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Vectors For Safety - May 2024

Safety Initiative Update

New Episode 19 of "Old Pilot Tips" Proves Valid

Episode 19 of "Old Pilot Tips" was published April 11 and discusses how insects can present problems for pilots. One item discussed is opening a fresh air inlet to find the cabin filled with bees. The daily ASIAS report from the FAA for April 12 included a landing incident involving a Cessna 140. It reads as follows: AIRCRAFT ON LANDING, LOST CONTROL WHILE GETTING STUNG BY WASPS THAT WERE IN THE VENT AND INCURRED A PROP STRIKE, GRAND JUNCTION, CO. Click here to view Episode 19 on YouTube.

Allergy Season is Here - Be Cautious and Prepared

Allergy medications can significantly lower a pilot's capability to effectively perform necessary tasks safely. We have a course for that! "The Terrible Triad - Stress, Fatigue, and Medication" addresses some critical safety issues and is valid for FAA Wings credit upon completion. Click here for the free, online course sponsored by Avemco.

April Events Went Well

Thanks to those who invited me to do presentations for their groups and to those who attended. Attendance was superb for my presentation of "Beware the Double-D" presentation for the American Bonanza Society. My colleague Tom Turner is always great to work with and the producer, John Teipen, brings an outstanding level of professionalism the these events. My presentation of "The Big E - Emergency" to the Grasshopper Flying Club in Hudson Valley, NY also went well with good discussion at the end.

Upcoming Live In-Person and Virtual Events

On Wednesday May 8, I will be in Lancaster, NY at EAA chapter 46 to present Dealing with the Big E - Surviving the Inflight Emergency."

On Saturday, June 1, I will present "Combatting Mental Inertia" to the spring meeting of the NY-NJ 99's in Binghamton, NY.

On Thursday, June 13, I will present (virtually) "Help! My Brain is Trying to Kill Me" to the Shelby County (Alabama) Pilots Association.

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.

Avemco Insurance sponsors Gene Benson
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The following is reprinted from the December 2021 Issue 503 of the NASA CALLBACK series.

Out of the Blue

■ I was instructing [my] student for a Commercial Multi add-on. After one hour of flight, we returned to practice touch and goes and short field landings and takeoffs.

The student landed the airplane, then retracted the flaps and accelerated for takeoff. The student [then] suddenly retracted the landing gear. I took the controls to save the airplane, but the nose went down. I put the landing gear down, but it was too late, and the propellers hit the ground. I aborted the takeoff, retarded throttles, secured the engines, and shut off the fuel system. After notifying Tower, the electrical system was shut down as well. To avoid this as a Flight Instructor, [I will] put my hand on the landing gear lever to [deter] the student [from] handling it.

Gene's Blog

Every Pilot Knows Something that I Don’t Know

I have many years and thousands of hours of flying experience, along with many years and a few thousand hours of instructing. I have taught flying from the beginning student through the professional pilot both in the air and in the classroom. But I stand by the statement that every pilot knows something about flying that I do not know.

Consider your own profession or occupation. If you have been engaged in it for more than five years, think about where you learned much of what you know. Was it in formal training or was it from tips, hints, and tidbits of information picked up from coworkers of colleagues? Have you gained any of your knowledge attending workshops or seminars? How about from a luncheon or dinner chat with an associate?

My experience over the years is that every time I talk about flying with a fellow pilot, I learn something new. It might be something about the flight characteristics of an airplane I have not flown before. It might be something about how an airplane system works or its common failure points. It might be about a more effective way of presenting a concept to a student. It might be a lesson to be learned from a near miss.

Recent years have seen a significant decrease in events that facilitate social interaction among pilots. This of course signals a decrease in the ability to learn from each other. I was recently a presenter at a rather large, all day, safety stand down. There were several presentations, with a short break between each one and of course, a lunch break. During each pause in the program, pilots gathered in small groups and engaged in conversation. We will never know how many stories were shared along with lessons learned or how many valuable tips on maintenance, some aspect of weather, or fuel management were passed on.

