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Vectors for Safety - March 2021

Safety Initiative Update

Many Happy Returns Webinar Report

On February 25, we presented the latest webinar in the Avemco Pilot Talk series, "Many Happy Returns.". Our subject was the prevention of runway excursions and runway overruns. Thanks to all of you who attended! We had 829 attendees plus an unknown number of folks on the YouTube live stream. For those who could not attend but would like to earn the same credit as for the webinar (1 credit BK-3 plus 1 credit AK-2) we have created a free online course from the same material as was presented on the webinar. Successful completion of an online quiz is required to earn credit for the course.

Click here to access the course.

Also, a video of the webinar material is available on YouTube. Sorry, no Wings credit for viewing the YouTube video.

Click here to watch the video on YouTube.

Recommended Reading

Only after you have finished reading this month's "Vectors," I want to suggest a good article from the FAA. "I've Got the Flight Controls - Or Do You?" is worth the time to read.

Failure is not an Option

This now famous statement spoken by Gene Kranz during the Apollo 13 mission helped to steel the engineers, scientists, technicians, and astronauts to perform the seemingly impossible task of returning the crew safely to earth. Mission accomplished.

General aviation sees many serious accidents each year involving some flavor of either loss-of-control-inflight (LOC-I) or controlled flight into terrain (CFIT) following an encounter with instrument meteorological conditions (IMC). This involves both airplanes and helicopters, and both instrument rated and non-instrument rated pilots. The FAA, along with an entire alphabet of organizations, and many others, have worked hard and produced a myriad of publications, videos, and other tools to prevent this kind of accident. Mission not accomplished.

Why not? What can we do differently? Probably not much. Is anyone shocked by that statement? That is not a politically correct statement to come from someone heavily involved in safety work. (I have been accused of being many things but being politically correct has never been one of them.) Of course, there is always room for improvement, but we have the body of knowledge and effective mitigation tools available to each and every pilot. Yet, every accident report I have read involving this kind of accident in the past couple of years could have been prevented had the pilot taken advantage of the knowledge and tools available.

We know how to avoid these kinds of accidents. Unfortunately, the "we" does not include all pilots. Access to the information is mostly free to the user, yet a segment of the pilot population does not take advantage of it. Since you are reading this right now, you are not part of that disengaged segment. Thank you.

I am not proposing that we give up on the disengaged segment of pilots. For many years I asked my readers to become "Evangelists for Safety" and to spread the safety message. We must continue that practice and we must not become an enabler to unsafe pilots or operations.

But the bottom line is simple. Our flying must be done with the attitude that "failure is not an option." If we cannot spread that to all pilots, we can at least make sure that it applies to us.

Aerobatics Anyone?

We typically do not list items for sale in our Vectors publications. but an exception is in order here. Many of you know my friend and colleague, Layne Lisser from our webinars. Layne often handles the Q&A for us. Layne has decided to sell his beautiful Christen Eagle II. Click here to see the details.

Gene's Blog

As pilot-in-command we always have the right to cancel a flight. But do we have the strength and courage to do it? It is difficult to disappoint someone. It is even more difficult to take an action that we know will create difficulty or complications for someone. It is extremely difficult to take that same action when we have a strong relationship with the affected person. It often takes much more strength and courage to cancel a flight than to go along with a plan or a schedule.

Old movies used to depict hero pilots as superhuman, daring creatures that always accomplished the mission regardless of the obstacles. Those movies did not end with a scene of scattered aircraft wreckage and bodies strewn about a crash site. The real-life hero might be the pilot who, after careful consideration of weather, aircraft condition, pilot capabilities, and other factors, cancelled the flight, diverted, or turned back and allowed the passengers live and deal with their disappointment or complications. Heroes save lives rather than risk them.

The NTSB conducted a four-hour hearing in early February regarding the helicopter crash that killed Koby Bryant and eight others. We are still months away from probable cause finding from the NTSB, but statements made during the hearing leave little doubt that much of the blame will be placed on the pilot’s decision to attempt and continue the flight given the weather conditions.

In the meeting, investigators said the pilot may have felt pressure to perform for a high-profile client and continued flying into deteriorating weather conditions. The pilot developed a "very close" friendship with Bryant, one of the investigators said, a type of relationship that "can lead to self-induced pressure" to fly in risky conditions.

The investigators said he climbed into what witnesses described as a "wall of cloud," possibly became disoriented, and unconsciously turned into a cloud-obscured hillside he knew was there.

The helicopter crashed into hilly terrain in low visibility conditions in Calabasas, California. The passengers were heading from Orange County, California to a sports complex in Thousand Oaks, California for a youth basketball game in which Kobe Bryant was to coach and his daughter and two others aboard were to play.

We usually limit our discussion in this publication to airplanes, but the human factors at play are not concerned as to the category and class of aircraft. Nor do they exempt us when we are operating an automobile, a boat, a motorcycle, a lawn mower, or power tools. Our humanness wants us to complete our task and works hard to make us believe that we are capable and to hide evidence to the contrary.

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.


Photo source: NTSB

This tragic crash resulted in four people dying and one person seriously injured. The airplane was a Cessna T310Q. The crash occurred in California in February of 2017. We can learn from this crash that external factors can be an extremely powerful force with strong negative implications for a pilot's decision making.

This was to be a return flight to the home base of San Jose. Two days prior to the accident, the group had flown from San Jose to Riverside to attend a cheerleading competition involving a family member.

