Stow It!
I know of a pilot who once received a call from the tower, just as he was taking the active runway for departure, informing him that his tow bar was still attached. He shut down, removed and stowed the tow bar and was on his way. To his chagrin, the airport diner constantly broadcast the control tower audio to all present. The pilot became the butt of many jokes for the next year.
But embarrassment is not the worst possible outcome of forgetting to disconnect and stow the tow bar before engine start. Many of these oversights result with a tow bar into a prop requiring an engine teardown. And if we think that is a bad outcome, taking off with the tow bar attached resulted in an accident with serious injuries and a Piper Lance destroyed in 2020. (Click here to download that accident report from the NTSB website.)
Do you think that you would never forget to disconnect the tow bar? We all think that we would not do that, but the pilot in the Lance accident had more than 3,000 hours and was a commercial pilot rated in single and multi-engine airplanes. We are humans and we make human errors. In my work in error reduction for various industries, the problem is first identified, then it is engineered out to the extent practical. (Our cars' transmissions will not come out of park unless the brake is applied, the lawnmower engine stalls if we release the bar on the handle, etc.) Finally, we provide appropriate human factors training to operators to raise their awareness of common human error causal factors.
Applying that principle to the tow bar problem, we have missed the engineering step. I suppose we could somehow route extra P-leads to prevent engine start with the tow bar attached, but we engineer out problems to the extent practical, and this is not a practical solution.
So, here are two things that might help. First, add "Tow bar removed and stowed" to your pre-start checklist. Second, it's time for arts and crafts. See the photo below. Just using things I had in my office, I took a badge holder from a convention and a cable bundle tie. I replaced the convention name card with "TOW BAR" printed on plain paper. The tag should be placed around the tow bar when it is stowed. As soon as the tow bar is removed from its stowed location, the tag should be placed around the control yoke or the throttle. When the tow bar is stowed after use, remove the tag from the yoke or throttle and place it around the tow bar in its stowed position. If a distraction during preflight inspection results in failure to remove the tow bar, the presence of the tag in the cockpit should provide a reminder.
Latch it!
Many accidents happen because of a distraction presented during a critical phase of flight. One example of such an accident is the crash of a Cessna 172 when the pilot notices that a passenger window was unsecured during the takeoff roll. No one was injured in the resulting runway excursion, but the airplane received substantial damage.
Mitigation for this kind of accident takes two steps. First, make sure that everything that needs to be latched is actually latched. Second, resolve to fly the airplane regardless of what else is happening.
Click here to download the accident report from the NTSB website.
Snug It!
It is our responsibility ensure that our passengers are secured in their restraints. A second row passenger in a Piper PA32R received a serious neck injury when she hit her head on the cabin ceiling during an encounter with turbulence. The passenger stated that she was familiar with the operation of the seat belt and flew in the airplane about once or twice a month for many years, but on this flight, she did not tighten the lap belt sufficiently. We cannot assume passengers, or even other pilots, will always secure their restrains. A pre-takeoff passenger briefing is required by regulation and a reminder at the first sign of turbulence is experienced.
Click here to download the accident report from the NTSB website.
Brief It!
I have often told the story about how, on my first flight as a first officer, the captain looked my up and down and pronounced, "Alright son, you can ride up front but don't touch nothin'." Perhaps the captain was correct being cautious of what I might do. I was in my early 20s but looked like I was 14. A recent accident illustrates the need to brief our passengers on flight deck etiquette. We can probably be more diplomatic than telling them, "Don't touch nothin" but the message is the same. Part of our passenger briefing should include instructing passengers that they must stay clear of flight controls and not touch any switches or levers without specifically being asked to do so by the pilot. No one was injured in this accident, but the Beech 55 Baron was substantially damaged. Shortly after landing, the front seat passenger, in an attempt to assist the pilot by raising the flaps, inadvertently retracted the landing gear.
Click here to download the accident report from the NTSB website.
Watch It!
