initial reports show that on May 19, 2022, a Bellanca 14, a rather rare, classic airplane, was consumed by fire resulting from a gear-up landing in Texas. There is no word yet on whether there was a problem with the gear or whether it was simply not extended. Avoiding the unintentional gear-up landing is not difficult. Any pilot flying a retractable gear airplane should of course follow a before landing checklist and should always make a habit of verifying that the gear is down and locked while on short final.
Check it!
Fuel that is. Verify both the quantity and the quality. Visual verification of quantity, either by a dipstick or by a known quantity tab in the tank is more reliable than a fuel gauge. Quality should be verified for both uncontaminated fuel and correct fuel before each flight and after each fueling. We still have accidents caused by jet fuel in the tanks of reciprocating engine airplanes and by water or other contaminates finding their way in. More information is available in our video, "Avoiding the Fuel Related Accident."
Read it!
I have reduced the prices for all my publications to encourage summer reading! Scroll to the bottom of the blog or click here to visit my Author Page on Amazon.
The Buffet
My monthly blog for Vectors usually focuses on one issue related to general aviation safety. To select a topic, I read almost all the NTSB accident reports and choose something that relates to a wide range of GA pilots and the airplanes they fly. Once a topic is chosen, I attempt to identify the causal factors and provide one or more mitigation strategies.
I admit to being a bit overwhelmed this month by the large buffet of topics available. Sadly, just like TV, GA accidents are amid a rerun season. It seems like those of us working in GA safety are engaged in an endless game of whack-a-mole. The same errors are being made repeatedly, just by different pilots but in similar situations.
So, this month, rather than selecting one topic, I am going to address several accident types, show brief examples, and present some ways that perhaps the accident could have been prevented.
The Daily ASIAS Report lists the incidents and accidents reported on the previous day. In addition to the location, the aircraft type, N-number, fatalities, and early assessment of the extent of damage to the aircraft, they include a very brief synopsis of what happened. It is common for significant changes to be found when the event is finally published as a completed report. Many events listed as incidents are later changed to accidents based on thorough evaluation of the damage to the aircraft. Many of the events initially include something similar to, “Aircraft landed in a field (or on a road or in a swamp, etc.) due to engine issues.” Months later when the final NTSB report is issued, we find that nearly all the engine issues were caused by fuel starvation.
Another common ASIAS synopsis states that the aircraft landed and the gear collapsed. These are correct in that the retractable landing gear collapsed, but further investigation frequently shows that the pilot was late in activating the gear extension and the airplane contacted the runway before the gear had time to fully extend and lock. In the case of fixed gear airplanes, the gear collapse is almost always the result of a very hard landing or a significant side load being placed on the gear by landing in a crab.
Please check the accident analyses below to see examples of items from the buffet.
If you are reading this, you are most likely not part of the problem but you can be part of the solution. Please consider encouraging other pilots to enroll in the FAA Wings program, attend live seminars or webinars, take online courses, and of course, join the Vectors for Safety email list.
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.
The pilot and sole occupant of this Piper Archer II escaped injury when he failed to properly manage his fuel. The airplane received substantial damage. He reported that the airplane’s fuel tanks were filled to the tabs during the preflight. He then departed on about a two-hour local flight, which included touch and go landings. He added that he did a soft field technique, where he pulled up abruptly. The engine then ran rough, so he leveled off, and the engine regained power briefly, before going to idle rpm. He lowered the flaps for the forced landing. During the forced landing, the left wing separated from the airplane after impact with a fence post.
NTSB Photo
The pilot stated that he ran the fuel tank too low and when he pulled up during the takeoff, the remaining fuel was unable to reach the engine. He added that he “just ran the left tank too long without switching” fuel tanks.
The NTSB Probable Cause finding states: "The loss of engine power due to fuel starvation and the pilot's mismanagement of the available fuel."
When we fly an airplane that has two fuel tanks and a fuel selector that does not have a "BOTH" position, we must take some steps to properly manage our fuel. There are a few things that I have learned and try to practice. It is important to plan the fuel consumption and approximate times to switch tanks. Setting a timer as a reminder is helpful if possible. We should plan our fuel use so that we do not arrive at our destination with just a small amount of fuel in each tank. It is better to have one tank low and the other with sufficient fuel so that we do not need to be concerned about running a tank dry during the landing approach or during a possible go-around. In addition to timing the fuel use, we should also monitor the gauges. The gauges are not always accurate, but if a tank appears to have considerably more fuel used than planned, we must consider the possibility of a fuel leak and take appropriate measures. Never assume that the gauge is indicating a low fuel level because it is inaccurate. Follow the manufacturer's recommendations for how to switch fuel tanks. If a boost pump should be turned on, be sure to turn it on. Make sure, double check, and then check again that the fuel selector is securely in the detent. Of course, this goes for before takeoff as well as when switching tanks. Finally, it is not always possible, but I prefer to switch tanks when I am within gliding distance of an airport or at least a suitable place for a forced landing.
