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Vectors For Safety - May 2022

Safety Initiative Update

Observe it!

Fueling that is. It really is a good idea to watch your airplane being fueled if at all possible. There have been accidents in which the wrong airplane has been fueled and the pilot takes off with insufficient fuel. There continue to be accidents caused by the incorrect fuel being put in the tanks. Jet fuel in your piston engine airplane will make for a very bad day. The ATP pilot of an Aerostar was probably flying both piston and turbine engine powered airplanes when he asked, twice, to have his piston powered airplane fueled with jet fuel. Though that is supposed to be impossible due to the design of the fuel nozzles, where there is a will there is often a way. The line service fueler figured out a way to hold the nozzle to that the jet fuel could be put in the tanks. Though the pilot had incorrectly asked for jet fuel, had he observed the convoluted way the fuel was being added, he probably would have realized that something was amiss. His error cost him his life. Click here to read the full accident report on the NTSB website.

Remove it!

The control lock that is. Taking off with a control lock inplace usually results in a fatality. Let's not do that! In addition to doing our dilligence during the preflight and/or pre-start checklists, following a procedure that we probably all were taught on our first flying lesson can eliminate the problem. Remember being taught, "controls free and correct?" Before we takeoff, we should always exercise the yoke or stick and rudder pedals to verify that the controls are free to move fully and that they move in the correct direction. The correct direction check also protects us from controls being rigged in reverse after maintenance, which happens more than often than we would think.

The pilot of an RV-8 died in June of 2020 after apparently not performing this check. The NTSB accident report lists the probable cause of the crash as, "The pilot's failure to remove the seat belt used as a flight control lock from the aft cockpit control stick before takeoff, which resulted in a loss of control during takeoff and collision with terrain." Click here to download the full accident report from the NTSB website.

Attend it!

If you can, that is. I am excited to be doing a live, in-person safety seminar for the first time in more than two years! If you are within range of western New York State, mark your calendar for May 24, 2022. The topic will be "The Big E - Surviving the Inflight Emergency." We are scheduled to begin at 7:00 PM EDT at the Genesee County Airport (GVQ) in Batavia, NY. The great folks at Boshart Aviation are providing the facility and refreshments and Avemco Insurance is providing me. Wings credit is available. Seating is limited so get full information and  register soon before the email invites go out from the FAA!

Follow it!

Manufacturer procedures that is. As we move up to more complex airplanes we are responsible for managing more complex systems. Fuel systems are a good example. The manufacturers generally do a great job of explaining how the systems work and how to operate them correctly. They do this through manuals, checklists, and bulletins. Failure to study and comply with the manufacturer's instructions can have dire consequences. The NTSB issued a report in April that they investigated several accidents resulting from uncommanded loss of engine power during climb out in Cirrus SR22T airplanes. At least two of the accidents resulted from the fuel boost pump being left in the HIGH BOOST/PRIME position during takeoff. This basically resulted in flooding the engine. This is contrary to the operating instructions provided by the manufacturer. This is but one example of pilots not following the manufacurer guidance on operating airplane systems. Whatever airplane we fly, we should thoroughly study the systems and know how to properly operate them. Click here to download the report from the NTSB website.

Avoid it!

Runway excursions that is. Nearly every day there are one or more instances of a runway excursion or runway overrun reported in the ASIAS daily report. Want some hints on how to avoid ending up on that list? We have an online course to address that. Sponsored by Avemco Insurance, "Many Happy Returns" provides some insight on the subject and will also earn some Wings credit. Completion of the course, including the quiz, qualifies for one Basic Knowledge-3 plus one Advanced Knowledge-2 Wings credits, as well as for the Avemco Safety Rewards Program. The course is free. Click here for more information and to enroll.

Stow It! (Another Tow Bar Update)

Thanks to a reader/CFI, Stephen, for this advice. "My solution to the towbar "problem"? Never, EVER, take your hand off the towbar while it is attached to the aircraft. Regardless of where the aircraft is located (ramp, hangar, junkyard, etc) nor phase of operation (pulling out or returning). I NEVER allow the towbar to remain attached if it is not in someone's hand. Need to stop pulling/pushing to clear a wing or tail? REMOVE the tow bar and place it on the ground near the wheel... Forgot to release the parking brake? REMOVE the tow bar and place it on the ground near the wheel... Putting the airplane away after a long day and you are on the schedule first thing in the morning for the first flight of the day? REMOVE the tow bar and place it on the ground near the wheel... You get the idea." He goes on to say, "I teach my students this practice from Day 1, explaining to them that I am trying to start them with good habits and that by using the "NEVER" rule, even when pushing the airplane into the hangar for the night, that you NEVER have to decide "Is this a time I can leave it attached?" I think the 1 to 5 seconds it takes to release and reattach the average tow bar is a very good investment in their future safety. I also encourage them to 'google' "towbar still attached" and watch a few of the videos that result from that search."

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Weather Ahead - Options

Last month in this space we addressed the importance of maintaining our proficiency in attitude instrument flying to help avoid the loss-of-control-inflight (LOC-I) accident. This month, I want to expand that theme and include an added strategy.

