
Safety Initiative Survey - New Video Series
Again, thanks to those of you who participated in the Safety Initiative Survey. Based on your input, we are happy to announce a new video series sponsored by Avemco. The "Essential Vectors" series of videos presents important concepts for general aviation pilots in brief segments. The first video in the series is "Emergency Essentials." Click here to view it on YouTube. We have also just released the second video in the series, "Crosswind Landing Essentials." Click here to view it on YouTube. Or better yet, subsc
Thanks to Finger Lakes Regional Airport and FLAPs
I was privileged to present "Just this Once" in Seneca Falls, NY on February 17. The Airport and Finger Lakes Area Pilots (FLAPs) sponsored the event and provided the venue, pizza, and soda. We had a great turnout. Thanks for inviting me, the great interaction, and of course the pizza!
Upcoming Live In-Person and Virtual Events
On Saturday, March 23, I will be presenting "Beware the Double-D Danger" which addresses delayed decisions at the annual Syracuse Aviation Safety Stand Down. We will have some nice door prizes courtesy of Avemco and others. Also, lunch is free! Plan to attend and be sure to say hello. Click here for more information and to register.
On Wednesday April 9, I will be the guest presenter on the American Bonanza Society Webinar Series. The topic is "Beware the Double-Danger." For more information, click here.
On Webinar May 8, I will be in Lancaster, NY at EAA chapter 46 to present Dealing with the Big E - Surviving the Inflight Emergency."
Thanks to Avemco Insurance for sponsoring all of my live presentations and for providing some very nice giveaway items for attendees at in-person events.
Planning an Aviation Event?
I have updated my presentation equipment and am open to conducting both live, on-site and virtual events. If you have an upcoming event and would like to have me deliver one of my presentations, please contact me at gene@genebenon.com. Click here to download my current presentation catalog.

The following is reprinted from the March 2023 Issue 518 of the NASA CALLBACK series.
Double Down on the Heads Up
Flying in less-than-ideal conditions, a Flight Instructor and student suffered predictable consequences immediately after they took a short, dual recess from their instrument scan.
In continuous moderate turbulence while performing the course reversal on the RNAV Rwy 19 approach into 9D4 with a 50-knot wind out of the southwest, my student disconnected the autopilot when he thought it was not going to be able to complete the parallel entry to the final approach course. He initiated a steeper turn than the autopilot had and then went heads down to look at the approach plate. I was also heads down looking at the approach plate when I noticed increasing positive G-forces and looked at the instruments. We were in a 45-degree bank losing 2,000 FPM of altitude. I immediately called bank angle twice and shielded the controls as the learner recovered. We lost 800 feet and ended up well below the minimum altitude for that segment of the approach. ATC notified us of a low altitude alert, by which time we were already recovering in a stable climb. There is an antenna in the area that reaches 1,927 feet MSL, less than 600 feet lower than our lowest altitude.… This was a poignant lesson for the student on the importance of maintaining an instrument scan, but our safety margin was fairly low. An incorrect recovery input could have quickly turned the upset into a disaster. The aircraft does not have an aural warning when the autopilot is disconnected, which would have [alerted] both of us…that the aircraft was being hand flown. In its absence, I recommend pilots announce…that they are disengaging the autopilot.

What Defines a Great Pilot?
Most people, if asked to name a great pilot, would look back in history for pilots who had been the first to accomplish an aeronautical feat or they would name pilots who had set records. Perhaps they would cite a well-known aviation author or podcaster or maybe they might think about a popular airshow performer.
I do not believe that fame or name recognition necessarily means that the person is a great pilot. Most of the pilots whose names would come up probably are great pilots but my experience has shown me that many pilots who never seek public attention are also great pilots.
I have flown with hundreds of pilots who had a wide range of experience and certification levels. It should be no surprise that I have an opinion on the criteria to be considered a great pilot. I realize that others may have differing opinions and I respect that. In my opinion, a great pilot is one who strives to continue on a path of continuous improvement and learning. Making mistakes and maybe even having a mishap does not disqualify a pilot, providing the pilot learns from the mistakes and takes steps to avoid repeating them. The great pilot learns and follows regulations and recommended procedures on each and every flight and does not take shortcuts in the interest of expediency. But here is the most important point. I think that most pilots who have received good instruction start out on the right path. Sometimes circumstances tempt the pilot to deviate just a bit from what they know is right. Each deviation that does not end badly reinforces further deviation in the future. As the pilot strays more and more, the deviations become normalized and a bad ending is often just ahead. That pilot is disqualified or often deceased.
I propose that a newly certificated pilot is very likely to be a great pilot according to my criteria. If that pilot continues on the right path and makes proficiency and safety a priority, then the title, “great pilot” remains regardless of the presence or absence of fame or name recognition.
Are you a great pilot according to my criteria? I hope so because I hate to lose readers because they died in a crash. If you are not a great pilot by my criteria, it is not too late to get on, or get back on, the right path.
The accidents discussed this month have the failure to follow a procedure as their common thread. great pilots know the procedures for the airplanes they are flying and follow them every time.