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.
The pilot and sole occupant of a Cessna 170B avoided injury when he was forced to make an emergency off-airport landing as a result of fuel contamination. The NTSB report contains the following, "The pilot reported that he took off from his private airstrip and flew for about 30 minutes before landing at a nearby airport for fuel. After fueling with 24 gallons of fuel, he did not perform a pre-takeoff run-up of the engine and departed the airport. About 1.5 miles from the airport the engine sputtered and lost all power. The pilot performed a forced landing to a small field. During the landing roll as the airplane was approaching the end of the field, the pilot applied heavy braking which caused the airplane to nose down coming to rest on it nose. The airplane sustained substantial damage to the left outboard wing."
The NTSB report continues, "The pilot reported that after the accident he sampled the fuel from the wing tanks and gascolator. The fuel sample from the gascolator was about one-half water and one-half fuel. The wing tank samples contained all water. The pilot provided photographs of the airport above ground fuel tank including photographs of the interior of the tank. The tank interior showed a large amount of rusted metal in the bottom of the tank."
NTSB Photo (courtesy of pilot)
The NTSB report also includes, "The airport manager reported that the airport fuel tank was about 30 years old and was of double wall construction. Water had entered the space between the inner and outer walls of the tank and the inner tank had rusted by allowing water to enter the inner tank and fuel supply. The tank did not have filtering on the outlet. The airport ordered a new tank and planned to include filters on the outlet, including a water separating filter."
Fuel contamination caused by water can be tricky to detect, especially in a tail dragger in which the fuel drains are positioned well above the lowest point of the tank when the airplane in parked in its tail-down stance. However, this pilot admitted that he did not do an engine run-up prior to takeoff. There is no guarantee that a run-up would have detected the problem, but if the water had not yet settled in the tank, enough water might have made it to the engine to raise a question. Knowing your fuel source and ensuring that it has the proper filters installed and is properly maintained is a very good idea. We do not know if this was the case here, but sometimes bargain fuel is not such a bargain in the end.
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.
A Cessna 172 received substantial damage but the pilot, sole occupant, was not injured as a result of this runway excursion. The event occurred in Georgia in January of 2021. Let's see what happened and then I will put my human factors twist on it.
The NTSB accident report begins, "The pilot was returning to his home airport after a short trip. Other than mild turbulence, there was nothing eventful about the trip. Upon nearing the airport and listening to the weather, he understood that winds were gusting from the northwest at 12 to 20 knots. This was on the high end of his personal minimums, but within the tolerance range that he had flown in the past. As he was preparing to land, he experienced some greater turbulence and crosswinds. The air traffic controller in the control tower gave him a straight in approach, and subsequently cleared him to land on runway 25. The approach was turbulent, and the plane was being bounced and pushed left intermittently. Due to the wind gust advisory, he landed with only 10°of flaps and about 10 knots more airspeed. His estimated speed over the threshold of the runway was about 70 knots. He stated that it was pretty gusty crossing the runway threshold. He landed the airplane and once the nosewheel was down, he started braking. Unexpectedly the plane moved to the left quickly. It seemed to him as though a large gust hit the airplane from the northwest side and pushed the airplane sharply to the left. He worked to counter the movement with right rudder but was unsuccessful in stopping the momentum. He nearly kept the airplane on the pavement, but the left tire just slipped off the edge of the runway. When the left tire contacted the newly sodded turf, combined with the recent heavy rain; the tire sunk quickly, as the turf was soft and very muddy. This rapid deceleration, and the left tire being off the pavement, caused the rear of the plane to “rise” and the propeller struck the runway. With this motion, and the left tire being below the pavement, the airplane pivoted to the left, and the leftwing tip struck the surface. The airplane came to rest on its landing gear, just off the runway surface."
The NTSB Probable Cause finding states, "The pilot's failure to maintain directional control during landing in a gusting crosswind, which resulted in a loss of control and runway excursion."
How can we look at this accident through a human factors lens? The pilot referred to his personal minimums and stated that the wind was "on the high end." So far, so good. The 121 hour pilot had established personal minimums and was within limits. However, it is not practical to establish any personal minimum for turbulence since we, as pilots experiencing it, cannot assign a numerical value to it. As he approached the landing, he experienced a very turbulent approach with strong crosswinds. He stated that, "It was pretty gusty crossing the threshold." Why did he not go around and re-evaluate the situation and consider his options?
One of our cognitive biases, continuation bias, might have been at work. That bias provides a strong influence to complete a task once it has begun. The pilot's decision to begin the approach was based on the information he had regarding the wind and the runway alignment. But perhaps continuation bias worked hard to filter out the significance of the turbulence and strength of the crosswind as he continued. By being aware of our humanness, including how our cognitive biases influence our decisions, we can be safer at everything we do.
Click here to download the accident report from the NTSB website.
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