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Vectors For Safety - November 2024

Safety Initiative Update

New "Essential Vectors" Video

The inadvertent stall is a leading cause of fatal GA crashes. Check out our 15-minute video sponsored by Avemco to see some situations that can lead to the inadvertent stall and some mitigation strategies. Click here to view the video on YouTube.

New Free Online Course for Wings credit!

Combating Cognitive Decline in Pilots looks at the main cognitive skills used by pilots, why each skill is important for safe flying, and strategies to slow, or possible even reverse, the normal decline in these skills associated with aging. The course is presented free of charge courtesy of Avemco. Click here to visit the course.

Check Out Our Wide Library of Videos!

Did you know that we have 65 aviation safety videos on YouTube? They are sorted into three categories, with the longer videos first, followed by our "Essential Vectors" series of streamlined videos running usually between 10 to 15 minutes, and then our "Old Pilot Tips" series that reinforces important points in less than one minute. Click here to view the video offerings on our website with links to each one on YouTube..

New Episode of "Old Pilot Tips" is Available

The latest episode of our "Old Pilot Tips" series sponsored by Avemco is now available. Episode 25 of the series reminds us why it is very risky to begin a takeoff with frost on the airplane. In less than one minute, see why frost can be a problem, conditions that can lead to frost formation, recommended methods for removing it, and ways to prevent it from forming on the airplane. Click here to view it on YouTube.

Have a Group of Pilots Age 40 and Over?

My presentation, "Combatting Cognitive Decline in Pilots," might be a good fit for your flying club, EAA Chapter, Civil Air Patrol group, etc. I can provide a no-cost virtual presentation courtesy of Avemco. Wings credit is available. Email me at gene@genebenson.com to discuss scheduling.

Avemco Insurance sponsors Gene Benson
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Divided Attention

We are making a takeoff in a complex airplane from a relatively short runway with rising terrain ahead. We have completed our takeoff briefing by reviewing airplane configuration, wind direction and velocity, our rotation, Vx and Vy airspeeds, and our go/no-go point. We verify that our radio is properly set to the correct frequency and we make the appropriate radio transmissions. As we begin our takeoff roll, we maintain the runway centerline with just enough right rudder to compensate for torque. We quickly glance at the manifold pressure gage and tachometer to verify that we are getting the expected power from our engine. We note “airspeed alive” verifying that our pitot system is functioning. We again verify that we are tracking along the runway centerline and we compare our increasing airspeed to our go/no-go point (takeoff decision gate). We reference our airspeed indicator and note that we have reached our rotation speed just prior to our takeoff decision gate. We apply back pressure to the yoke and we are airborne. We check the attitude indicator to verify a proper pitch attitude and the turn coordinator to ensure that we are maintaining coordinated flight in the climb. We monitor our acceleration to Vx, confirm a positive rate of climb and select the “UP” position on the landing gear lever. We listen for the sound of the landing gear retracting and note, on the airspeed indicator, that we have reached Vx. We apply just a bit more back pressure on the yoke to maintain Vx in our climb. We visually check the rising terrain and estimate that we will clear it by several hundred feet. We do a quick scan for any conflicting traffic, reconfirm engine power, airspeed, pitch attitude, and coordinated flight. We confirm that the landing gear has retracted properly. We visually reconfirm that we will clear the rising terrain with a safe margin. We reconfirm that our airspeed is at Vx, we are in coordinated flight, there is no conflicting traffic, and that engine power output is as expected. We visually note that we have cleared the terrain so we decrease pitch attitude a bit to enable the airplane to accelerate to Vy. We will do another scan of flight and engine instruments and note that we have reached Vy. We retard the throttle to attain the recommended climb manifold and adjust the prop control to reduce RPM to the recommended climb setting. We note the engine temperature indications, close the cowl flaps, adjust trim for the climb, scan for traffic, and turn to our desired departure heading. We again verify engine instruments including temperatures and adjust the mixture control to achieve the desired fuel flow for the climb*.

