Return to site

Vectors For Safety - June 2023

Safety Initiative Update

Yet Again and Again

On May 8, the daily ASIAS report included the following, "AIRCRAFT WAS STARTED WITH CHALKS IN PLACE, PILOT ATTEMPTED TO REMOVE THE CHALKS AND WAS STRUCK BY THE PROP, TAHLEQUAH, OK." I think it is safe to assume the writer intended to say "chocks" rather than "chalks." In any case, the event happened on May 6 and involved a Beech F33A. The NTSB has a preliminary report posted which provides no additional information except for listing the extent of the injury as serious. The ASIAS report for May 30 includes this regarding a Cessna 182, "AIRCRAFT LANDED, PILOT EXITED TO INSPECT GEAR AND WAS STRUCK BY THE PROP, KINGMAN, AZ" People-into-props accidents with potentially lethal results happen several times each year. We should resolve to never allow anyone, including ourselves, to enter or exit an airplane with the engine running.

Flight Test After Maintenance

The NTSB recently issued a Safety Alert regarding proper torque of the "B Nut" after maintenance. Obviously, the Safety Alert is intended for technicians, but as pilots, we can take an important step to avoid an accident by doing a flight test after engine maintenance. The test flight should be done after a rigorous run-up followed by a careful leak check. The test flight should be done close to the airport and with the minimum crew, usually just one pilot. aboard. This topic was featured in our December 2022 issue of "Vectors." It might be worth another look.

New Episode of "Old Pilot Tips"

Our new Episode 8 of "Old Pilot Tips" is now available. The topic of this under one-minute video is tow bars not removed before engine start. Check it out here.

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.

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.

Scholarship for Veterans

I recently became aware of a scholarship to help veterans begin or continue training toward a career as a professional pilot. I am not connected with the scholarship in any way, but I believe it is worth a look for anyone who can take advantage of it or is willing to contribute. Click here to visit the Ashton Johnson CloudDancer Scholarship.

Live Presentation at Canandaigua, NY

If you are within range of Canandaigua, NY (KIUA) join us on June 27 for a live presentation of "Just This Once." Located in the beautiful Finger Lakes Region of New York State, Canandaigua offers plenty of other vacation opportunities, from a lake for fishing or boating to numerous wineries. Complimentary dinner will be served starting at 4:30 PM and the presentation will begin at 6:00 PM (EDT). For more information and to register, click here.

Avemco Insurance sponsors Gene Benson
Gene's Blog

Brushing Teeth

We don’t think very much about brushing our teeth. Adults would almost unanimously agree that the practice helps to keep teeth and gums healthy and prevents our breath from causing those who enter our near proximity to rapidly seek escape to fresher air. Most of us have a routine for when we brush and that routine usually involves brushing before we venture out in the morning. We seldom vary from our routine without good cause.

But what about the morning a person oversleeps? We all know that we only oversleep on a day which includes a very important activity as the first thing on the schedule. A significant oversleeping event might necessitate the need to compress our morning routine and maybe even skip an item or two. Given the latter of those two, which item or items, if skipped, would have the least negative impact on the day? Maybe skip the shower? Probably not. Maybe skip getting dressed? Definitely not. Maybe skip shaving or makeup, depending on gender orientation? Probably not. Maybe skip breakfast? Perhaps a breakfast bar could be substituted. Maybe skip brushing teeth? Maybe so if we do a quick swirl with the mouthwash. It won’t contribute to long term dental health but will at least keep our close contacts from fainting.

Fine. We shaved a few minutes off our routine by substituting a breakfast bar for a substantial breakfast and substituting a swirl of mouthwash for brushing our teeth. The breakfast bar will hold us until we can get some substantial food and skipping one tooth brushing will not result in immediate tooth decay or gum disease. Perhaps our day has been saved.

