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Vectors For Safety - November 2022

Safety Initiative Update

Consider it!

Registration is open for our popular Human Factors Ground School-Live for January 2023. As always, registration is limited to facilitate discussion. The course consists of three live sessions on three consecutive Thursdays, Jan. 5, Jan. 12, and Jan. 19 with each session beginning at 7:00 Eastern. Missed sessions can be made up via watching the video. Couse completion is valid for all three FAA Wings credits at the basic level. Click here to for more info and to register. Enter coupon code EARLYHALFOFF during checkout to take advantage of 50% off during early registration until Dec. 10.

Wait for It!

Next month's Vectors will feature my project on accidents after having maintenance performed. The focus is to increase awareness of the increased risk of having something go wrong and to provide some tips on mitigating that risk. Several reports from pilots who have experienced these problems will be included.

View It!

Planning a flight in conjunction with any of the upcoming holidays? Please consider viewing "Holiday Travel Hazards." Our recorded webinar examines some of the factors that can increase the risks of holiday travel in general aviation airplanes. Strategies to help mitigate those risks are presented. Several recent accidents are analyzed and discussed. (Note: Watching the video is not valid for FAA Wings credit.)

Speak about it!

Avoiding the person-into-prop accident that is. It happened again. Quoting the ASIAS report for October 17: AIRCRAFT LANDED, TAXIED TO THE RAMP, A PASSENGER EXITED AND WAS STRUCK BY THE PROPELLER, STATESBORO, GA. A local news report says that the victim was a 21-year-old college student. shows that the airplane landed at 10:36 PM. I cannot imagine a type of accident that is more preventable than this. No GA pilot should allow anyone to enter or exit an airplane with the propeller turning. Myself and others have been writing about this for many years, yet it keeps happening. I am asking all my reader to help spread the word on this. Please bring it up to other pilots, flying clubs, aircraft rental companies, and flight schools.

Use Meds Safely!

We know that the aircraft must be performing at peak to have a safe flight. The same is true for the pilot and both OTC and prescription medications can reduce our capabilities in a number of ways. We already know this, but sometimes our cognitive biases tell us that it will be fine. Illusory superiority tells us that we are good enough that we can still be safe with some reduced capabilities. It might be fine to go anyway. But then again, it might not. The downside of cancelling a flight compared to the downside of making the flight and having an accident must be considered. The FAA has an excellent publicaton on the subject of meds and flying, particularly on the interaction of those meds.. Check out "Avoiding Adverse Drug Interactions."

See it and Avoid it!

Midair collisions continue to plague general aviation. The FAA has just issued a new, hot-off-the-press Advisory Circular on the subject. Down load it here from the FAA website.

Vectors Navigation Change

Our Safety Concepts page was getting too long to be useful so the Safety Concepts tab at the top of the Vectors For Safety site is now a dropdown menu with each concept having its own page. That change will make it possible to provide a link to a specific concept rather than to the general page with a need to scroll down to find the desired section.

Avemco Insurance sponsors Gene Benson
Gene's Blog

Our Complex Systems

My first flying lesson was in a Piper J-3 Cub. The most complex system was the ignition. It was important to get the ignition switch in the correct position to avoid killing the person spinning the prop to start the engine. As I moved up to the new and sophisticated Piper Tri-Pacer, the most complex system was the avionics. It consisted of a communications radio in which the frequencies were selected by a knob that was turned to click into the desired frequency and a navigation radio to tune to the newly established VOR system. That radio required turning a crank to find the desired frequency on a dial. Once the Morse Code was heard, the crank was rocked gently to fine tune for the strongest signal and then the station had to be identified and verified via the Morse code. A few intermediate steps later, I found myself in the Piper Navajo. The avionics were simple upgrades to nav and comm radios, a few additions such as DME and weather radar. The most complex system on that airplane was landing gear with its inboard and outboard doors, all having to open and close at appropriated times in the extension and retraction sequences. A close second was the automatic wastegate which kept a constant manifold pressure and avoided over boost without constant throttle adjustment during takeoff and climb. Then, as I moved on to turboprops and jets, there were far too many complex systems to decide which was the most complex.