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
Two people died in the crash of this Cessna 441 in Tennessee, which occurred in February of 2021. The NTSB report includes the following: "The pilot was conducting a cross-country flight and was beginning an instrument flight rules approach from the south. Weather conditions at the destination airport included a ceiling between 800 and 1,000 ft and light rime icing conditions in clouds; the pilot was aware of these conditions. Elevated, wooded terrain existed along the final approach course."

NTSB Graphic
The NTSB report continues: "Radar and automatic dependent surveillance-broadcast data revealed that the airplane crossed the intermediate approach fix at the correct altitude; however, the pilot descended the airplane below the final approach fix altitude about 4 miles before the fix. The airplane continued in a gradual descent until radar contact was lost. No distress calls were received from the airplane before the accident. The airplane crashed on a north-northwesterly heading about 5 miles south of the runway threshold. The elevation at the accident site was about 1,880 ft, which was about 900 ft higher than the airport elevation. Postaccident examination of the airframe, engines, and propellers revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation."

Instrument Approach Chart
The NTSB report continues further: "Because of the weather conditions at the time of the final approach, the pilot likely attempted to fly the airplane under the weather to visually acquire the runway. The terrain along the final approach course would have been obscured in low clouds at the time, resulting in controlled flight into terrain."

NTSB Photo
The NTSB Probable Cause states: "The pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain."
The pilot is listed as an occupational pilot holding ATP and flight instructor certification, age 78 with total flight time of 18,800 hours. The pilot-rated passenger is listed as holding commercial pilot, instrument and flight instructor certification, age 58, with total flight time of 775 hours. Both pilots had current FAA class 2 medical certificates.
Instrument pilots reading this know that intentionally descending below specified altitudes is unwise. The highly experienced pilot clearly knew how to fly the approach safely yet chose to deviate from the established procedure. Why? It was probably done to save a few minutes on the approach. Had he done that before and gotten away with it? We do not know, but it seems unlikely that a pilot with more than 18,000 flight hours accumulated over many years would suddenly decide to deviate from such a critical procedure. A pilot who chooses to deviate from a procedure once and has a successful outcome is much more likely to deviate again. Eventually, deviating becomes normalized and continues until a flight ends very badly.
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.

Photo Source: Desert News
If anyone was setting out to create a public relations campaign against general aviation, this crash would probably be featured. The pilot, as it appears from the NTSB accident report, was not properly certificated, failed to adequately plan for fuel, and did not follow established procedures for a power loss on one engine. The result was a crash and explosion into a residential neighborhood endangering many people. The pilot died in the crash, but fortunately there were no other reported injuries or deaths. Under the pilot information section of the NTSB report, the pilot is listed as having a Private Pilot Certificate with ratings for single-engine land and single-engine sea. Yet, he was flying and had regularly flown a Cessna T310. His flight time was estimated to be 13,000 hours. The crash occurred in Utah in January of 2020.

Graphic Source: NTSB
The NTSB report includes the following: "The pilot was conducting a personal flight to relocate the twin-engine airplane back to his home base following maintenance. A leak check on the left-wing tip fuel tank was also performed prior to the flight. About 2 1/2 gallons of fuel was added to the tank to perform the leak check. According to a witness, the pilot did not refuel the airplane prior to the accident flight."

Photo Source: Desert News
The NTSB report continues: "Another witness reported hearing popping sounds as the airplane approached the destination airport and thought that one of the engines was trying to restart while it flew overhead. The witness also stated that the landing gear and flaps were extended. A third witness saw that the airplane was in a yaw to the left and appeared to be struggling to stay airborne. Subsequently, the airplane’s left wing dropped, the airplane momentarily stabilized, and the left wing dropped again, banking the airplane further to the left. The airplane continued to the left when the nose dropped and was soon out of view."

