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Vectors For Safety - May 2023

Safety Initiative Update

Time and Time Again

I spend a great amount of time studying airplane accident and incident reports. Many times I feel like I have read this story before with only the characters and airplane type changed. So many preventable accidents and incidents occur "time and time again." So that is our topic for this month's blog and analysis of four recent accidents.

New Episode of "Old Pilot Tips"

Our new Episode 7 of "Old Pilot Tips" is now available. The topic of this one-minute video is the importance of and some tips on doing a check of our primary flight controls before takeoff. Check it out here.

Recommended Videos

In flying, like in everything else in life, it is often not the big issues but the little things that cause problems. Check out our YouTube videos "Sometimes It's the Little Things" Parts 1, 2 and 3. Part 1 Part 2 Part 3

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Time and Time Again

Myself and several other writers put forth considerable effort in our attempts to help pilots be safer. But that is all we can do – help pilots be safer. We cannot make a pilot safer. The desire to be safer and the effort necessary to increase safety can only come from within the pilot.

We collectively have identified accident types and compiled the causal factors that have led up to each type. We have formulated many procedures and tools to mitigate the effects of the causal factors and reduce the likelihood of the crash occurring. Using a wide variety of platforms, we have disseminated this information freely and widely via articles, videos, webinars, seminars, and courses.

Yet, the same types of accidents, resulting from the same causal factors, continue to occur with regularity. If you are reading this, you understand that being safer requires effort and you are making that effort. Thank you for that! But general aviation needs something more from you. No, I am not suggesting a monetary donation to some safety group or cause. I am requesting that you become an “evangelist for safety” and talk to other pilots about how they can be safer. I do not mean to stand on the airport tarmac with a bullhorn or that you march around the airport wearing a sandwich sign. We all know a pilot (or two or three) who needs a little nudge in the safety direction. Providing that nudge by telling a pilot about an article or publication you have read, a video you have watched, or giving an invite to a safety seminar just might cause that pilot to take a first step along the safety journey.

We all have a stake in aviation safety. Aside from the altruistic motivation to spare families the tragedy and hardship of having a loved one die or be seriously injured, we have personal impact of crashes. Nearly all crashes result in an insurance claim which increases everyone’s premiums. The cost of litigating or settling lawsuits against manufacturers and service providers is passed on to us through higher prices. The negative publicity in local news outlets following a crash impacts public perception of general aviation and can even result in demands to close or curtail operations at a GA airport.

This month, breaking from my usual format of addressing one specific area and providing two or three related accident analyses, I will share NTSB information, along with some limited commentary by me, on several recent crashes.

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Reprinted from NASA "Callback" Issue 460 May 2018

Though this article involves a flight crew in a regional operation, the lessons learned are also appropriate to general aviation.

After departure, this CRJ200 crew heard an unfamiliar noise and perceived a minor irregularity. The misunderstood problem and multiple classic threats spawned a domino chain of self-induced complications. The first Officer is recalling the flight.

[After departure] as we accelerated through 200 knots, we both noticed a loud noise that we could attribute to… airflow over an open panel on the aircraft. [We] agreed it was likely the Headset and Nose Gear Door Switch Panel.… The Captain…called for…the After Takeoff Checklist.… After completing the procedure, I read through the checklist silently and then called, “After Takeoff Checklist Complete.” Around…8,000 feet MSL,… the autopilot disconnected on its own. The Captain reengaged the autopilot, [but] within a minute, it disconnected again.… The Captain chose to handfly the aircraft.

Passing through 10,000 feet I [toggled] the “No Smoking” sign switch to signal to our Flight Attendants.… The switch did not chime. I tried the “Fasten Seatbelts” switch, which also did not chime.… It was at this point we began to notice… extremely diminished climb performance, and [we] were not able to accelerate past 260 to 270 knots.… We knew something was wrong, but we could not figure out what. The Captain asked me to begin reviewing all of the system status pages to see if there were any other indications to give us a clue as to why we did not have any climb performance.… We began calculating our fuel burn, and discovered we were burning…about 4,800 pounds per hour. With about 5,000 pounds of fuel and about 40 minutes of flight time remaining, we decided it was best to divert.…