The above paragraph gives us a look at the pilot’s need to divide attention. That paragraph is just a macro look at all the things demanding the pilot’s attention. An attempt to include everything that the pilot must attend to would require many pages.

We know that pilots need to divide our attention among various tasks. The specific tasks change depending on the phase of flight, complexity of the aircraft, whether VFR or IFR, and more. The ability to divide our attention is critical to flying and to many other tasks that we encounter in our lives.

To fully understand divided attention, we must understand that we cannot really divide our attention. As marvelous as the human brain is, it can only attend to one thing at a time. Divided attention is the brain’s ability to switch extremely rapidly and process different information sources and successfully conduct multiple and sometimes dissimilar tasks at a time.

As the number of tasks to be processed and/or the complexity of those tasks increases, the efficiency of the performance will decrease and a poor outcome may result. We sometimes hear the term, “task saturation.” That is simply asking the brain to divide its available attention between too many simultaneous tasks. We often read about a pilot who encountered difficulty due to a distraction. Arguably, the source of the distraction was merely one more task that required attention and the brain was unable to cope. Returning to our example of the pilot executing the takeoff, what if the landing gear does not fully retract as commanded? The pilot will have two more items demanding attention. Will the airplane be able to clear the rising terrain ahead with reduced airplane performance with the landing gear extended? And what should be done about the problem with the landing gear? Now there are more tasks with each requiring attention and pushing the pilot closer to task saturation.

When the brain is approaching task saturation, it may drop off several of its assigned tasks and concentrate on what it perceives to be the one or two that are most critical. If the brain chooses to drop off the task of monitoring traffic, odds are good that the flight will continue at least for now. But if the brain decides to drop off airspeed monitoring, a stall spin becomes a real possibility with a very bad outcome.

Unfortunately, the choice of what is most critical may be flawed by outside circumstances. Take the case of a cabin door popping open soon after takeoff. The solo pilot may recognize that the airplane will fly fine with the door ajar, though it will be noisy and maybe breezy. But the pilot who has a nervous front seat passenger who begins to scream incessantly, might lose control of the airplane while attempting to latch the door. The pilot’s brain has decided that calming the screaming passenger is the most critical task.

Like everything else in our humanness, there are significant individual differences in the ability to divide our attention successfully and efficiently among tasks. Disorders or pathologies can significantly impact an individual’s ability to divide attention, but that is beyond our scope here. A very influential element is proficiency which comes from training and experience. Consider the student pilot who is approaching task saturation while flying a standard traffic pattern and trying to maintain altitude, adjust power, flaps and trim while correcting for wind, watching for traffic and conducting radio communications. Fast forward to that same pilot after having logged 100 hours now flying that same traffic pattern with ease and confidence.

Ideally, a recurrent training program will keep a pilot’s skills sharp. Sharp skills mean that less time is required for the brain to perceive, process, and respond to stimuli. Heuristics take over many routine tasks allowing the brain to use its resources on non-routine items that may require a larger amount of that divided attention. Proficiency gains can also be made by receiving some dual instruction from a competent CFI, reading aviation safety articles, viewing safety videos, and taking online aviation safety courses. Even sitting in the aircraft and running checklists with the master switch off and touching, but not moving appropriate switches and selectors. Even “hangar flying” with other pilots or “armchair flying” can be beneficial. Anything that improves overall proficiency can improve a pilot’s ability to effectively divide attention.

Beyond sharp skills, other factors can influence the ability to divide attention. Illness, fatigue, stress, dehydration, low blood sugar due to not eating, or medications can degrade the ability to effectively divide attention along with causing other performance problems.

Fortunately, there are ways in which we can become better at effectively dividing our attention among different and unrelated tasks. The technical term is neuroplasticity. It is a process that involves adaptive structural and functional changes to the brain. The brain is not a muscle, but it shares similar characteristics to our muscles. If we do not exercise our muscles regularly, we begin to lose functionality. If we do not exercise certain aspects of our brain, it will also lose functionality. But like our muscles, these aspects of our brain functionality can be regained through neuroplasticity if we stimulate and exercise them.