I have created a new video titled, "Dealing With Sleet." March is a prime month for encountering sleet in some parts of the U.S. especially where I live in Western New York State. The video is brief, a little less than seven minutes. Click here to view it on YouTube.
Enroll in it!
Our main focus for March is the importance of knowing when to be assertive and knowing how to do it effectively. We created a YouTube video on the subject a few years ago, but we have just released an online course titled, "Being Effectively Assertive." Successful completion of the course and the associated quiz is valid for 1/2 credit for Advanced Knowledge-3 in the Wings program. The course will require approximately 40 minutes to complete, including the quiz. The course is free. Click here to enroll.
Subscribe to it!
Many of you know that in addition to aviation, I have a passion for applying human factors to improving human performance and reducing errors. I am now writing a biweekly post on LinkedIn titled, "The Being Better Blog." A new article will be posted every other Wednesday. The first edition is up now and the second edition will be available on March 2. I am beginning with a series of articles on decision making. You do not need a LinkedIn account to view or subscribe to the blog. Click here to check it out.
When and How to Be Assertive
What does it mean to be “Pilot-in-Command?” The FAA states, “The pilot-in-command of an aircraft is directly responsible for and is the final authority as to the operation of that aircraft.” That is a lot. We are directly responsible for the safe operation of the aircraft. WE are directly responsible for the safety of ourselves, our passengers, and the people and property in the vicinity of our aircraft and below our flight paths. We have final authority as to how the aircraft is operated or if it is operated at all. Again, that is a lot.
The issuance of a pilot certificate bestowed upon us that responsibility and that authority. Part of the responsibility, as we addressed in this space last month, is to maintain our proficiency both in skill and in knowledge. Part of the authority is to know how to use it effectively. For help with that, we look to human factors.
One of our widely recognized human error causal factors is “lack of assertiveness.” Being assertive is not the same as being aggressive or bullying. It is the ability to express opinions and needs in a positive and productive manner. It is of course, not limited to aviation but aviation will be our focus here.
A pilot’s lack of assertiveness has contributed to many accidents over the years. We have instances of pilots not being assertive with ATC when needed. Pilots have crashed after taking off with known maintenance issues or after taking off into adverse weather conditions when they were uncomfortable.
Before we continue, we should state that being assertive assumes that we are knowledgeable enough to be correct in what we want. Remember the old saying, “Be careful what you wish for because you might get it.”
We can look at situations requiring assertiveness as being either immediate or not immediate. Different approaches are needed for each. We will look at the immediate situations first. Immediate situations require immediate action. That action is determined by either rapid or urgent decision making. (For more information on decision making, check out our video “Better Decision Making” on YouTube.) With our decision on what action is required made and with no time to waste by debating, we exert our authority as P-I-C and do what is necessary. If ATC is involved, we simply declare an emergency and inform them what we are doing. That may be a course reversal, a change in altitude, a return for landing on a specific runway, or whatever else is needed in the interest of the safe operation of your aircraft. If we are given an instruction by ATC that we believe is impractical or unsafe, we simply state, “UNABLE.” (Note that we did not include inconvenient in that.) If we know of a viable alternative to the instruction we just declined, it is helpful to state it to the controller. We must also be realistic and not demand something that unreasonably puts other aircraft at risk.
Situations not requiring immediate action might involve a flight into adverse weather, a flight that would require an overweight takeoff or a takeoff from a runway that is only marginally long enough, a flight that violates your personal minimums or the IM SAFE checklist, a flight for which the pilot does not meet recent experience requirements, or a flight with a known aircraft discrepancy.
We have an established process to follow if our situation does not require immediate action. There are necessary steps to take. First, we must get the attention of the person or persons pressuring us to make the flight or do something that makes us uncomfortable while enroute. We must state the problem clearly and without exaggeration. Second, again without exaggeration, we must state the likely consequences. Third, we must offer a viable solution. Finally, we must solicit feedback. The situation and the actions to be taken can be discussed or debated, but we must remember our responsibility and authority as P-I-C and make the final decision. (For more information and an example, check out our YouTube video, “How to be Effectively Assertive”).