[When the] Captain called for gear down,… I reached for the gear handle and noticed that it was down.… We immediately realized our mistake.… I had never selected the gear up on departure. I am not sure what to attribute this mistake to other than complacency and distractions. On departure, I do recall reaching for the gear handle. I believe I became distracted by reaching for the SPEED mode button and NAV button. We became distracted by the noise generated by the gear.… We further became distracted by an autopilot that wouldn’t stay engaged and having to hand-fly the aircraft.… We became fixated on only one…problem while dealing with other small, seemingly unassociated problems.… The maximum gear extended speed was exceeded by approximately 10 to 20 knots. There was also a flap overspeed on final, and the thrust reversers were not armed for landing (I don’t recall completing the landing checklist) It is one thing to miss a flow; it is another to read and verify a checklist and still miss an item—that is what the checklist is for. Additionally, once an issue is discovered in flight, you must also sit back and review even the most basic reasons why a problem is occurring. We failed to notice that our gear was down for the entire hour we were in flight. We were very focused on other possible issues, and failed to sit back and evaluate the big picture.

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.

ERA23LA049 NTSB Photos

Photo Source: NTSB

ERA23LA049

This crash involved a Cessna 172 and resulted in one serious injury and one minor injury. The NTSB report includes the following: "The pilot departed for the visual flight rules cross-country flight with about 12 gallons of fuel in each fuel tank for the planned 1 hour and 40-minute flight. She reported that while enroute the fuel gauges were reading “low” and were fluctuating. Closer to the destination, the fuel gauges indicated that more fuel was present in the right fuel tank, so the pilot moved the fuel selector from the “both” position to the “right” position. About 1.5 hours into the flight, while flying at an altitude of about 2,000 feet above ground level and while being provided with radar vectors to the airport traffic pattern at the destination airport, the engine “started sputtering and got quiet.” The pilot attempted to restart the engine, but was unsuccessful, and she subsequently performed a forced landing in a field. The impact with the ground resulted in substantial damage to the fuselage and right wing. Post-accident examination of the airplane found that the intact right-wing fuel tank was empty, that the intact left-wing fuel tank had about 6 gallons of 100LL aviation fuel remaining, and that the fuel selector was in the right tank position."

The NTSB report also states: "During a postaccident interview the pilot stated that when the engine lost power she did not use a checklist in her attempt to restart the engine. Review of the power loss in flight checklist found aboard the airplane revealed that the sixth item stated “fuel selector – check/switch/both.” Based on all available information, it is likely that after the pilot selected the right fuel tank earlier in the flight, its fuel supply was eventually exhausted and the engine lost power. It is also likely that, had the pilot used the checklist and selected the “both” position on the fuel selector, the fuel remaining in the left fuel tank could have restored engine power before the forced landing."

The NTSB probable cause states: "The pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation. Contributing was the pilot’s failure to use the checklist aboard the airplane during her attempts to restore engine power."

Time and time again, we learn about crashes in which a pilot did not follow a checklist either in normal, abnormal, or emergency operations.

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

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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.

CEN22LA206 Photo/Graphic Source: NTSB

Photo/Graphic Source: NTSB

CEN22LA206

This crash involved a Piper Arrow and resulted in two minor injuries. The NTSB Report includes the following: "The pilot reported that he attempted a takeoff with an estimated 10-12 knot left quartering tailwind. During the takeoff ground roll, the airplane veered left, departed the side of the runway, and collided with trees. The airplane sustained substantial damage to the left and right wings. The pilot reported no mechanical failures or malfunctions with the airplane that would have precluded normal operation. A review of aviation weather data found the potential for the wind to gust over 20 knots at the time of the accident."

The NTSB probable cause states: "The pilot reported that he attempted a takeoff with an estimated 10-12 knot left quartering tailwind. During the takeoff ground roll, the airplane veered left, departed the side of the runway, and collided with trees. The airplane sustained substantial damage to the left and right wings. The pilot reported no mechanical failures or malfunctions with the airplane that would have precluded normal operation. A review of aviation weather data found the potential for the wind to gust over 20 knots at the time of the accident."

Time and time again, we encounter crashes that involved either taking off or landing with a tailwind. Much has been written about the additional risks involved in tailwind operations. It is simply not a good idea.

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

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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.

WPR23LA042 Photo Sources: NTSB/KEPR

Photo Sources: NTSB/KEPR

WPR23LA042

This crash resulted in serious injury to the pilot of the Cessna 180. The NTSB Report includes the following: "The pilot reported that, his mechanic had just completed an annual inspection on the airplane, and he was flying it home. While en route at 1,000 ft above ground level, the engine experienced a total loss of power. During the forced landing to a road, the airplane stalled about 40 ft above ground level and impacted the ground hard, which resulted in substantial damage to the upper fuselage.

After the accident, the pilot learned that the mechanic had moved the fuel selector from the BOTH position to the LEFT position. The pilot further reported that he did not check the fuel selector position before takeoff."