We must note that doing one or two exercises will not produce effective results any more than doing one or two sit-ups will make a noticeable difference in our abdominal muscles. Significant improvement requires frequent exercise whether we seek physical or mental improvements.

Several reputable companies offer games and activities online to improve our divided attention skills along with other cognitive skills. There are reasonable fees for the use of these activities, but usually one subscription will provide access to exercises addressing multiple cognitive skills. These paid activities have been shown to be effective but choose the companies wisely and check their websites for validity studies.

There are also ways to do self-directed activities without paying any fees. It is still necessary to have a plan and the self-discipline to follow the plan if good results are to be attained. The following are suggestions.

Set aside 15 minutes. Put a news program on a radio or TV. Take all your eating utensils of all sizes (spoons, forks, knives, etc.) out of the drawer and mix them all up in a pile on a table. While listening to the news program, try to remember as many facts as possible and the identities of all advertisers while sorting the utensils as quickly as possible. When finished sorting, try to recall and count as many facts as possible from the news program. Mix the utensils up again and repeat the process. Make note of your score and repeat the exercise a few hours later or the next day. Keep a running total over a period of a week and watch for improvement.

Note what time a weather report usually is broadcast on a local TV station. As the time for the weather broadcast draws near, get ready to plan a game of solitaire either on a device or with actual playing cards. A typical weather broadcast during a news program usually has about a three-minute duration. As soon as the broadcast begins, start your game of solitaire, and play as rapidly as possible while trying to remember as many details presented during the weather broadcast as you can. Write down the details you recall. Repeat this exercise daily and watch your score improve. If you have a DVR, try recording a weather broadcast or news program and doing the same exercise with the same program daily.

In summary, we can see how important our skill in effectively dividing our attention is to flying and to many other aspects of our lives. We know that our divided attention ability will degrade over time if it is not used, but that it can be strengthened if we actively work at it.

*The procedure indicated is generic. The manufacturer’s recommended procedures should always be followed as procedures can vary for different makes and models.

I hope you find this series interesting and helpful. I will continue to present more on our cognitive skills next month. Meanwhile, I would suggest that you subscribe to my Being Better mailing list. Click here to subscribe.

Gene's Blog

Keep the Weight on the Wheels

We have all heard the statement, “It is better to be on the ground wishing that you were flying than to be flying and wishing that you were on the ground.” I can attest from personal experience that the statement is correct. Of course, our goal is to avoid that feeling of wishing we were safely on the ground. Experience has been a great teacher for me. I have been flying continuously since my first lesson at the age of 14 so you know that I have gone through all the stages of knowing it all, being indestructible, believing that I was better than most other pilots so cutting corners was okay, and thinking that though I was getting older, my experience and knowledge made up for the effects of aging. Through each of those phases, something gave me a wakeup call and reminded me that here I was again, flying and wishing I was on the ground. Each experience provided me with a specific lesson on something to do or not to do. Eventually, I think it all came together and allowed me to develop a mindset that I would like to share.

I call my mindset “WOW” since we are dealing with aviation and we can never have too many acronyms. “WOW” is short for “Weight on Wheels.” I want to keep the airplane’s weight on the wheels until I am sure that I have done everything reasonable and practical to be safe when the weight transfers to from being on the wheels to being on the wings. Of course, things can still go wrong, but I try to eliminate the most common causes of those “PASS” moments. (PASS is another acronym: Pants Almost Seriously Soiled.)