Let’s put on our pilot helmet and goggles and look at a similar scenario. In this case, we are behind schedule, for whatever reason when we arrive at the airport. Like oversleeping, arriving late for a flight only happens when the flight and schedule are important. Time is of great importance so what can we compress or skip? Maybe we could skip the last-minute weather check? Bad idea. Maybe we could skip the IFR clearance and go VFR? Not today with a front upon us. Maybe we could skip adding fuel and the expected wait for the fuel truck to show up? Not for this flight that is near the maximum range of the airplane. Maybe we could compress the preflight inspection? Not a good idea but it is looking like a more attractive option. What can we skip that will save some time and not likely be a problem. We usually observe the fueling of the airplane but we can skip that and use the time to file the IFR flight plan. We usually do a visual check of the quantity of fuel in the tanks after fueling, but we can skip because there has never been a problem with this FBO in the past. We can skip taking a fuel sample because we have never observed water or other contaminants in the fuel. There. We saved some time on the preflight inspection. Let’s get our passengers loaded and depart! We can skip the passenger briefing because these people are frequent passengers and know the drill. We start the engine, get our IFR clearance and clearance to taxi. Away we go to the active runway. There is traffic on base so we can compress the before takeoff checklist down to setting the heading indicator and the trim, doing a quick mag check and flight control check. Tower clears us for takeoff ahead of the arriving airplane and we are on our way and should arrive on schedule! Hooray for us!

Forty minutes into the flight, we detect a skip in the engine. Probably nothing. Thirty seconds later, the skip is sustained and is real. That’s odd. Let’s switch tanks and see if it clears up. It does. That was a relief. About fifteen minutes after switching tanks, the engine stops producing power entirely. A quick look at the fuel gages shows that the tank selected is empty. How can that be? Well, no choice but to switch back to the other tank. As soon as the switch is complete, the engine roars back to life. That’s a relief, but we will have to plan a fuel stop before our destination. Now we will be late for sure! Oh no! the engine is running ruff again. We had better tell ATC and ask for a vector to the nearest suitable airport. We are given a vector to an airport eighteen miles ahead, but it is IFR and we will have to execute an approach. A hope that the engine keeps running is followed soon by a complete loss of engine power. We communicate our situation to ATC. There are no other airports nearby and we are flying over somewhat mountainous terrain. We remember that the most important thing to do is maintain aircraft control. We will break out of the clouds and find a road, a clearing, or somewhere where we can land and walk away. We are getting low now. We should break out of the clouds at any second. Oh! Is that…

The accident investigation revealed that one fuel tank was empty while the fuel in the other tank had significant water contamination. It was also noted that the severity of the injuries to the rear seat passengers may have been lessened had they been properly secured with the installed harnesses rather than only by the lap belt. After 18 months of investigation, the probable cause of the accident states, “Collision with terrain while attempting to execute an emergency off-airport landing following a complete loss of engine power. Contributing was the failure of the pilot to ensure an adequate supply of fuel and to ensure that the fuel available was free of contamination.”

The above is a hypothetical, but very possible scenario. The lesson here is that while there are many things in our normal lives that we can skip or compress, that is not the case in our aviation lives. Everything that we have learned along the way regarding regulations and standard procedures is important. In our scenario, the pilot failed to monitor the fueling of the airplane and to verify that the ordered fuel was onboard. The pilot also did not sample the fuel to detect contamination. Finally, the pilot did not conduct a passenger briefing, leaving the rear seat passengers secured only by their lap belts. Skipping even a small step or series of small steps “just this once” can have catastrophic consequences.

broken image

Reprinted from NASA "Callback" Issue 482 March 2020

The Best Teacher

A C172 pilot attempted to thread the needle while taxiing to the runway. Failure was forged into wisdom, and judgment was honed to resolve when experience taught a tough lesson.

■ While taxiing from the ramp, I chose a route that led me to a confined area between an FBO building and several hangars.… Several…tenants had parked their vehicles near one side of the taxiway.… An airplane had been parked on the other side of the taxiway such that its vertical tail was…intruding into the taxi area. I slowed…and attempted to weave between the two obstructions. Unfortunately, the area was too narrow, and my left wingtip contacted the rudder of the parked aircraft. I immediately shut down and secured my airplane. The FBO, having observed the incident, helped me separate the two airplanes, took pictures, and had an on-site A&P Mechanic visually inspect both airplanes.