Now as I reflect on my lifetime of flying such a wide variety of airplanes while doing many different kinds of flying, I realize that I missed an important point. Regardless of the kind of airplane or the mission, the most complex system is the pilot’s brain. That complex system can also be a single point of failure, something we try to avoid in airplane design.

We have two magnetos. We have two spark plugs in each cylinder. We have two communication radios. We have two or more fuel tanks. So maybe we can avoid having a single point of failure by having two pilots and therefore two brains. That has been generally effective, but there have been cases in which one brain has a partial failure and convinces the other brain to fail in the same way. One of our accident analyses to follow has an example in which that may have happened.

Most pilots of small GA airplanes are flying single pilot operations. We are flying with that single point of failure. Any single point of failure needs to be checked and maintained regularly and that includes our brains. Our brains need proper nutrition and hydration perform at their peak. Like any other complex system, they need to be free of contaminants. We don’t want sand in our oil and we don’t want drugs or alcohol in our brains. Running an engine at excessively high manifold pressure or RPM will take its toll over time on engine performance just as sustained high levels of stress will adversely affect brain performance. An airplane needs to be flown regularly to keep everything exercised and lubricated and our brains need to be exercised to maintain optimum performance. Taking challenging recurrent training is a good way to accomplish that. Finally, perhaps as a departure from our aircraft system analogy, our brains need adequate sleep. Fatigue is a prominent error causal factor. A well-rested brain is a more reliable complex system.

Also, let’s not forget that our airplanes and their complex systems need to be inspected regularly to identify any weak areas. I know this may seem like a foreign concept to many, but private, accurate, convenient, and affordable cognitive testing is available online. Our cognitive skills can decline, not just with age, but for other causes. In many cases, specific cognitive skills can be improved through prescribed activities. My recommendation is to have a cognitive skills evaluation at age 55 to establish a baseline and then repeat the evaluation every couple of years. Any noted areas of decline can be addressed or further evaluated if necessary. Over age 55? Get a cognitive skills evaluation now to identify any weak areas and establish a baseline. Rinse and repeat every couple of years. Cognitive skills and their decline are a subject dear to my heart. If anyone would like to explore it, please feel free to contact me at

The accidents analyzed in this month’s issue of Vectors are chosen to illustrate flawed decisions by pilots. I have written about and produced videos and online courses about decision making many times in the past and I did not want to repeat myself here. Instead, I wanted to address brain health which is directly related to decision-making. The following are some links to material I have produced regarding decision making.

Free Courses:

"Urgent Decision Making" (Wings Credit)

"Combating Mental Inertia" (Wings Credit)

broken image

The following article is reprinted from the NASA CALLBACK PUBLICATION #465 of October 2018.

A Tale of Two Takeoffs

After taking all the usual precautions at a non-towered airport, this private pilot began the takeoff roll. The reporter perceived an unexpected object ahead, which was quickly identified and became a significant threat.


■ [It was a] beautiful, crisp, sunny day, and the wind was light. I monitored CTAF during startup and ground flight checks, but I did not hear any traffic. The hangars and ramp area are at the Runway 32 [approach] end, and there is no taxiway parallel to the runway, so with the light crosswind, I setup to depart on Runway 32. While holding at Runway 32, I transmitted on the radio my intention to take off on Runway 32 and depart the pattern to the southwest. When about 300 feet down the runway on takeoff roll, I noticed a large white object at the far end of the runway that looked unusual, but I could not discern its shape.… The runway is…3,500 feet [in length] plus approximately 300 feet of displaced threshold. Since the departure end terminates adjacent a busy road, my first thought was that a large semi-trailer had parked on the side of the road. As I was about to rotate approximately 700 feet down the runway, I saw the aircraft rolling toward me on Runway 14. [The plane] was still on the ground, so I elected to continue the rotation, climbed, and banked to the right. The other aircraft broke ground very nearly the same time as I had, climbed, and banked to his right. We passed about 100 feet laterally! At that point, I made several calls on the radio, but there was no reply. The other aircraft appeared to be some kind of low wing aircraft. Either the other aircraft was NORDO (unlikely), or using the wrong frequency (unlikely since there is only one frequency at that field), or simply did not use the radio.… If I had been flying a more conventional airplane, I would have had a longer ground roll, and both airplanes would have been on the runway at rotation speeds – a head on collision on the narrow runway pavement!