The first part of my WOW mindset is to recognize that my brain is working against me. From the moment we decide to go flying, all our cognitive biases and several of our human error causal factors begin to work against us. Take complacency for example. It is composed of familiarity and expectancy. The more experience we have, the more familiarity we have. We are familiar with the airplane and the operation. That breeds expectancy. We are familiar with everything we check on the preflight inspection and then expect to see that things are as they should be. Even though we look, we might not see that loose cowl fastener, unlatched baggage door, or pitot cover still in place. During taxi we expect that if we keep the nosewheel on the centerline we will be clear of obstacles. We might not notice the fuel truck that is parked not quite clear of the taxiway. During the run-up, we ordered the tanks topped off so we expect to see the fuel gages reading full. That is what we see, though the line crew did not fuel the airplane yet. During the takeoff roll, we expect engine RPM to be around 2,400 so we do not recognize a problem when only 2,100 RPM is showing on the tachometer. Of course, if we become airborne in that situation, we will experience our PASS moment when we are climbing at 100 feet per minute toward rapidly rising terrain.

By now, most still-living pilots have learned the importance of using checklists. But we must remember that our humanness is working against us while we mentally check off the items. We must resolve to really check the items to prevent expectancy from setting the stage for a future PASS moment.

That being said, it might be time for editing some of those checklists help PASS proof them. We should never remove anything from a manufacturer’s checklist, but we can add all we want. The following are a few suggestions to think about adding if they are not already there. Obviously not all these items are appropriate for all airplanes but consider them a buffet. Take what you want and leave the rest.

Preflight Inspection:

Baggage doors secured

Oil access door secured

Fuel caps secured

Towbar removed & stowed

Cowl plugs-pitot cover removed and stowed

Control locks removed and stowed

Controls free

Frost and ice removed

Before Taxi

Belts-harnesses

Seat latches locked

Loose items secured

Note time (for tracking fuel consumption)

Animals secured

Passenger brief - sterile cockpit, who is PIC and who will fly in emergency - harnesses and doors briefed

Before Takeoff

Doors secured

Controls free and correct

Note WX - what will you go into soon after TO?

Avionics programmed

Fuel verified - correct tank selected

Abort point noted

Takeoff Briefing - emergency plan, V speeds, departure procedure

Before Liftoff

Everything sound okay?

Power as expected

Airspeed alive

Controls feel normal

Nothing can guarantee a PASS-free flight, but a little extra effort while the weight is on the wheels can go a long way toward a PASS-free flight once the weight is on the wings.

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.

We want to keep the weight of the airplane on the wheels until we are sure it is safe to shift the weight to being supported by the wings. Our last opportunity to keep the weight on the wheels is in the initial stages of our takeoff roll. What should have been noticeably reduced engine power during the takeoff roll eventually led to the pilot and passenger perishing in a crash. The 50-year-old private pilot and his 59-year-old pilot-rated passenger died in the Piper PA-32-260 crash in Colorado in May of 2022.

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NTSB Photo

The NTSB Report includes the following, "The pilot and pilot-rated passenger conducted a personal flight that included troubleshooting an avionics issue. Following an extended taxi of longer than 1 hour, the airplane departed with a longer-than-normal ground roll and made a shallower-than-normal climb out. About ½ mile past the departure end of the runway, the airplane turned left and descended toward a road, which was a flight profile that was consistent with a forced landing attempt. The airplane impacted the road and then a large tree, which separated the engine and cockpit area from the fuselage, resulting in substantial damage."

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NTSB Photo.

The NTSB report continues, "Recorded data indicated engine performance during the accident takeoff was significantly lower than a previous takeoff. The engine power increased very slowly on the accident takeoff roll and fuel flow was about 45% less than the previous takeoff. The reason for the lower fuel flow during the accident takeoff could not be conclusively determined. However, one possibility was that the pilot(s) leaned the mixture during the extended ground operations of more than 1 hour and subsequently forgot to enrich the mixture before takeoff. A second possibility for the lower fuel flow was carburetor ice. The weather conditions at the time of the accident were conducive to serious carburetor icing at glide power. Carburetor ice can affect the fuel flow by disturbing the venturi effect in the carburetor throat that draws fuel into the cylinders. The result is lower fuel flows."