Following the incident, per FBO procedure, I taxied the aircraft back to parking and secured it for the day. During discussions with the Chief Instructor of the FBO, I learned that the FBO taxi procedures had recently been revised to avoid this area of the ramp due to the narrow confines.
I made several poor decisions that led up to the incident. I selected a route of taxi with a known choke point even though a less constrained route was available, simply because I was in the habit of using that particular route. Once a possible conflict was identified, I elected to continue instead of turning around, because I thought there might still be sufficient room. Finally, after realizing how little room there was, I chose to…squeeze through the area instead of shutting down, because back-taxiing by hand would have been a hassle.
In the future, I will…avoid all taxi choke points.… If I must taxi through a confined area, I will shut down and make sure there is adequate clearance before proceeding. If there appears to be less than a foot of clearance on both sides, I will either have the obstacle removed or…find someone to help direct me through the confined area.
Barring all those options, I will simply back-taxi by hand to a turn-around point and either identify a better route of taxi or wait for the obstacles to be cleared.

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.

ERA23LA049 NTSB Photos

Photo Source: NTSB


This crash involved a Cessna Citation Mustang. The 67-year-old private pilot was not injured. It happened in Arizona in December 2021. The NTSB report includes the following: "The pilot reported that, during an unstable approach, he did not perform a pre-landing checklist and did not configure the landing gear. Subsequently, the airplane touched down with the landing gear retracted and slid to a stop, in which a post-crash fire ensued over the right wing. The lower fuselage and right wing were substantially damaged. The pilot reported there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation."

The NTSB stated the probable cause as, "The pilot's failure to extend the landing gear during landing. Contributing to the accident was the pilot’s failure to use a pre-landing checklist."


Photo Source: NTSB

Shown below is the pilot's description of the flight as submitted as part of the NTSB's Pilot-Operator Report. It appears that he is being honest and straight forward.

Pilot-Operator Report Excerpt-1

Next, we can see the pilot's entry in the "Recommendations" section of the Owner-Operator Report.

WPR22LA058 Pilot-Operator Report Excerpt-2

Photo Source: NTSB

The private pilot was instrument and multiengine rated. Total flight time was reported as 1977 hours with 484 hours in the Citation Mustang. He had a current Class 3 Medical Certificate and current Flight Review.

We have no reason to doubt that the pilot is sincere in his statements and recommendations. He shows that he is aware of the potential impact of the unconscious mind. It would be interesting to know what was the trigger that caused the pilot to abandon the approach plan and begin an abbreviated approach. The lesson to be learned here is that we cannot skips that we know are necessary. That applies whether we are flying a Cub or a sophisticated jet.

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

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.

CEN22LA411 Photo/Graphic Source: NTSB

Photo Source: NTSB - Airplane against metal fence


This crash happed in Oklahoma in August of 2022. It involved a Cessna T210 piloted by a 45-year-old pilot with 725 hours total flight time, including 197 hours in this type airplane. The pilot was current in regard to medical certification and Flight Review requirements. The NTSB accident report includes the following, "The pilot stated that he "landed long and thought he had plenty of room to stop”. Near the end of the runway, the pilot tried to veer into the grass on the right side of the runway to avoid going onto the highway. He thought he could make a U-turn in the grass but was unable. The airplane slid into a fence, which resulted in substantial damage to the fire wall. The pilot said there were no mechanical malfunctions with the airplane that would have precluded normal operations."


Photo Source: NTSB - Photo shows left side damage resulting from contact with the fence.

The NTSB probable cause is stated as, "The pilot's failure to land the airplane within the desired touchdown zone, which resulted in a long landing and collision with a fence."


Phot source: NTSB

The pilot described the damage as follows, "aircraft experienced a prop strike which damaged the prop and most likely the engine as well. There was also sheet metal damage, flat spot on tires, and a dent in the firewall." The pilot's recommendation says it all as shown below.

CEN22LA411 Excerpt from NTSB pilot report

This pilot joins a very long list of pilots who, in retrospect, recognize that a go-around could have prevented a costly and potentially dangerous runway excursion. Why do pilots continue with the landing when clearly things are not going as planned? The answer is found in our humanness. Our unconscious mind, working through optimism bias and continuation bias, tells us that it will be okay and to just keep going. The best way to fight these cognitive biases is to have established criteria that clears us to continue. In this case, having and knowing parameters for a stabilized approach, and having a predetermined spot on the runway that calls for a go-around if the airplane is not on the surface when passing that point. That point can be some known marker or simply "first third." Obviously, that point will have to be determined for the specific runway before the approach is begun.

Click here to download the full report from the NTSB website.(link updated for June)

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