Knowledge and proficiency go hand-in-hand. Let’s set a goal to be more socially involved with other pilots. Attend a live event, invite a few local pilots to have lunch, or be proactive and organize a live safety event. We never know what bit of information we might provide or receive that can make us just a little safer.

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.

WPR23LA290

NTSB Photo

Two people were seriously injured and a third person received minor injuries when a Beech C23 crashed during a high density altitude takeoff attempt. The 108-hour, age 46, private pilot crashed immediately following an attempted takeoff from the Cavanaugh Bay Airport in Idaho. The event occurred in July of 2023.

The NTSB accident report includes the following: "The pilot reported that during the takeoff roll, he “saw rotate speed” and then pitched for best climb speed. He had no further memory of the event. A witness reported that they saw the airplane lift off from the runway and remain in ground effect until it crossed the departure end of the runway. As it crossed the departure end of the runway, it was in a left bank and then struck a tree. The airplane impacted a public beach and came to rest upright, in shallow water. The wings and fuselage sustained substantial damage. At 1535, the temperature was 30°C, the dewpoint was 4°C, and the altimeter setting was 29.98. The calculated density altitude was 4,790 ft." The report also states that the runway has a length of 3,100 feet.

WPR23LA290

NTSB Photo

The NTSB probable cause finding states: "The pilot’s failure to maintain clearance from trees after takeoff, during high density altitude weather conditions."

WPR23LA290_Pilot-Operator-Report (excerpt)

Pilot-Operator-Report (excerpt)

In the Pilot-Operator-Report shown above, the pilot explains the preflight planning steps that he took. His description appears to indicate that he did his due diligence.

But the takeoff was unsuccessful and we must ask why. Perhaps the pilot should have leaned the mixture for takeoff to compensate for the density altitude. Perhaps the airplane, built in 1962, was not performing as it did when it was new. However, the NTSB report indicates that the airframe had just 2078.97 hours, with 1065 hours since engine overhaul. The report also indicates that the maximum gross weight of the airplane is 2300 pounds and that the weight at the time of the crash was 2037 pounds. The pilot, with 108 hours total flight time, reported that he had flown 4 hours in the past 90 days with 2 of those hours in the last 24 hours. The pilot had a current flight review and Class 3 Medical Certificate.

We cannot be sure what went wrong. But to play a little "what if" game, would have more informal conversations with more experienced pilots have raised this pilot's awareness of some of the finer points of making a high density altitude takeoff. Someone might have mentioned that leaning the mixture for maximum RPM before brake release might improve performance just a bit. Or the conversation might have included a discussion of why not to totally trust the performance information provided by the manufacturer, especially in an older airplane.

Click here to download the accident 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.

CEN22FA383

NTSB Photo

Two people died in this crash that happened in Illinois in August of 2022. The airplane was a Mooney M20K. The commercial pilot, age 74, had 2900 total flight hours. There is no mention of a recent flight review in the NTSB report, though it does show that he did not have current medical certification. However, it does not appear that any medical issues contributed to the crash.