Let’s look at a scenario that plays out frequently. A pilot has basic competency in attitude instrument flying but is not as proficient as a pilot who routinely flies in instrument meteorological conditions (IMC). Our pilot may or may not be instrument rated. Having a bit of additional ink on a pilot certificate does not guarantee proficiency. Today, the pilot has begun a flight that will likely include a segment in marginal VFR conditions. There will be one passenger who is a non-pilot. The total flight time should be about three hours, twenty minutes. The pilot is conscientious and has done due diligence to ensure that both pilot and airplane are in good condition to fly.

The takeoff and climb to cruise altitude go well. The weather is good for about the first hour of the flight but some fair-weather cumulus clouds are beginning to appear ahead. Our pilot is using a tablet that provides basic navigation and weather information. The pilot was hoping to remain clear of clouds but a check of the weather ahead shows that the cloud bases are lower than expected. The pilot will have to fly at about 1,500 feet AGL to remain below the clouds. To maintain VFR minimums, the pilot would need to fly 500 feet below the clouds, or at just 1,000 feet AGL.

The pilot earned an instrument rating about two years ago but has not flown in clouds since that time. A flight review was completed ten months ago and the pilot successfully demonstrated basic attitude instrument flying skills. A decision must be made. The pilot believes that there are three workable options. The flight could be aborted with a return to the departure airport. The flight could be continued below the clouds, but at an altitude that makes the pilot uncomfortable. An IFR fight plan could be filed to get through the clouds at a safer altitude.

The pilot decides that even though not technically incompliance with IFR recent experience requirements, the most viable option is to file an IFR flight plan. The tablet has all the IFR charts and approaches necessary so a call to ATC yields a clearance including instructions to climb to 6,000 feet. The airplane climbs into the cumulus cloud bases at about 2,800 feet and continues to climb to 6,000 feet per the clearance.

The pilot has little experience in flying in clouds and is not aware of how much turbulence there can be even in fair-weather cumulus clouds. The airplane is not equipped with an autopilot and the pilot is working hard to maintain altitude and heading. Even a few seconds of looking at the IFR Enroute chart on the tablet produces significant deviations in both heading and altitude. The ambient light is decreasing and this causes the pilot to realize that the clouds are thicker. Light rain begins to stream across the windshield and side windows but rapidly increases to a moderate intensity. Maintaining airplane control is now a full-time job and checking weather on the tablet is out of the question. To add another complication, the passenger asks for an airsickness bag. Too late. Vomit is everywhere.

We will hit the pause button here and look at the pilot’s present options.

Option #1 is to stay the course and pass through the present weather. Better weather ahead was forecast in the weather check done just before takeoff. Let’s look at the pros and cons. On the pro side, if the pilot can get the airplane through the clouds successfully, they will arrive at their destination on time and the pilot will be praised for the skill shown in dealing with the weather. After a bit of vomit cleanup, all will be well. But on the con side, the pilot may reach task saturation and lose control of the airplane.

Option #2 is to declare an emergency. On the pro side, immediate help will be available regarding a heading to reach better weather, possibly even VFR conditions, with no need to reference the electronic charts or weather information. Since the pilot’s workload will be decreased, the likelihood of losing airplane control will be significantly reduced. The con side is very small. Contrary to popular belief, the pilot will not have a mountain of paperwork. There might be an inquiry into recent experience requirements, but the likelihood of certificate action or a violation is very low.

Which option will the pilot choose? That will depend on several factors including the pilot’s personality, level of risk tolerance, and decision-making skills. Hopefully, the pilot will realize that the decision to be made is also made on behalf of the pilot’s family, the passenger, the passenger’s family, and those who are beneath the airplane’s flight path.

The logical choice should be easy. The pro side of both options has the pilot arriving safely at the destination. The con side of Option #1 is nearly certain death for both the pilot and the passenger while the con side of Option #2 ranges from none to a slap on the wrist. We hope our pilot chooses wisely. What would you do?

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 took the lives of the pilot and passenger. It involved a Beech A36 Bonanza and happened in Ohio in June of 2019. The 65-year-old non-instrument rated private pilot had 1,640 total flight hours.

The NTSB report describes the accident flight as follows: "The pilot departed Maquoketa Municipal Airport (OQW), Maquoketa, Iowa, about 1255 and was destined for Toledo Executive Airport (TDZ), Toledo, Ohio. Visual meteorological conditions prevailed near OQW about the time of departure and weather information indicated that the initial portion of the flight was conducted in visual meteorological conditions. However, weather conditions deteriorated as the flight progressed. Automatic Dependent Surveillance – Broadcast (ADS-B) position data indicated that the airplane climbed to an altitude of about 9,000 ft mean sea level (msl) and proceeded southeast before turning east and transitioning south of the Chicago, Illinois, metropolitan area while maintaining 9,000 ft msl. The pilot subsequently returned to a southeasterly course until nearing Logansport, Indiana, when he again took up an easterly course and transitioned south of Ft. Wayne, Indiana. During this time, the airplane began a gradual descent over the next 30 minutes eventually leveling at 2,000 ft. msl. The track data depicted multiple course changes, including two 360° turns within 20 miles of the accident site. About 1610:45, the airplane entered a right turn, changing its course from southeasterly to southwesterly over about 30 seconds. About 1611:15, the airplane entered a second right turn, which transitioned into a right descending spiral until the final data point at 1612:14. At that time, the airplane was located about 1/4 mile north-northwest of the accident site at an altitude of 2,110 ft msl, which was about 1,330 ft above ground level (agl).

