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Vectors For Safety - March 2023

Safety Initiative Update

"Just This Once"

We are excited to be rolling out our new program, "Just this Once." The live presentation will be premiered at the Syracuse NY safety stand down on March 25. Click here to visit the Events page for more information. The online course associated with this project, along with a video presentation, will be released on March 27. Check the Vectors website for the links. If you would like a no-charge virtual presentation for your flying club, FBO, flight school, or any other group of at least 10 people, please let me know via email and we will work out a schedule. We thank Avemco Insurance for their support of this project.

Check It Out!

If you have not seen any of our "YouTube Shorts" videos yet, check them out. Click here to visit the playlist on YouTube.

Recommended Free Online Course

Somewhat in line with this month's blog, our course "Combatting Mental Inertia" addresses how pilots sometimes continue or begin a flight that is clearly beyond the capabilities of themselves or of their aircraft. Completion of the course and the quiz is valid for 1 credit, Basic Knowledge-3 in the FAA Wings program. Click here to visit the course.

Sara Update!

Granddaughter Sara has completed her training course! She is now Commercial Pilot, SEL-MEL, Instrument-airplane, CFI, CFII, MEI. Not bad for 19-years-old! Grandpa is very proud! I hope that she always remembers to fly like her life depends on it!

Avemco Insurance sponsors Gene Benson
Gene's Blog

Don't Believe Your Own Press

The phrase “Don’t Believe Your Own Press” is often attributed to the actor Leif Garrett. His entire quote was “Don't believe your own publicity. You can't; you'll start thinking that you're better than you are.” He was likely talking about press releases and the hype coming from the media. Most of us general aviation pilots do not have a public relations department working on our behalf. We do, however, have reputations developed either within aviation or in other fields and those reputations can influence our self-confidence overall.

Self-confidence is good until it isn’t. The human factors world refers to excess self-confidence as illusory superiority. That is a cognitive bias in which a person believes that they are smarter or have more knowledge or skill than the next person. The unfortunate aspect of that is developing an unrealistic belief in our overall abilities.

Clearly skill and knowledge in one area does not automatically transfer to another area. The highly skilled and successful attorney or physician is not automatically a superior any more than the superior pilot is not automatically a competent attorney or physician.

The concept also applies to a specialty skill set within a field. The skilled heart surgeon might not be an appropriate choice for performing a knee replacement. The successful mergers and acquisitions attorney might stumble as a defense attorney in a murder trial. The experienced captain of widebody airliners might not be a good candidate to ferry an Aeronca with no gyro instruments nor electrical system to the other side of the country. The highly regarded airshow performer might have difficulty in the execution of a single pilot, hard IFR flight in a complex multiengine airplane into a busy metropolitan airport.

It is also important to recognize that holding higher or additional certificates and ratings does not guarantee competency on a particular flight especially if recent experience is not very recent. Just as the attorney advertisements state that past performance does not guarantee future results. Past experience does not guarantee future competence.

It is important for us to recognize our personal areas of expertise and not mentally transfer that competency to other areas, even if those areas are loosely connected.

broken image

The following article is reprinted from the NASA CALLBACK PUBLICATION #503 of December 2021.

Quick actions resolved a critical conflict that had no definitive singular cause nor any discernable warning.

 

■ My student, whom I was instructing at the time, made his departure call from Runway 23 at Monroe. We cleared the runway visually and didn’t see anyone. I always look at our oil pressure and temperature and verify ‘airspeed alive,’ which it was. We rotated at 60 [mph] and began to climb out. At about that time, I saw another small aircraft right in front of us climbing out from the opposite runway. I couldn’t believe it! Where…did this aircraft appear from? Evasive action was needed, so I took control and turned to the right with approximately 30 degrees of bank and 40 degrees of [heading] change to avoid collision. I called out frustrated but not mad, “Aircraft departing Monroe opposite direction, didn’t you hear us announce departure?” …They replied, “No we did not.” …I think this situation…developed [from] the light and variable wind we had and the confusion it can create for which runway should be used. Also, my student has a strong accent. Could it be that the…pilots in the other plane didn’t understand him? We had completed a radio check on UNICOM and had received a ‘loud and clear,’ so I know our radios were functioning properly. Another factor may be that our runway is highest in the middle and could have made it harder to see another aircraft coming [from] 7,000 [feet away] at the opposite end.

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, upon first look, would appear to be the classic VFR flight into IFR conditions. Most of those accidents happen when the pilot is either not instrument rated or instrument rated but not current on instrument flying. On occasion, we see an accident in which the pilot is rated and meets recent experience requirements, but the airplane has no gyro instruments. Though not certified for instrument flight, this airplane did have basic gyro instruments installed. This case is different in that the pilot was a qualified and current Naval aviator. At age 31, he was qualified as aircraft commander in the E‐2C Hawkeye. His present assignment was as an instructor in the T-45 Goshawk jet trainer. He also held a civilian Airline Transport Pilot Certificate and had recently received his civilian Flight Instructor Certificate.

