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Vectors For Safety - October 2023

Safety Initiative Update

Safe Leaf Peeping

October is a great time for an aerial view of the fabulous autumn foliage. Before you go, consider checking out our Avemco sponsored video, "Autumn Scenery Safety" for some tips on making it a safe flight.

New Episode of "Old Pilot Tips"

Our new Episode 12 of "Old Pilot Tips" is now available. The topic of this under one-minute video shows how to quickly and easily verify that the P-Leads are connected to avoid an unintentional engine start when handling the propeller. Check it out here.

New Spatial Disorientation Video

Many accident reports from the NTSB list “spatial disorientation” in the probable cause findings. In this video, we will look at what spatial disorientation is, what are the causes of it, and some steps pilots can take to help avoid an accident related to spatial disorientation. Check it out here.

Again! CFI Struck by Spinning Propeller

I have been writing about (some would say ranting about) not allowing anyone, even yourself, to enter or exit an airplane with the engine running. A CFI was seriously injured in November 2022 when he came into contact with the spinning propeller after exiting the airplane to remove a forgotten nosewheel chock.

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

Prepare for the Upcoming Cold Weather

A pilot experienced a catastrophic engine failure in his Cessna 172F in December 2022. The engine failure was attributed to using an incorrect grade of engine oil. Click here to download the accident report from the NTSB website.

Recommended Reading - The SAFE Blog

My friend and long-time colleague David St. George has done amazing work as the director of the Society of Aviation and Flight Educators (SAFE). He authors "The Safe Blog" and the most recent edition is a very interesting and valuable read for all pilots. I highly recommend The Secret of Chandelles (and Safety): “Cross-Coordination!”.

Avemco Insurance sponsors Gene Benson
Gene's Blog

Risk After Dark

Once again summer has seemingly zipped by as we usher in October with fewer hours of daylight and nearly the end of Daylight Savings Time. We might find ourselves more likely to be flying after darkness has fallen upon us and we all know that night flying adds additional risk. That does not mean that we should avoid night flying, but rather that we need to identify specific risks and take appropriate steps to mitigate them.

In preparation for this article, I searched the NTSB database for accidents involving reciprocating engine powered airplanes, operated under Part 91 General Aviation, from January 1, 2019, through August 8, 2023. I selected to see only reports of accidents in which the investigation had been completed and that included the word “night” in the probable cause.

My search identified 59 accidents. When sorting by the highest injury level, the result was no injuries = 11, minor injuries = 7, serious injuries = 4, and fatal injuries = 37. Airplanes involved ranged from small amateur built to technologically advanced models. Only one accident involved a multiengine airplane, a Beech Baron Model 58. Certificate levels of the pilots ranged from unlicensed, through solo student pilots (some carrying passengers), private pilots, commercial pilots, flight instructors, and airline transport pilots. Flight experience ranged from less than 100 hours to more than 10,000 hours. Pilot ages ranged from 18 years to 79 years.

More than a third of the identified accidents (22 out of 59), in addition to “night” included “spatial disorientation” in the probable cause finding. Just 4 of the 59 identified accidents included “controlled flight into terrain” in the probable cause. VFR conditions prevailed during 37 of the 59 identified accidents. For the 22 identified accidents that occurred in IFR conditions, 20 were fatal. Of the 20 fatal identified accidents, 13 included “spatial disorientation” in the probable cause finding. We should note that loss of control due to spatial disorientation in instrument conditions may or may not have been a direct result of the night condition.

Based on all that, we can conclude that spatial disorientation and its resulting loss-of-control is statistically the greatest risk enhancer for night flying. Controlled flight into terrain (CFIT) follows as a distant second as a night flying risk enhancer. Various other contributing factors also appeared, including 2 mishaps in which the pilots chose to land on an unlit runway. Another 2 accidents involved wildlife strikes on landing. We should note that wildlife strikes also occur during daylight hours so they may or may not be relevant to our discussion. One accident with serious injuries involved night VFR flight into inadvertent flight into a snow squall. That accident reminds us of the importance of knowing the weather conditions since we cannot easily see deteriorating conditions while operating at night. The remaining accidents resulted from the same general lack of proficiency that we find in daylight accidents. My experience tells me that any marginal lack of proficiency is magnified into a significant lack of proficiency during night operations.

Let’s target our top two causal factors, spatial disorientation and CFIT, for risk mitigation. CFIT is the most straightforward so we will look at that one first. The obvious rule, especially at night or in low visibility conditions, is to always know the elevation of the terrain over which the airplane is operating. Flying through mountain passes at night, as exemplified by one of our identified accidents, is simply a bad idea. Night approach and departures require special consideration and planning. The instrument approach plates provide detailed instructions on departures from runways where terrain clearance may be an issue. Whether VFR or IFR, any night departure is safer if those resources are used. In the absence of that information, close scrutiny of the Sectional Chart is in order. Night approaches are safer if visual or electronic guidance is provided and followed. In any case, preflight planning should include study of the intended airports of use with special emphasis placed on terrain and obstacles surrounding the airports.