Time and time again, we learn of a crash that occurred because a pilot did not use a checklist and lost engine power due to the incorrect positioning of the fuel selector.

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

broken image

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.

CEN23LA058 Photo Source: NTSB

Photo Source: NTSB

CEN23LA058

This Stinson 108 crashed after striking wires. The three occupants all received minor injuries. The NTSB Report includes the following: "The pilot reported that while maneuvering the airplane at low altitude to observe sculptures on the ground, he did not see the high-tension wires due to diverted attention and the setting sun. The airplane collided with the wires, the vertical stabilizer sheared off, and the engine seized. Subsequently, the airplane impacted terrain."

The NTSB probable cause states: "The pilot failed to maintain clearance from high tension wires while maneuvering at low altitude."

Time and time again we see a crash in which low flying results in a collision with wires or some other object. Low flying is seldom necessary, but if it is, it is the pilot's responsibility to learn about the area, including the location of wires and other obstacles. Wires are difficult to see from the air, but poles and towers are not. A brief survey of the site by circling over it at a safe altitude, plus study of possible hazards via a sectional chart, can avoid this kind of crash.

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

broken image

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.

WPR22LA072 Photo Source: NTSB

Photo Source: NTSB

Airport video of crash. Source: NTSB

WPR22LA072

The pilot was fortunate to have received only minor injuries when the Cessna 120 he was piloting crashed after encountering the wake turbulence of a helicopter. The NTSB Report includes the following: "The pilot of the tail wheeled-equipped airplane reported that, he was on an approach to land at an uncontrolled airport behind two helicopters. An airport surveillance video showed the accident airplane flying over the runway about 20 seconds after a helicopter was in a slow hover taxi adjacent to the runway. The pilot reported that he saw the helicopter and decided to land long to maintain separation. He added that while on short final, he saw a helicopter “cross” the runway, so he increased engine power to full and attempted a go-around. About one-third of the way down the length of the runway, the airplane encountered the helicopter’s downwash, and the airplane entered an uncommanded steep right bank. The pilot applied opposite aileron, but he was not able to maintain control of the airplane. Subsequently, the airplane impacted right of the runway and sustained substantial damage to the right wing and fuselage."

The NTSB probable cause states: "The pilot’s loss of airplane control during a go-around as it encountered wake turbulence from a slow hover taxiing helicopter."

The pilot prepared a very thorough and detailed document explaining what happened. While we all know that it is the pilot's responsibility to avoid wake turbulence, there were some extenuating circumstances in this crash. It is well worth the time to download the pilot's statement and read it thoroughly. Click here to download it from the NTSB accident docket.

Time and time again, we see crashes resulting from wake turbulence encounters. We should take away from this that wake turbulence is real and not just some concept that is taught in ground school. We should also take away that helicopters, especially big ones, can present a greater danger since their flight and hover taxi paths are much less predictable than that of an airplane. As this crash illustrates, helicopter operations at non-towered airports present an even greater danger. This pilot was apparently aware of the danger and attempted to take evasive action, but by the time he was aware of the helicopter's location, it was already too late.

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

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Ramp Safety

ERA23LA055

A flight instructor was seriously injured when he exited the Piper PA28-140 with the engine running to remove a nosewheel chock. The NTSB accident report includes the following; "After engine start, the student pilot and the flight instructor realized that the airplane’s nosewheel chock was still in place. The flight instructor decided to deplane to remove the chock without shutting down the engine. After removing the chock, the flight instructor moved to signal the student pilot that the chock was removed. In the process, the flight instructor made physical contact with the spinning propeller, resulting in serious injury."

The NTSB probable cause unsurprisingly states: "The flight instructor’s decision to remove the nosewheel chock while the engine was still operating."

Time and time again, we learn that someone has made contact with the spinning propeller of a general aviation airplane. Myself and others have pleaded with pilots to never let anyone enter or exit the airplane while the engine is running. Yet, a couple of times each year we have a serious or fatal injury involving a human body versus a spinning propeller. Spoiler alert: the propeller will win every time.

In October 2022, a college student was struck and killed by a propeller after exiting the airplane with the engine running.

Even more disturbing is the fact that two such recent injuries have both involved a flight instructor. In one, the instructor told the student to get out and move a chock. She was seriously injured when she contacted the spinning propeller. In the accident in this article, the instructor decided to move the nosewheel chock himself. Flight instructors should always model safe practices to their students. Is there any hope to make general aviation safer when some flight instructors demonstrate risky behavior?

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

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