The NTSB report also includes this bit of speculation, "The slow acceleration and extended ground roll due to the degraded engine performance necessitated an abort that was not accomplished by the pilots. Since a purpose of the flight was troubleshooting an avionics issue, it is possible that the pilots were distracted by the avionics issue during the takeoff roll. This distraction could have led to inattention to ensuring that the fuel flow/engine performance was adequate during the takeoff roll and to abort the takeoff."

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NTSB Graphic

The NTSB probable cause finding states: "The pilot’s failure to abort the takeoff due to degraded engine performance. Contributing to the accident was the reduced performance of the engine, the reason for which could not be determined."

CEN22FA208 Google Earth Image  (Arrow added by GB)

For the purposes of our discussion, why full power was not being developed is immaterial. Our question is why the pilots did not abort the takeoff. The NTSB speculates that they may have been distracted by an avionics issue. The pilot was relatively inexperienced with just 149 hours total flight time while the pilot-rated passenger had 1,900 hours. Neither of them had apparently been taught, or did not remember, to verify takeoff power early in the takeoff roll so that an abort with a stop on the runway can be safely accomplished. Even a late decision to abort resulting running off the end of the runway would likely not have been fatal. The graphic above shows the departure end of the runway used.

We must consider what effect, if any, the pilots' cognitive biases might have played. Continuation bias could be a prime suspect. Once a task has been initiated, our humanness pushes us to complete it and can even filter out information that is contradictory to any evidence that we should not continue. It is possible that neither pilot was aware of the low engine power output due to this bias.

The lesson learned here is to always make a conscious effort to verify the power output early in the takeoff roll. It is part of keeping the weight on the wheels until we are sure that it is safe to transfer the weight to the wings.

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.

This crash occurred in Arkansas in June of 2021. The 38-year-old, 211-hour, private pilot died in the crash.

The NTSB report includes the following, "A witness reported that he heard the accident pilot report an emergency landing on runway 2, which was not a runway at the accident airport. Shortly thereafter, he observed the airplane make a left turn and it overflew the runway. He stated that the airplane appeared “crazy fast.” The airplane then entered a steep left bank and spun 1 ½ rotations before impacting the ground." The NTSB report continues, "During the impact sequence, the airframe parachute deployed, and the canopy was found still bundled in a straight line away from the wreckage. A postaccident examination revealed the pitot tube cover remained secured on the pitot tube with a “REMOVE BEFORE FLIGHT” banner attached."

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NTSB Graphic

CEN21FA277

NTSB Photo

Also included in the NTSB report is this, "Toxicology testing detected an antidepressant and a mood stabilizing medication in the pilot’s blood and urine. These medications and the associated medical conditions for which they are prescribed can negatively impact judgment and psychomotor performance. However, the investigation was unable to obtain psychiatric records to determine the severity of the conditions for which the pilot was being treated. Also, given the pilot’s skill and experience in this model airplane, the investigation was unable to distinguish between deficits in his capabilities and signs of his psychiatric illness. Thus, this investigation was unable to determine whether the effects from the pilot’s use of the medications or his psychiatric condition were factors in the accident."

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NTSB Photo

The NTSB probable cause states, "The pilot’s failure to maintain adequate airspeed, which resulted in an aerodynamic stall and spin. Contributing to the accident was the failure of the pilot to perform an adequate preflight inspection, to include removal of the pitot tube cover."

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NTSB Photo

As the NTSB states, we cannot know what role the pilot's meds, the condition for which they were prescribed, or lack of proficiency, played in this crash. But the initial, triggering factor was the pilot's failure to remove the pitot cover during the preflight inspection. The pilot passed two "gates" that should have been closed. The first "gate" was using and precisely following a printed checklist for the preflight inspection and the second "gate" was verifying "airspeed alive" early in the takeoff roll. Had these "gates" been recognized and followed, the pilot would have kept the weight on the wheels and not become airborne.