The NTSB accident report begins as follows: "The airline transport pilot and four passengers planned to make a 300-nautical-mile cross-country flight in the airplane to return home. They arrived at the airport about noon and loaded their bags into the airplane. The pilot made an unsuccessful attempt to start the engines, and the occupants deplaned and waited for some time. During a second attempt to begin the flight, a ground controller informed the pilot that he was required to file an instrument flight rules (IFR) flight plan before departure. After the occupants deplaned a second time, they went to the airport terminal where the pilot asked a flight school employee to provide instructions for filing an IFR flight plan. According to the flight school employee, the pilot appeared rushed, and the passengers were anxious to complete the flight. According to the surviving passenger, after one of the other passengers started to make ground transportation arrangements, the pilot's wife insisted they would fly the passengers home. The pilot filed an IFR flight plan, and the pilot and passengers boarded the airplane for the third time."

That paragraph illustrates how the stage was set for this crash. External factors are very strong motivators. The pilot would have felt considerable self-induced pressure to complete the flight since it was clearly important to the passengers. Then his wife added additional pressure when she insisted that they would fly the passengers home.

the NTSB report continues: "At the time of the accident, IFR conditions prevailed at the departure airport with a visibility of 2 miles in light precipitation and mist, scattered clouds at 600 ft above ground level (agl) and an overcast ceiling at 4,200 ft agl. It could not be determined when the pilot had last flown in instrument meteorological conditions or when he had last completed an instrument competency check. However, it is likely that the pilot was not instrument current as he was unfamiliar with basic instrument flight planning procedures and had to be coached through the readback of his IFR clearance."


Photo Source: NTSB

The NTSB report also includes the following: "The airplane departed normally and entered a climb. Seconds later, the airplane entered a cloud and began a turn, at which time it began to shake violently as the stall warning horn sounded, consistent with an aerodynamic stall. The airplane descended from about 900 ft above ground level and impacted multiple residences about 1 nautical mile from the departure airport. Examination of the airframe and engines revealed no evidence of any preimpact mechanical malfunctions that would have precluded normal operation. The blades of both propellers displayed rotational damage signatures that were consistent with the engines producing power at impact."

Though no one on the ground was injured, this serves as a reminder that not only the occupants of an airplane affected by a crash, but people going about their normal lives can be seriously impacted.
The 83-year-old pilot held an ATP Certificate and a current Class 2 FAA Medical Certificate. He also held a Flight Instructor Certificate with ratings for Airplane Single Engine Land and Instrument Airplane. His application for his medical certificate, about five months prior to the accident, indicated that he had 9,600 hours total flight time with 21 of those hours within the previous six months. It could not be determined when the pilot had last flown in instrument meteorological conditions or when he had last completed an instrument competency check. The pilot also purchased several terminal instrument procedure charts and en route low altitude charts from the FBO on the day of the accident. That perhaps demonstrates that the pilot was not intending to fly IFR but was pressured into doing so.


Photo Source: NTSB

The NTSB Probable Cause finding states, "The pilot's failure to maintain airplane control upon entering instrument meteorological conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Contributing to the accident was the pilot's personal pressure to complete
the flight despite the weather conditions."


Photo Source: NTSB

So in summary, we see a clearly and easily avoidable crash that took the lives of four people and left another with serious injuries. Additionally, at least three private residences were damaged. An additional casualty is the reputation of general aviation. An accident such as this, into a residential neighborhood, is precisely what calls for people living near GA airports to lobby for their closure. Click here to read a report from a local news source in the aftermath of this crash.

This is categorized as a loss of control-inflight. But clearly this was a human factors crash with the pilot falling victim to both self-induced and external pressure to depart. We have a large body of information on how to resist those pressures and we have tools, such as the personal minimums checklist or flight risk assessment tool to assist. We must remember to use those tools and we must encourage other pilots to do so also.

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 crash occurred in North Carolina in July of 2018. The 63-year-old pilot of the Piper Saratoga and his passenger died in the crash that occurred about one minute after departure. The purpose of the flight was to attend the air show in Oshkosh Wisconsin. The pilot did not possess an instrument rating, but he attempted the flight with 1 1/2 mile visibility in mist and ceiling 200 feet AGL, in dark night conditions. At the time of impact, the airplane was descending at greater than 4,000 feet per minute according to an onboard GPS recording.


Photo Source: NTSB

The NTSB report includes the following: "The restricted visibility due to the dark night and instrument conditions was conducive to the development of spatial disorientation, and the airplane's flight track was consistent with the known effects of spatial disorientation. According to a family member, the pilot stated that he was going to attend an air show and had planned to leave early in the morning for "a window of good weather." The crash occurred at 0521 local time.
The NTSB report also states: "Despite not being instrument rated, the pilot likely chose to depart due to his self-induced pressure to complete the flight as planned. It is likely that the pilot's decision to depart into IMC resulted in his spatial disorientation and a subsequent loss of airplane control."


Photo Source: NTSB

The private pilot had 624 hours total flight time. He had a special issuance Class 3 FAA Medical Certificate with the limitation "Not valid for any class after June 30, 2018." Since the crash occurred in July of 2018, his medical certificate was not valid at the time of the crash. The NTSB reports do not indicate the reason for the special issuance medical certificate nor for the early expiration date. He did have a current flight review.


Photo Source: NTSB

The NTSB Probable Cause finding states: "The noninstrument-rated pilot's intentional visual flight rules flight into instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing the accident was the pilot's self-induced pressure to complete the flight as

Once again we see the powerful impact of self-induced pressure.

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

Human Factors Ground School

Want to be a safer pilot and save money too? Learn much more about Human Factors by taking the Human Factors Ground School, authored and narrated by Gene Benson. Completing the course and the quiz qualifies for all three Wings credits at the basic level. Click here for more information and to enroll for 50% off through March 31, 2021. All proceeds are used to support the Safety Initiative.

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Books by Gene Benson

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