In summary, we are given enormous responsibility and authority as pilot-in-command of an aircraft. To be worthy of that, we must strive to be as knowledgeable and proficient as we can and we must know how to responsibly and effectively be assertive in the interest of safety.
One of the accidents detailed below involving a Cirrus SR20 included "lack of assertiveness" in the NTSB probable cause. Scroll down to see it.
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.
NTSB Photo
This crash resulted in serious injuries to the pilot and his passenger. The Piper Lance was destroyed in a post crash fire. It occurred in Missouri in October 2020. The NTSB accident report includes the following: "The pilot reported that he moved the airplane out of the hangar using a tow bar and his personal vehicle. The pilot added that he did not remove the tow bar from the airplane. The pilot and passenger then departed on a cross-country flight. Witnesses at the airport notified the pilot by radio that the tow bar was still attached. The plot then entered the traffic pattern to land at the airport. During the approach the tow bar, which was hanging from the airplane’s nose wheel, impacted and got entangled in trees. The airplane then impacted ground objects and terrain. A post-crash fire ensued and destroyed the airplane. The pilot added that he did not know why he got so low on the approach to the airport."
NTSB Photo
The 73-year-old commercial pilot had more than 3,000 hours total time and was rated in both single engine and multiengine airplanes. He had completed a flight review in the accident airplane about eleven months prior to the crash. He reported having flown 15.4 hours in the past 90 days, including 4 hours in the past 30 days.
The 73-year-old commercial pilot had more than 3,000 hours total time and was rated in both single engine and multiengine airplanes. He had completed a flight review in the accident airplane about eleven months prior to the crash. He reported having flown 15.4 hours in the past 90 days, including 4 hours in the past 30 days.
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 accident involving a Cirrus SR20 took the lives of three people. It happened in Texas in June of 2016. The NTSB report includes the following: "The pilot was attempting to land the airplane at a busy airport with high volume airline traffic. While attempting to sequence the airplane between airplanes, the air traffic controller issued numerous instructions to the pilot, which included changing runways multiple times. The pilot was instructed to go around twice by the local controller; the first time because an air carrier airplane was overtaking the accident airplane and the second time because the airplane was too high to make a safe landing. During the airplane's third approach, a new local controller came on duty. On this approach, the pilot again had difficulty descending fast enough to make a safe landing, and she elected to perform another go-around. The new local controller then issued the pilot a lengthy clearance as the pilot was performing the go-around procedure. Data retrieved from the airplane revealed that, during the go-around, the pilot did not follow the recommended go-around procedure; specifically, the pilot did not attain a speed between 81 to 83 knots indicated airspeed (KIAS) before raising the flaps. Rather, the airplane's airspeed was 58 KIAS when the pilot raised the airplane's flaps while in a left turn, which resulted in exceedance of the critical angle of attack and a subsequent aerodynamic stall and spin into terrain."
Photo Source: NTSB
The NTSB accident report continues: "The pilot was attempting to comply with ATC instructions throughout the flight and the pilot's actions are understandable as the instructions were largely consistent with the pilot's goal to land at the busy airport. However, compliance with ATC instructions greatly increased the pilot's workload as it led to an extended period of close-in maneuvering at a Class B airport due to the larger and faster airplanes converging on the airport. During this extended period of maneuvering the pilot did not assert the responsibilities that accompany being a pilot-in-command and did not offload the workload by either requesting to be re-sequenced, telling the controller to standby, or stating "unable." This allowed for an increased likelihood of operational distractions associated with air traffic communications and affected the pilot's ability to focus on aircraft control."
NTSB Graphic
The NTSB Probable Cause finding states: "The pilot's improper go-around procedure that did not ensure that the airplane was at a safe airspeed before raising the flaps, which resulted in exceedance of the critical angle of attack and resulted in an accelerated aerodynamic stall and spin into terrain. Contributing to the accident were the initial local controller's decision to keep the pilot in the traffic pattern, the second local controller's issuance of an unnecessarily complex clearance during a critical phase of flight. Also contributing was the pilot's lack of assertiveness."