E2C Hawkeye and T-45 Goshawk in flight

According to the NTSB accident report, "The airline transport pilot, who was a US Navy flight instructor and newly certificated civilian flight instructor, was flying his cousin to his home base where he planned to provide her with initial flight training. He received a weather briefing earlier in the day, and the briefer indicated that visual flight rules (VFR) flight was not recommended due to instrument meteorological conditions (IMC) at the surface. Despite the briefer's statement, the pilot indicated he planned on remaining VFR throughout the flight." The pilot and his 18-year-old college student cousin died in the crash.

ERA16FA074

Photo source: NTSB

The NTSB report continues, "Before taking off for the accident flight, during ground operations, the pilot discussed the weather with a former flight service station pilot weather briefer, who told the pilot that the weather was "really bad" in the direction of the pilot's destination, and the pilot agreed, yet he chose to depart anyway. He reported that the pilot appeared to be "in a hurry." No evidence was found indicating that the pilot received any additional weather briefing information before taking off for the accident flight."

ERA16FA074

Photo source: NTSB

The NTSB report further states, "The flight departed to the northwest toward an approaching cold front. The conditions associated with the front included low clouds and mist. As the pilot proceeded toward his destination, the flight encountered the front, and the pilot declared an emergency with air traffic control (ATC), stating that he was in instrument flight rules (IFR) conditions and that his airplane was "not capable of IFR." Radar data of the final segment of the flight showed the airplane in a left, 180-degree turn for 43 seconds, immediately followed by a right, 90-degree turn for 37 seconds before radar and radio contact was lost. The last radar return was observed at an altitude of about 1,200 ft mean sea level."

The NTSB Probable Cause states: "The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's decision to initiate the flight into known adverse weather conditions, in an airplane that was not approved for instrument flight, which resulted in an encounter with instrument meteorological conditions and his subsequent spatial disorientation and loss of airplane control."

ERA16FA074

Photo source: NTSB

We must note that while the airplane was not certified for IFR flight, it did have the necessary instruments for basic attitude instrument flying. Certification for IFR requires the installation of pitot heat and alternate static source systems. The airplane was an amateur-built RV 4 which the pilot had purchased from the builder.

The pilot's father provided a written statement to the NTSB providing some additional information that is likely relevant to the perceived urgency of the flight. He stated in part, "Clearly, both were very driven and highly motivated individuals who pushed themselves to squeeze the experience of her learning to fly a small plane into already crowded lives. James had told me he was extremely busy at work leading up to the flight, sometimes leading as many as three training flights per day at NAS Meridian. He pushed himself to get his CFI expressly for the experience and had just obtained it beforehand. Maitland's entry showed her as having worked hard at school followed by a burst of self-study about flying leading up to the adventure. I don't think either one really had time for the experience, but they made the time anyway."

So why would a properly rated and highly skilled pilot begin a flight into such weather that he apparently recognized as very adverse? We are all aware of the strong influence of external factors and our humanness. In this case, there was a perceived need to work within a tight schedule. But the pilot was clearly familiar with the limitations of the airplane so perhaps he believed that his superior flying skill would overcome the shortcomings of the airplane. If that is the case, he demonstrated a common cognitive bias, Illusory superiority, which leads us to believe that we are more capable than the next pilot. This could have been amplified by his association with general aviation pilots who generally consider Naval aviators as being the epitome of skill, knowledge, and courage. We cannot know all the circumstances nor precisely what the pilot was thinking. But perhaps the quote, "Don't believe your own press" is a lesson to be learned here.

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.

A Mooney M20E, impacted terrain after departing the Angel Fire Airport in Angel Fire, New Mexico. The private pilot and three passengers were fatally injured. The group had been on a ski weekend in New Mexico and the accident happened shortly after departure for their return flight to the Dallas-Ft. worth area of Texas.

 

Before we get into the details of this accident, let’s always remember one thing. Our aeronautical decisions are made on behalf of ourselves and our families, our passengers and their families, the people beneath our flight paths and their families.

In addition to the pilot, three other people also lost their lives. They were the pilot’s girlfriend age 26, the pilot’s sister, age 41, and her daughter, the pilot’s niece, age 13.

Actual accident airplane

Actual accident airplane

The NTSB accident report includes: "When the pilot arrived at the fixed base operator (FBO), an employee from the FBO questioned the pilot's intent to fly in the windy weather. The pilot indicated that he planned to fly and that the winds would not be a problem. When the pilot radioed on universal communications (UNICOM) that he was taxiing to runway 17, the current wind and altimeter were relayed to the pilot by the FBO employee, which were repeated by the pilot. Due to snow piles on the airfield, the FBO employee could not see the takeoff and next saw the airplane airborne with a significant crab angle into the wind, about 40 degrees right of the runway heading. The airplane rose and fell repeatedly as its wings rocked. Then employee saw the airplane's right wing rise rapidly. The airplane rolled left, and descended inverted with the airplane's nose pointed straight down."

 

The NTSB report also includes the following: “Before takeoff, strong, gusting wind from the west was present, so a fixed-base operator (FBO) employee asked the pilot about his intent to fly. He stated that the pilot seemed "confident" about his ability to fly the airplane and that he was not concerned about the wind.”