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.

WPR22FA210

NTSB Photo - First Point of Impact

This crash resulted on the death of the 68-year-old, 2459 hour commercial/instrument pilot. It involved a Mooney M20K and happened in California in June of 2022. The NTSB report includes the following, "The instrument-rated pilot planned to fly to his home base. The departure airport was enveloped in marine layer conditions with low visibility, mist, and clouds tops between 400 and 1,600 ft. The pilot received this weather information during a briefing about 30 minutes before departure, during which he filed an instrument flight rules (IFR) flight plan with a visual flight rules (VFR)-on-top clearance.

The pilot was unfamiliar with the airport. After making a wrong turn, the pilot was given taxi instructions to the departure runway. The engine run-up and takeoff appeared uneventful, and the pilot’s communication with the control tower was routine.

Shortly after takeoff, the airplane likely entered the clouds, and the pilot was instructed to contact the departure controller. Although the pilot acknowledged the instruction, he did not contact the departure controller."

WPR22FA210

NTSB Graphic - Outboard Section of Right Wing

The NTSB accident report continues, "A short time later, a witness who was driving along a freeway parallel to the departure runway saw a low-flying airplane that was traveling perpendicular to the takeoff direction. The airplane did not appear to have any trailing smoke or vapors. The airplane then impacted the ground just past the freeway. A video from the witness’ dashboard-mounted camera captured the flames from the impact and showed the fog and low clouds enveloping the area. The reported weather observations matched the weather conditions observed in both the security camera video and the dashboard camera video."

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NTSB Photo - Debris Field

The NTSB report continues, "Engine and propeller evidence and the associated propeller ground scars indicated that the engine was producing high levels of power at impact. The airplane was equipped with conventional vacuum and electrically powered flight instruments. Although the autopilot and Page 2 of 13 WPR22FA210 flight instruments were destroyed due to impact and thermal damage, the vacuum pump, which had recently been installed, was recovered and found to be operational. Also, evidence within the wreckage indicated that the airplane was configured appropriately for the initial takeoff climb, with the landing gear retracted and the trim set for takeoff. Thus, the loss of control did not occur due to a loss of engine power, a preimpact mechanical malfunction or failure, or pilot error in configuring the airplane for takeoff."

And one very important statement appears in the NTSB Report: "The pilot’s logbook showed only the flight time required to meet Federal Aviation Administration (FAA) currency requirements; and based on his entries, while he had undergone a flight review the year prior, it appeared that he was not instrument current at the time of the accident."

WPR22FA210

NTSB Photo

The NTSB probable cause states, "The pilot’s spatial disorientation and loss of airplane control after entering instrument meteorological conditions shortly after takeoff."

A big part of our responsibility as a pilot is to maintain our proficiency including regulatory recent experience requirements. A recurring theme shows us instrument rated, but not current and proficient, takeoff into IMC perhaps believing it will be okay "just this once," but is not. Usually, the pilot's humanness uses cognitive biases to justify the action. Perhaps illusory superiority allowed the pilot to believe that he was a bit better than those other pilots. Maybe optimism bias told the pilot that the airplane would climb through the marine layer quickly and the sky would be clear above. Or maybe continuation bias determined that the task had begun when the pilot arrived at the airport and masked the facts regarding the low ceiling.

Whatever the case, in addition to other items we must consider before transferring the weight from the wheels to the wings we should evaluate the flight condition to be expected very soon after takeoff. Will be immediately in clouds with no horizon reference? Or will be departing over featureless terrain into darkness?

If we are not current and proficient in the conditions to be encountered, it is much safer to keep the weight on the wheels.

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

50 Years of Flying Insights by Gene Benson

Great Holiday Gift!

"Fifty Years of Flying Insights" by Gene Benson

Paperback version just $12.99 on Amazon (Kindle version also available)

Click here to purchase on Amazon

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