The 46-year-old private pilot had 332.6 hours total flight time including 303.6 hours in this make and model including 7 hours in the 30 days. The accident date was June 9, 2016 and the pilot had passed the private pilot checkride on May 2, 2014. Therefore her flight review was not current, but only by a few days. We will never know whether a recent flight review would have included a review of go-around procedures and may have prevented this crash.
We must always remember that as pilot-in-command, we must decide on a desired course of action and then be assertive to make that happen.
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 fatal crash in involved loss-of-control inflight in a Beech A36 Bonanza. It happened in North Carolina in September 2015. The 55-year-old instrument rated private pilot had about 750 hours total flight time. He had completed a flight review five days prior to the crash and had received a third class FAA medical certificate about five months prior to the crash.
NTSB Photo
The NTSB accident report includes the following: "The private pilot had recently purchased the airplane and it was more complex than the airplane he had flown previously. The accident airplane was also equipped with an upgraded avionics suite. The pilot had practiced loading and flying instrument approaches with the new avionics during recent flights with a flight instructor and another pilot onboard, and the flights were conducted in visual meteorological conditions (VMC). The pilot's most recent logbook was not available for review, so his instrument currency, as well as his recent and type of flight experience could not be verified."
NTSB Photo
The NTSB accident report continues: "Review of the flight from departure to entry into the arrival airport's airspace revealed no unusual events or problems, and it was conducted in VMC. However, once the pilot began the higher workload phase of flight preparing to execute the instrument landing system (ILS) approach in actual instrument meteorological conditions, he began to exhibit some uncertainty and confusion. The first approach controller had to confirm the runway assignment three times and the pilot's assigned altitude once. After contacting a second approach controller, who vectored the flight to the ILS, the pilot had difficulty becoming established on the localizer, eventually causing the controller to cancel the approach clearance and issue vectors for a second attempt at the approach.
The instructions issued by the second approach controller were not complicated, but the pilot had difficulty flying assigned headings and altitudes. The controller also did not immediately detect some of the unusual maneuvers conducted by the pilot or recognize that he was perhaps suffering from spatial disorientation until the pilot explicitly said so. Instead of simply issuing a single heading and having the pilot climb a few hundred feet back into VMC, the controller asked the pilot if he was able to accept "no-gyro" vectors. The pilot accepted the offer, and the controller then issued turn instructions that required turns in both directions. This excessive maneuvering possibly exacerbated the pilot's spatial disorientation. The controller then directed the pilot to climb in an attempt to get him into VMC, but shortly thereafter, the airplane entered an aerodynamic stall/ spin and impacted terrain. When interviewed, the controller was unable to explain the basics of no-gyro vectoring and was unable to demonstrate the ability to effectively provide the service."
NTSB Photo
The NTSB Probable Cause finding states: "The pilot's loss of airplane control due to spatial disorientation, which resulted in an aerodynamic stall/spin. Contributing to the accident was deficient Federal Aviation Administration air traffic control training on recognition and handling of emergencies, which led to incorrect controller actions that likely aggravated the pilot's spatial disorientation."
Though not mentioned in the probable cause finding, perhaps the pilot could have avoided the loss-of-control by being assertive with the controllers. He was certainly aware that he was struggling to follow instructions and to properly execute the approach. Apparently, the pilot explicitly stated that he was suffering from spatial disorientation. Only the pilot can determine when the task load and capabilities curves are about the cross. He most likely knew that visual conditions existed only a few hundred feet above his altitude. Had he simply told the controller that he wanted to cancel the approach and receive vectors to VFR conditions, he might have been able to overcome the spatial disorientation. He then could have either attempted the approach again or preferably, received vectors to an airport with VFR conditions.
For more information on how to be more effectively assertive, see the article above in Gene's blog.
Click here to download the accident report from the NTSB website.
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