At 1647, a local resident saw the wreckage in an agricultural field and contacted authorities. There were no known witnesses to the accident.


NTSB Graphic

The NTSB accident repport also includes: "There was no record that the pilot obtained an official preflight weather briefing or that he had requested any weather information during the flight. At 1555, conditions at the Putnam County Airport (OWX), Ottawa, Ohio, about 14 miles north-northeast of the accident location, included scattered clouds at 600 ft agl, broken clouds at 1,700 ft agl, and 5 miles visibility. At 1555, conditions at the Van Wert County Airport (VNW), Van Wert, Ohio, about 20 miles west of the accident site, included broken clouds at 500 ft agl, overcast clouds at 1,000 ft agl, and 2 miles visibility in rain. Satellite imagery depicted cloudy conditions across the region. Overcast clouds prevailed near the accident site, with cloud tops above 10,000 ft msl and localized build-ups to about 30,000 ft msl. The presence of any intervening cloud layers was not known. Radar imagery depicted light to heavy precipitation across the region. The accident occurred as the airplane approached an area of moderate to heavy pprecipitation. An AIRMET warning of instrument conditions was in effect at the time of the accident."


NTSB Photo

The NTSB Probable Cause finding states: "The noninstrument-rated pilot's decision to continue visual flight rules flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing was the pilot not obtaining a weather briefing prior to the flight."


NTSB Photo

What could this pilot have done differently to avoid this accident? Prior to the flight he could have more thoroughly checked the weather and of course, even though non-instrument rated, he could have maintained sharp attitude flying skills just in case. Once enroute, seeing the weather ahead he could have diverted to another airport. Once entering the clouds and rain, he apparently flew for some time without visual reference. During this time he could have declared an emergency and recieved assistance, including vectors to VFR weather.

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 involved a Piper PA32-300. It happened in Oregon in September of 2019. The 82-year-old, 2230 hour instrument rated commercial pilot died in the crash. The NTSB accident report includes the following: "The pilot departed on a visual flight rules cross country flight. GPS data revealed that, about 30 minutes into the flight, the airplane began deviating from its previously established on-course heading to the destination. During the last 5 minutes of the flight, the airplane’s altitude and heading varied, and during the last minute of the flight, the airplane climbed about 400 ft and its ground speed slowed from 140 knots (kts) to about 53 kts. The airplane then entered a descent that continued until the end of the recorded data, about 450 ft from the accident site. The fragmentation of the airplane and distribution of the wreckage were consistent with a high-speed impact. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation."


NTSB Photo

The NTSB accident report continues: "Weather reports near the departure airport, along the route of flight, and at the destination airport indicated visual meteorological conditions with light rain, 10 statute miles visibility, and overcast cloud ceilings beginning at 3,300 ft above ground level; however, an AIRMET for instrument flight rules conditions and mountain obscuration was valid for the area of the accident site at the time of the accident. Satellite imagery identified cloudy conditions across the accident region, including the accident site, weather radar displayed light rain in the area of the accident site, and witnesses reported rain and heavy fog in the area near the accident site about the time of the accident; therefore, it is likely that the pilot encountered instrument meteorological conditions. The extent of the pilot’s preflight weather planning and what information he may have accessed before departure could not be determined."


NTSB Photo

The NTSB Accident report also includes the following: "The pilot held an instrument rating, and the airplane was equipped for instrument flight; however,neither the recency of the pilot’s instrument experience nor his level of instrument proficiency could be determined. Based on the available information, the pilot likely encountered instrument meteorological conditions inflight, which resulted in spatial disorientation, a loss of control, and subsequent impact with terrain."


NTSB Graphic: Capture of the route of flight


NTSB Graphic: Last 5 minutes of recorded flight route


NTSB Graphic: Last minute of recorded vertical flight path

The NTSB Probable Cause finding states: "The pilot’s decision to continue visual flight rules flight into instrument meteorological conditions,which resulted in spatial disorientation and a loss of control."


NTSB Graphic: Satellite imagery showing cloud coverage. The accident site is identified by a red dot.

The pilot was obviously having difficulty flying the airplane during the last five minutes of the flight. Would things have ended diffentenly had the pilot declared an emergency and received radar vectors? Of course we cannot say for sure. If nothing else, the pilot could have been assured that the vectors would be heading toward visual conditions and at a safe altitude regarding terrain. That reduction of workload might have allowed the pilot to focus on aircraft control and prevented the loss of control.

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

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