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Vectors For Safety - November 2021

Safety Initiative Update

Human Factors Ground School - LIVE

My preferred delivery method for my Human Factors Ground School is to a live audience. I believe that the interaction among attendees adds an important dimension to the learning. During the pandemic, I moved the course online. The online course has received wonderful reviews, but I would still prefer to do it live. However, as the pandemic drags on causing travel and in-person events to be a bit risky, I will do the course live, but in a virtual setting. Beginning in January 2022, I will be offering the course via Zoom meeting, not webinar, to a small group (maximum 35 attendees). Discussion and interaction will abound. The course will consist of three live sessions (recorded is someone misses one), of about one hour each. Completion of the course is valid for all three Wings credits at the basic level. Click here for complete details and a discount registration offer.

Urgent Decision Making Course

We have added "Urgent Decision Making" to our online course selections. The course is on our new interactive platform, will take about 40 minutes or less to complete, and is valid for one-half credit Basic Knowledge-1 in the FAA Wings Program. Click here to enroll in this free course.

Holiday Travel Hazards Video Available

About a year ago, on behalf of Avemco Insurance, I conducted a webinar and published a video on the same material. The subject was related to safe holiday travel in general aviation airplanes. If you are planning any holiday travel this year, I would encourage you to watch the video. Click here for the YouTube video. Sorry, no Wings credit for watching the video.

Avemco PIREP on Insuring to Value

Avemco Insurance recently published a great article on how to decide on the value of your airplane for your insurance coverage. It is not a sales article. It explains some things that I did not know, and I have been insuring airplanes for a very long time. It is a must read for all airplane owners. Click here to see the article on the Avemco website.

NAFI Mentor Live Presentation

I had the honor to be the presenter for the October 20 edition of the NAFFI Mentor Live series. My topic was "Gatekeepers - Lessons from Experience and Research." It was primarily aimed at flight instructors, but all are welcome to view. Click here to visit the archived presentation on the NAFI website.

Safety Initiative Featured

The current issue of "On Approach" includes an article about our Safety Initiative and of course yours truly. Click here to check it out and scroll down to page 6.

Different Twist on a Presentation

On November 22 at 20:00 Eastern Time, Bob Katz will conduct an online event with a different twist. He will present a scenario involving flight planning to avoid a CFIT accident and invite participants to join the discussion and share their ideas live. Check it out on by clicking here.

Gene's Blog

Is More Always Better?

Once upon a time at a flight school I was running, I overheard two students arguing about which one had the better flight instructor. One of the students had an instructor who was just a few years older than he was and had earned his CFI within the past year. The other student was bragging that his instructor had more than 12,000 hours total flight time and had even flown jets. It reminded of my youth and a time when a couple of 8-year-olds would argue about which one of their fathers could beat up the other. It also reminded me that the measure of a good flight instructor and, for that matter a good pilot, should not be defined by a fat logbook.

Experience is important and valuable. I spend a lot of time in my human factors work helping people make better decisions. Of the three kinds of decision making, urgent decision making relies heavily on past experiences for achieving the best outcome to a problem. But for deliberative decision making and rapid decision making, the importance of experience is shadowed, and sometimes even eclipsed, by other skills and abilities.

With the accumulation of thousands of hours of flight time also comes the process of aging. Aging drags along its companion known as cognitive decline. The degree of cognitive decline varies widely among individuals, but it is never completely escaped. Not necessarily related to aging but years of experience also often brings increased susceptibility to some of our common accident causal factors such as familiarity and expectancy which lead to complacency.

Of course, the younger and less experienced pilot may be more likely to fall victim to other accident causal factors such as lack of knowledge, lack of awareness, and lack of assertiveness.

I believe that how “good” a pilot is should not be measured by the number of flight hours or by the complexity of the airplanes the pilot has flown. To state the obvious, a “good” pilot has command of the knowledge requirements for earning the applicable pilot certificate and ratings. The pilot also has comprehensive knowledge of the flight characteristics and the operation of all aircraft systems, including avionics, for the airplane(s) to be flown. Beyond the obvious, the pilot will have at least a working knowledge of the human factors aspects of error causal factors to which we are all susceptible and will have a toolbox of mitigation techniques as countermeasures.

Understanding our humanness and how to avoid allowing it to lead us down a dangerous path can be much more valuable than simply the accumulation of flight hours.

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.

Midair collisions frequently have a bad ending, and this accident demonstrates that. It happened in Georgia in 2016 and involved a Beech F33 Bonanza running down a Diamond DA20 while both airplanes were on final approach. The pilot of the Bonanza as well as the flight instructor and student pilot in the DA20 died because of the accident.

The airport is non-towered so aircraft in the pattern customarily make position reports in the traffic pattern to alert other airplanes to their presence and their location. Witnesses reported hearing positions reports from the DA20 crew, but not from the pilot of the Bonanza.