Photo Source: Desert News
Also included in the NTSB report: "Postaccident examination of the airplane revealed that the left propeller blades exhibited minimal rotational signatures, which is consistent with the left engine producing low-to-no power at the time of impact. The visual evidence indicated the left propeller was not feathered at the time of impact, which was counter to procedures indicated for operating with one engine inoperative during flight. The right propeller blades showed evidence of the engine operating at mid-to-low power at the time of impact. Examination of the airframe and engines revealed no evidence of preaccident mechanical malfunctions or anomalies that would have precluded normal operation. It is likely that during the flight, the left-wing tip fuel tank’s remaining fuel was exhausted, resulting in the loss of power to the left engine. Available evidence suggests that the left engine shut down during flight due to fuel starvation, resulting in the airplane yawing to the left with a decrease in performance followed by banking left."

Graphic Source: NTSB
And perhaps the most revealing information is also included in the NTSB report: "The pilot was known to land the airplane on a single engine on multiple occasions. He was also described as not likely to declare a flight emergency because of the paperwork involved. It is likely after he lost power to the left engine, the pilot continued his approach to his destination without declaring an emergency. As the flight continued there was a loss of airspeed, which resulted in the airplane entering multiple aerodynamic stalls, which precipitated the final left turn toward the accident site."
The NTSB Probable Cause finding states: "The pilot’s inadequate preflight fuel planning and fuel management, which resulted in a total loss of power to the left engine due to fuel exhaustion. Also causal was the pilot's failure to follow the one-engine inoperative checklist and maintain the airplane's minimum controllable airspeed by properly configuring the airplane, which resulted in a loss of airplane control."

Photo Source: Desert News
The pilot, age 64 was a very successful business man. He was the founder and president of a ski technology company. We do not know if it applies here, but I have written before about "success transference" in which an individual who is very successful in one field comes to believe that they are somehow automatically successful in all things. Of course, one of the prominent cognitive biases and a nearly universal human trait, illusory superiority, may also be involved.
As pilots, we must always remember that when we choose to operate outside accepted procedures and regulations, we not only endanger ourselves and our passengers but also those people beneath our flight paths.
ps. Pilots need not fear the repercussions of declaring an emergency and doing so opens a variety of assistance. Click here to watch our video, "The Big E - Emergency."
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 mishap occurred in New Mexico in October 2022. The airplane was a Piper Malibu Mirage (PA 46-350P). The 69-year-old pilot and his passenger were not injured. the NTSB report includes the following: "As the pilot approached the destination airport, the wind was reported as light and variable. He stated that as he flew the visual approach to runway 4 and prepared to land, he encountered a major gust of wind and elected to perform a go-around. The pilot reported that he applied full engine power, retracted the landing gear and flaps, and initiated a climb when the “stall shaker started shaking”. The pilot lowered the nose to prevent the airplane from stalling and initiated a gear-up landing to an open field adjacent to the runway."

Photo Source: NTSB
The NTSB accident report includes the following: "The pilot reported encountering a gust of wind; however, the wind reported at the airport 4 minutes before the accident was from 180 ° at 11 knots. The wind reported about an hour after the accident was from 160° at 10 knots. Neither weather report indicated wind gusts or significant changes in wind direction. The calculated crosswind component at the time of the accident was about 7 knots, with a tailwind of about 8 knots."
and the NTSB report continues: "Postaccident examination of the airplane revealed no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. Given the pilot’s description of the go-around and the absence of a mechanical failure or malfunction, he likely retracted the flaps before establishing the required climb airspeed and positive rate of climb. The quartering tailwind would have contributed to the loss of expected airplane performance, resulting in an incipient stall and the subsequent gear-up landing."

Google Earth view of the Clovis regional Airport (Annotations by GB)
The NTSB Probable Cause states: "The pilot’s failure to follow the go-around procedures by prematurely retracting the flaps and not establishing a proper go-around climb speed after attempting to land with a quartering tailwind, resulting in the airplane’s inability to climb."
Far too many crashes happen during faulty go-around attempts. We need to know the correct procedure and practice it regularly. This pilot made a good decision to settle for the gear-up landing which resulted in only damage to the airplane and not injury to the occupants. I recommend that pilots review the go-around procedure each time they are on downwind leg of the traffic pattern or when they near the airport if landing straight in as in an instrument approach.
Click here to download the accident report from the NTSB website.
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