The NTSB accident report includes the following: "The pilot had flown about 4.8 hours and was about 10 miles from the destination airport when he reported to air traffic control that the engine lost all power and that he was not going to be able to reach the destination airport. A review of automatic dependent surveillance-broadcast (ADS-B) data showed the airplane aligned with a road with the last data point about 675 ft above mean sea level (msl). Surveillance video footage captured the airplane near the last ADS-B data point. In the video, the landing gear was extended, and the propeller appeared to be windmilling. As the airplane descended, it struck powerlines. A second video taken from inside a vehicle showed the airplane immediately after the powerline contact. The airplane continued the descent and touched down on the roadway. After touchdown, the left wing impacted a bridge railing, a road sign, and a power pole, which separated the left wing. The remainder of the airplane impacted a building, which resulted in substantial damage to the fuselage. A postaccident examination revealed that the left-wing fuel tank was breached during the impact and absent of fuel. The right-wing fuel tank remained intact, and only a small amount of fuel was present inside the tank. The fuel selector was positioned on the “RIGHT TANK.” The fuel strainer contained about 3 oz of fuel and the fuel line into the fuel flow divider was absent of fuel. No mechanical malfunctions or failures were discovered with the airframe or engine that would have precluded normal operation. The airplane was equipped with a fuel-injected engine and, as such, was not susceptible to carburetor icing. Although the pilot added 54 gallons of fuel the day before the accident, the exact amount of fuel onboard at the time of departure could not be determined. A review of airplane performance charts and wind aloft observations revealed that if the flight had departed with just the 54 gallons, the endurance would have been between 3.7 and 4.7 hours. Had the airplane departed with full fuel tanks (75.6 usable gallons), the endurance would have been between 5.4 and 6.8 hours. These calculations do not include additional fuel required to climb to altitude. Based upon the lack of fuel in the fuel lines, flow divider, and right wing fuel tank, it is likely the engine lost power due to fuel exhaustion."

Compiled videos of the actual crash (Viewer discretion advised)

CEN22FA383

NTSB Photo

The NTSB probable cause finding states: "A total loss of engine power due to fuel exhaustion."

Fuel exhaustion continues to be one of the leading causes of general aviation airplane crashes. Why is that the case when all pilots know the importance of having sufficient fuel? All humans can become complacent over time. We need frequent reminders of the basic things we learned as beginning students. Reading articles, taking online courses, attending seminars, and engaging in social activities with other pilots increases the odds that we will hear, see, or read something that provides some of these reminders.

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 took the life of the 76-year-old, 14,000 hour, ATP flying a Beech B35 Bonanza. The crash happened in Indiana in August of 2022. The NTSB accident report includes the following: "The pilot was returning to his home airport at the conclusion of a cross-country flight and was attempting to make a visual approach to land at night. A review of radar data revealed the airplane overflew the airport about 500 ft above the ground before making a sweeping, descending left turn onto final approach before the data ended 0.2 miles from the end of the runway. At that time, the airplane was traveling at a groundspeed of about 86 knots at an altitude of about 33 ft above ground level (agl). Airport surveillance video captured the airplane on landing rollout. The airplane was observed departing the left side of the runway before it started a climb and impacted trees."

CEN23LA330

NTSB Photo

The NTSB report also includes the following: "Based on the available radar data, the pilot had not stabilized the airplane during the approach to the runway and was at a critically low altitude when the airplane was .2 miles from the end of the runway. Surveillance video also suggested the airplane was not stabilized after it touched down. Visible tire marks on the runway confirmed that it departed the left side of the runway during the landing rollout. The pilot may have attempted to regain control of the airplane after the unstabilized approach, touchdown, and runway excursion by attempting to abort the landing; however, the airplane subsequently collided with trees. Based on this information it is likely that the pilot performed an un stabilized approach that resulted in a loss of directional control during landing, ultimately resulting in a runway excursion and collision with trees."

ERA22FA386

NTSB Graphic

ERA22FA386

NTSB Graphic

The NTSB probable cause finding states: "The pilot’s failure to make a stabilized approach, which resulted in a loss of directional control during landing."

ERA22FA386

NTSB Photo

A 14,000 hour ATP most certainly knew all about stabilized approaches and how critical they are to a safe landing. Why did he continue? Perhaps our favorite cognitive biases, illusory superiority, optimism bias, and continuation bias were at work. Maybe if he had established an approach decision gate as I recommended in the March 2024 issue of Vectors, he would have executed the go-around sooner and successfully. But, in keeping with our theme this month, attendance at a safety event, reviewing some of the literature on safe approaches, or having a social conversation with fellow pilots would have provided a reminder of the necessity of only continuing a stabilized approach.

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

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