If the other aircraft had been burning its landing light when I taxied into takeoff position, I would have seen that and clearly identified the object as an airplane and subsequently taxied off the runway.… “Burn the light” just made my departure checklist.… If the other aircraft had been required to use the radio, then this near miss would likely have been avoided. It is ironic that my antique aircraft has a radio, yet the much newer aircraft pilot felt that radio traffic wasn’t important.… I think it’s time for the FAA to require radio use at all uncontrolled public use airports, no exceptions.

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 tragic crash demonstrates the powerful effect external factors can have on decision making. A 55-year-old student pilot and his 74-year-old mother died in the crash of a Piper Turbo Arrow in April of 2021. They were on a flight from Texas to Kentucky when control was lost inflight over Tennessee. At the time control was lost, the airplane was in night, instrument meteorological conditions. The stated purpose of the flight was to visit the student pilot's father who had recently been hospitalized. The student pilot's flight instructor had provided a cross country endorsement for the flight, but said that he expected the student to depart much earlier due to approaching weather.

ERA21FA189 Accident airplane from FlightAware

Actual accident airplane -

The NTSB accident report includes the following: "The pilot was receiving visual flight rules (VFR) flight following services from air traffic control at the time of the accident. As the pilot prepared to begin a descent from cruise altitude to the destination airport, he was advised by air traffic control of instrument flight rules (IFR) conditions immediately ahead and along the remainder of his route, and was told to maintain VFR. The controller provided alternate VFR airports and suggested a course to maintain VFR.
The pilot acknowledged the information and advised that he would deviate to remain clear of the weather; however, flight track and weather information revealed that, about this time, the airplane likely entered IMC conditions, which included precipitation and clouds in addition to light to moderate turbulence."


NTSB Graphic

The NTSB report continues: "Shortly after entering the IFR conditions, the airplane entered a descending, tightening, rapidly accelerating spiral that continued until impact. The spiral was indicative of a pilot
experiencing the effects of spatial disorientation, and the airplane reached an airspeed significantly greater than its never-exceed speed. Before entering the spiraling descent, the flight was cruising below the freezing level, which made the risk of airframe icing minimal."


Photo credit: ARFF

The weather encountered was essentially as forecast. that was addressed in the NTSB report: "Review of the forecast conditions was consistent with the weather conditions encountered during the accident flight. Review of hourly observation weather data revealed that, had the pilot departed earlier in the afternoon as was expected from his flight instructor, the flight likely would have been completed in day VFR conditions. The pilot did not receive a weather briefing before departure, and what, if any, weather information the pilot reviewed before departing could not be determined."

The NTSB Probable Cause States: "The student pilot’s continued visual flight rules flight into night instrument meteorological conditions, which resulted in spatial disorientation and a rapid uncontrolled descent into terrain. Contributing to the accident were the self-induced and external pressures that likely
influenced the pilot’s decision to both initiate and continue the flight."

We examine this accident and first reaction is likely to be, "What was that student pilot thinking?" The NTSB report indicated that he had flown the same route previously both dual and solo, but in day VFR conditions. Why his departure time was delayed causing the flight to be conducted at night was not stated.

The strong influence of external factors is our prime suspect. The student pilot's father had been hospitalized and he had his mother onboard as an unauthorized passenger. There was likely a sense of urgency in making the flight. The student pilot not only fell victim to the likely self-induced pressure, but probably also to his cognitive biases. We all exhibit illusory superiority at time in which we believe that we are more capable than most people. The student pilot knew he was heading into instrument meteorological conditions but continued even though several VFR airports were available. Optimism bias perhaps also played a role. That bias tells us that bad things happen to other people and not to us. Finally, continuation bias was probably present. We have a strong desire to complete a task, in this case a flight, once it has begun. I created a short video on the subject of these three cognitive biases and how they gang up against us. Click here to view it on YouTube.