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Photo Source: NTSB

The absence of radio calls from the Bonanza pilot on the Common Traffic Advisory Frequency was most likely caused by the Bonanza Pilot being on the incorrect frequency for the airport. A flight instructor in the pattern at another airport in the area reported that he had heard the Bonanza pilot broadcasting traffic pattern calls for the accident airport, but the calls were being made on the CTAF on the frequency for the other airport. The pilot was, in fact, making the necessary calls, but on an incorrect frequency so they were not being received by the traffic at the accident airport, including the crew of the DA20.

The airport manager reported that the CTAF for the accident airport had been changed at least four years prior to the accident. NTSB analysis of the GNS 530 unit recovered from the Bonanza had the active communication frequency set to the outdated CTAF frequency. Additionally, a laminated card titled "LOCAL AREA FREQ" dated April 27, 2009, was found in the cockpit of the Bonanza. The card listed the outdated frequency for the accident airport.

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Graphic Source: NTSB

The NYSB Probable Cause finding states: "The failure of the Beech pilot to see and avoid the Diamond that was in front of and below his airplane on final approach and his use of an incorrect radio communication frequency for the airport."

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Photo Source: NTSB

The Bonanza pilot age 79, held a Private Pilot Certificate with a current Class 3 Medical Certificate and a current flight review. The NTSB report stated that he had 2,500 hours total flight time. He was a well-respected member of the local aviation community. A news article published shortly after the crash quoted a 20-year friend as saying, "I wouldn't go anywhere without first calling Bill," he said. "Say, 'Bill, I want you to look over my flight plan. See if there's anything I'm missing.' His knowledge was so extensive, I mean, he could tell you page and verse what's in the Airman's Information Manual." The pilot was an 18-year member of Civil Air Patrol and had served for five years as a squadron commander. The article also stated that the pilot was a long-time employee of the FAA but did not state in what capacity.

This crash illustrates how a simple oversight can have tragic results. The oversight was of course not doing thorough flight planning to verify the current frequency. Of course, our humanness plays into the scenario. Honestly, how many of us do thorough flight planning for a local flight? The human factors perspective shows us that we may suffer from familiarity if a flight is local. We become very familiar with our local area. That familiarity breeds expectancy. We expect familiar things to be unchanged. Familiarity and expectancy work together to produce some level of complacency.

We can fight complacency by vowing to verify all details prior to every flight. Today, unlike in years past, information is available easily and quickly.

Specifically, regarding this crash, if we are in a traffic pattern, seeing other airplanes, but are not hearing other airplanes on the CTAF, something may be wrong with our communications radio, or we might be on the wrong frequency. It is something worth looking into.

This crash also illustrates the inherent weakness in the see and avoid policy. This accident occurred before ADS-B was required. ADS-B may or may not have prevented this tragedy. It is difficult to see an airplane that is at a lower altitude than our airplane. Trying to see an airplane against a terrain background is much more difficult than seeing one against the sky.

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

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Let's begin our discussion of this crash by citing the NTSB Probable Cause finding: "The National Transportation Safety Board determines the probable cause(s) of this accident to be: "The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain." That is a common probable cause finding, appearing several times each year. It usually involves an inexperience pilot who was not current or not proficient in executing an instrument approach in instrument meteorological conditions (IMC).

That is not the case this time. The pilot was an occupational pilot, age 60, holding ATP, Commercial, and Flight Instructor certificates. The NTSB report states that he had 12,493 total flight hours, 718 hours in this make and model, 91 hours in the past 90 days and 19 hours in the past 30 days. He held a current Class 1 medical certificate and he had completed all required training and a competency check for the Title 14 CFR Part 135 operation. His toxicology report was clean. He had just returned from one week of vacation and this was his first flight since returning to duty.

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Photo Source: NTSB

The NTSB accident report includes the following: "A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft. above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft. above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft. above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full-downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach."

The NTSB report continues: "Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed."

And the NTSB report also states: "The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain."

At the time of the crash, the ceiling was overcast at 300 feet, the wind was calm, and the visibility was reported to be one mile. The crash took the life of the pilot and his sole charter passenger, a prominent eye surgeon, age 62.

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Photo Source: NTSB

The pilot's toxicology report was clean. He did have several medical issues which he had reported on his medical certificate. They were multiple sclerosis (MS) which was first diagnosed 15 years before the crash, and he had a neurological report a few months before the accident stating that the condition was unchanged. Recently reported were diabetes and sleep apnea, both reported to be controlled. the NTSB report includes the following: "It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined."

So, assuming that the pilot's medical condition did not play a role in the accident, why would he continue the unstabilized approach? We will never know for sure, but we can look at some human factors, any, or all of which might have played a role. We do not know if any external factors were involved. A news article stated that the passenger as making the flight to perform eye surgery. Was the flight late, placing additional pressure on the pilot to continue? Was there a distraction present? Was the pilot victim to illusory superiority, causing him to believe that with all his experience he could recover from the unstabilized approach and complete the landing? Was it continuation bias whereby the pilot had begun the approach, so he was determined to complete it?

Whatever caused this crash, our lesson to be learned is that we must understand the concept of a stabilized approach, whether VFR or IFR, and never continue an approach that is or becomes unstabilized. For more on the stabilized approach concept, click here.

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

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Publications by Gene Benson

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