CEN13FA183

Photo source: NTSB

The pilot was a successful aerospace engineer, and a graduate of the University of Texas. He was a third-generation pilot. His grandfather had been a World War II pilot and his father had been a Naval Aviator. He held a Private Pilot Certificate with a Single Engine Land Rating. He had about 459 hours total flight time with about 384 of those hours in the Mooney.

CEN13FA183

NTSB Graphic with annotations by GB

The NTSB Probable Cause states: “The pilot's loss of control while flying in a turbulent mountain-wave environment. Contributing to the accident was the pilot's overconfidence in his ability to safely pilot the airplane in gusting wind conditions and his lack of experience operating in mountainous areas.”

CEN13FA183

Photo source: NTSB

Why did this pilot decide to depart under these circumstances? We must also look at the strong influence of external factors and our humanness. Possibly the pilot, his girlfriend, or his sister had a pressing need to return to work on Monday morning. Perhaps we see illusory superiority exerting its strong influence. The pilot was successful in his profession as an aerospace engineer. We often see a person who is successful in one area believing that they will be automatically successful in another area. Perhaps his growing up in a family of aviators instilled a belief that he possessed innate abilities in flying.

We cannot know what was going in the pilot's head. But if illusory superiority or "overconfidence" as the NTSB report says, played a role, we must again remember the quote, "Don't believe your own press."

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 perhaps fits into our theme of illusory success transference, but certainly illustrates the impact that external factors and continuation bias can influence a pilot's decisions. The 56-year-old current airline pilot and his 20-year-old son died in the crash.

CEN18FA384

Photo source: NTSB

The NTSB accident report states the following: "The commercial pilot and his son were conducting a cross-country flight from New York to Missouri. Before the final fuel stop, they communicated to the pilot's fiancée via text message that the airplane was experiencing a "small electrical problem." The pilot refueled the airplane about 275 miles from the destination airport and continued on the final leg of the flight into dark night conditions.

The passenger subsequently messaged the pilot's fiancée and asked her to stand at the end of the runway with a flashlight to help direct the airplane toward the runway for landing. He stated that they would attempt to use a handheld radio onboard to activate the runway lights but were unsure if the radio would have sufficient battery. The passenger also indicated that they had "picked up a head wind" during the flight.

The pilot's fiancée reported that the airplane attempted to land, but she was unsure if it touched down on the runway due to the night conditions and the fact that the airplane was "blacked out" and did not have any exterior lights on. The last text message from the passenger stated, "keep light on." The airplane impacted terrain about 1/4 mile from the departure end of the runway in a nose-down attitude consistent with an aerodynamic stall. The two intact fuel tanks contained no usable fuel, and the propeller blades lacked chordwise scratches or torsional deformation, consistent with a loss of engine power. No preimpact mechanical malfunctions or failures with the airframe and engine were noted during the examination, with the exception of the voltage regulator, which was found to be inoperable."

CEN18FA384

Photo source: NTSB

The NTSB accident report continues, "The pilot's fiancée reported that the airplane attempted to land, but she was unsure if it touched down on the runway due to the night conditions and the fact that the airplane was "blacked out" and did not have any exterior lights on. The last text message from the passenger stated, "keep light on." The airplane impacted terrain about 1/4 mile from the departure end of the runway in a nose-down attitude consistent with an aerodynamic stall. The two intact fuel tanks contained no usable fuel, and the propeller blades lacked chordwise scratches or torsional deformation, consistent with a loss of engine power. No preimpact mechanical malfunctions or failures with the airframe and engine were noted during the examination, with the exception of the voltage regulator, which was found to be inoperable."

CEN19FA384

Photo Source: NTSB

The NTSB report also includes the following, "Though the extent of the pilot's preflight and inflight fuel planning could not be determined, it is possible that the airplane consumed more fuel than planned, as the passenger indicated that the airplane had encountered a headwind inflight, and it is likely that the absence of a fuel quantity indication contributed to the fuel exhaustion.

Based on the location of the airplane relative to the runway, it is likely that the pilot initiated a go-around following the first landing attempt. During the go-around, the airplane experienced a total loss of engine power and the pilot subsequently failed to maintain airspeed and exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall and impact with terrain."

CEN18FA384

The NTSB probable cause states, "A total loss of engine power due to fuel exhaustion and the pilot's subsequent exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall. Contributing to the accident was the pilot's decision to initiate and continue the flight into dark night conditions with a known electrical problem."

We can never know what precisely the pilot was thinking, but we have a pilot who is currently working as an airline pilot and he is conducting a cross county flight in a very simple airplane in VFR conditions. There was likely some pressure to complete the flight due to work schedules so we see the possibility of external factors and continuation bias playing a role in the decision to depart into night conditions with no electrical system. We must consider the possible effects of illusory superiority and illusory success transference.

This is perhaps also in line with our topic, "Just This Once." Did the pilot feel pressure to complete the flight and decide that night flight with no electrical system would be okay just this once?

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

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