How can we avoid getting drawn into circumstances like what happened to this pilot? I suggest two things. First, follow the regulations. They are not arbitrary. They were written the blood of pilots before us based on recurrent accident causal factors. Second, have and follow, without deviation, a personal minimums checklist or flight risk assessment tool (FRAT). For more information on these tools, click here and scroll down to "Decision Tools."

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.

The 73-year-old private pilot with about 1550 hours total flight time died of thermal and inhalation injuries in this crash. It happened in Iowa in May 2021 and involved a Cessna T210M. The pilot and sole occupant was a doctor and clinical professor of internal medicine. He had informed ATC that he was going to practice landings at the accident airport.

The NTSB accident report includes the following: "A witness reported that, after the airplane touched down on runway 15, it bounced, and the right wing lifted up to an estimated 45° angle. The airplane’s wings then leveled, and the airplane bounced a second time. The airplane landed, exited the runway surface to the left, and continued into a harvested cornfield. The witness heard the engine power increase, and the airplane pilot attempted to take off from the field. The airplane impacted a power pole and power line near the corner of the harvested cornfield, then impacted terrain and was destroyed by a postcrash fire."


NTSB Photo

The accident report continues: "The closest weather observing station reported wind from the southwest about 19 to 20 knots, gusting 27 to 30 knots. The airplane’s maximum demonstrated crosswind component during takeoff or landing was 21 knots. It is likely that the gusting crosswind lifted the airplane’s right wing and the pilot was unable to maintain directional control during landing. The pilot’s subsequent decision to attempt to take off from the corn field resulted in impact with the power pole/line."

NTSB Photo

The NTSB probable cause finding states: "The pilot’s loss of directional control during landing in gusting crosswind conditions that exceeded the airplane’s capability and his decision to attempt to takeoff from a field, which resulted in collision with a power pole/line and terrain."


NTSB Photo with tire track annotations by GB

Since decision making is my thing, here is my analysis which represents my opinion which is based on facts available to me.

The pilot had just experienced an eventful landing but was on the ground but off the runway. He was uninjured and most likely in an undamaged airplane, but he was not yet stopped. He saw open field ahead, he still had some speed and he had 300 horsepower up front. Yet, NTSB photos appear to indicate that there was ample room available to stop. The photos also show the field suitable for taxi to return to the runway. His options appear to be either bring the airplane to a stop and evaluate options or to power up for a takeoff. His decision was to attempt the takeoff from his present position and speed.

Since he had just seconds to make a decision regarding stopping or attempting a takeoff, it would be considered an urgent decision. Urgent decisions do not allow for much conscious analysis and are made primarily in the unconscious mind. All of our training, experience, cognitive biases, heuristics, and other aspects of our humanness influence our urgent decisions.

We cannot know what caused the pilot to make this flawed decision to attempt the takeoff. Was on a tight time schedule and needed to be somewhere? Was he embarrassed by the runway excursion and wanted to avoid being noticed? Did he simply overestimate the airplane's ability to clear the powerlines? Was he not aware of the powerlines?

I find it interesting that the tire tracks through the cornfield appear to show the airplane in a constant left turn after departing the runway. Why? Was he not applying right rudder to counteract the left turning tendency during takeoff? Was he not correcting for the effect of the wind? Was the landing gear damaged during the hard landings? Was he not proficient in handling the airplane or was he experiencing a physiological event which was not detected during autopsy due to the thermal injuries?

There are many questions raised which we cannot answer. What is important is that we learn from the mistakes of others so that we do not repeat them. We have a YouTube video on decision making which can be viewed by clicking here. We also have a free online course on Urgent Decision Making which is valid for one credit Basic Knowledge Topic1 in the FAA Wings program. Click here for more info and to enroll.

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 happened in Idaho in June 2021. The Cessna 182P was destroyed by post crash fire and the two private pilots aboard, ages 59 and 51 respectively, received serious injuries. The NTSB accident report includes the following: "The pilot reported that, while on final approach to land, he was “concerned they had too much speed” to stop in time but elected to continue with the landing. About midfield, as the airplane was floating down the airstrip, the pilot aborted the landing and applied full power. During the climb out, the airplane was unable to out climb rising terrain or maneuver in the narrow canyon to return to the airstrip. The airplane subsequently collided with trees and terrain."


Graphic by GB

The following is an excerpt from the Pilot-Operator Report submitted to the NTSB by the flying pilot. "As we turned left for final, we briefly discussed and agreed that it appeared (by the wind sock) to be a little windy and gusty so we agreed to not put a final notch of flap in and maintained 20 degrees of flap and continued our approach. We made the final approach radio call. We descended down to the airfield with airspeed approximately 75 knots at the threshold. We became concerned that we had too much speed to be able to stop in time, but we greed to continue the landing. Approximately mid-field as the airplane was floating down the airstrip, I knew we could not stop in time and immediately put full power in to halt our descent and climb out. As the airplane climbed out, the landing gear was struck by the top of a tree, without damage. We reduced the flap to zero and continued our climb in rising terrain. We agreed to look for an opportunity to turn around back to the airstrip; however the canyons were too narrow and offered no available space. We were getting roughly 100-200 feet per minute of climb. After flying for several minutes, eventually the canyon closed in on us. There was nowhere to turn around and we could not get over the top We had just a few seconds. I looked over at John McClelland and told him we were going to crash. I slowed the airplane down as much as I could without stalling), pulled a high angle of attack, and looked quickly for a spot of trees and flew directly into them. We crashed thru the trees, wings were ripped off, and we fell mostly intact on the forest floor with minor injuries (I had a broken ankle and finger). Our seatbelts had held us in place. It was within seconds that the airplane filled with gas and sparked a fire inside the cockpit. We struggled to get free. We eventually released our seatbelts opened the pilot side door and both exited the left side together. Very shortly after, the airplane exploded and burned down mostly to ash."

Calculations based on conditions included in the NTSB report put the density altitude at approximately 8,500 feet.

Warren Idaho Airport

Warren Idaho Airport (GoogleEarth)

Terrain surrounding the Warren Idaho airport

Terrain Surrounding Warren Idaho Airport (GoogleEarth - annotation by GB)

The NTSB probable cause finding states, "The pilot's decision to continue the approach for landing with excess airspeed, which resulted in an aborted landing and subsequent collision with trees."

WPR21LA237_NTSB Photo stating source unknown

Photo supplied by NTSB stating source unknown

The big question here is why the two pilots continued the approach to a point that they could not climb out safely. On final approach, they became concerned that they had too much speed to stop but agreed to continue. Why continue an approach in which a successful outcome is in doubt? Perhaps neither pilot wanted to be the one to call for a go-around. Normative social influence may have played a role here. Of course our old cognitive bias friend, completion bias, was probably weighing in as well.

Putting all the psychology aside, the approach was not stabilized by definition since the airspeed was too high. If we vow to immediately discontinue an unstabilized approach, we can bypass all those human factors that try to convince us to keep going.

Cessna 182P Rate-of-Climb Table

Cessna 182P Rate-of-Climb Table

Another question and perhaps lesson to learn, is why the airplane was climbing at just 100-200 feet per minute as the pilot reported. The climb table above clearly shows that, even with the 8,500 feet density altitude, the climb rate should have been greater. The pilot did not report leaning the mixture for the climb out as the chart conditions require. Perhaps he did but did not mention it in his statement to the NTSB. The pilot did not state the airspeed at which he was climbing out. Any variation from the airspeed listed in the chart conditions would have a detrimental effect on the rate of climb. In addition to density altitude, the other environmental condition may have been a downdraft caused by the wind interacting with the mountains. No mention was made of that either by the pilot nor by the NTSB in the report. We must also note that this was far from a new airplane. It was built in 1976 and would typically have a few dings and dents in leading edges which all contribute to degraded performance. The same goes for the propeller; a few dings can also contribute to degraded performance. The airplane had a current annual inspection but no information was provided regarding engine time since overhaul. A tired engine will not deliver full rated horsepower. And finally, the pilots planned to land at this airport. Had they calculated takeoff distance from this airport given the current density altitude? If the airplane, already airborne, could not execute a go-around would a takeoff and obstacle clearance from a standing start been possible?

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

Books by Gene Benson

Check out publications by Gene Benson on All proceeds from book sales are used to help support the Safety Initiative. Click here to visit Gene's author page on Amazon.

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