Attacking spatial disorientation is more complex. A brochure from the FAA simply titled, “Spatial Disorientation” states, “Statistics show that between 5 to 10% of all general aviation accidents can be attributed to spatial disorientation, 90% of which are fatal.” Spatial disorientation can occur whenever outside visual reference is lost. It is most frequently associated with flying in instrument conditions, but it also happens in VFR conditions at night when outside visual reference is not present or is confusing.

I make sure my students understand three risk factors associated with spatial disorientation. They are reduced visibility, lack of proficiency, and physiology. Any flight in reduced visibility adds the risk of spatial disorientation, but pilots have all been trained, to some extent, on attitude instrument flying. Lack of proficiency, supported by our humanness, adds significant risk of spatial disorientation. I know from personal experience that instrument scanning and interpretation skills have a rather short shelf life and must be refreshed frequently. Finally, physiology plays a big role in the risk of succumbing to spatial disorientation. The IM SAFE checklist is an excellent guide here. Just about any illness can add significant risk and many medications, both prescription and OTC, can wreak havoc and increase susceptibility to spatial disorientation. In addition to the items on the IM SAFE checklist, physiology includes having an awareness of the various illusions that can be present when operating in night or IFR conditions.

In summary, night flying involves more risk than does flying in the daylight. That added risk can be managed by careful preflight planning to become aware of terrain and obstacle elevations and calculating airplane performance to make sure a safe altitude can be achieved and maintained. Maintaining proficiency in all aspects of piloting skills is important, but it is even more crucial when night operations are planned. And being mindful of the physiology involved in night flying and choosing not to fly when flags are raised by the IM SAFE checklist is critical.

broken image

Reprinted from NASA "Callback" Issue 491 December 2020

Early Lessons

This student pilot learned a good lesson from a situation that has surprised and prepared many who have gone before.

■ I was on a solo cross country. All forecasts showed overcast clouds at 6,000 feet. My route was 4,500 feet [outbound].… [Enroute], I realized the clouds were not at 6,000 feet as forecast. I continued, as I was still under the cloud level. Just inland, I contacted Departure that I was descending down to 4,000 feet to continue VFR. As I descended, the clouds descended with me. Just a few miles [over] the land, I flew into a cloud accidentally, as the [cloud] layer was much lower. I then put the pitot heat and carb heat on and descended out of the cloud.

At 2,500 feet, I came out of the cloud [and] noticed the visibility wasn’t much better and that the field might go IFR soon. [I] also noticed visible moisture on the windshield and texted my instructor that I had possible icing and that I was returning to [home base]. I then contacted Approach saying that I was [experiencing] possible icing. They then gave me straight…to the runway with no delay.

Thankfully, I was first in line and didn’t need to declare an emergency. I flew straight toward [the airport],… landed safely, and taxied to [the ramp]. Once back, I showed my instructor the icing and discovered moderate mixed icing along all leading edges. I was able to stay calm and make a quick decision with…my instructor’s help.… This experience was very humbling, and the decision to go was probably wrong, but I trusted the forecast.

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.


NTSB Photo

Miraculously, the three people aboard the Cessna 172 shown above escaped with only minor injuries. the crash happened in Kentucky in November 2020. The NTSB accident report includes the following, "The pilot was approaching the destination airport for landing at night. On short final approach to the runway, he observed he was slightly low via the precision approach path indicator (PAPI) lights. Due to a 20-knot crosswind, the pilot was attempting to maintain runway centerline and entered an inadvertent slip, subsequently losing 20ft of altitude. As he looked up, he saw all red on the PAPI lights and reached to the throttle to reacquire the glideslope. He then observed the treetops in front of the propeller and the airplane contacted the trees. The airplane subsequently the ground and came to a stop. The airplane’s fuselage, both wings, and empennage were substantially damaged.


NTSB Photo

The NTSB Probable Cause states, "The pilot’s failure to maintain proper glide path during a visual approach that was conducted at night, resulting in a collision with trees and terrain." 

The 64-year-old private pilot was instrument rated. The accident report includes the following under Pilot Information: 428 hours (Total, all aircraft), 131 hours (Total, this make and model), 428 hours (Pilot In Command, all aircraft), 2 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft). While the pilot did have a current flight review and Basic Med certification, nothing in the accident report indicates whether or not he met the Part 61 recent experience requirement to carry passengers at night. The regulation requires the pilot to have completed three full-stop landings within the preceding 90 days. The pilot reported having flown just 2 hours in the past 90 days, all within the past 24 hours. The crash is reported to have happened at 6:44 PM local time on November 19, 2020. Official sunset that day was at 5:23 PM local time meaning that night recent experience requirements took effect at 6:23 PM. Officially, it had only been night for 21 minutes, but clearly it was dark. It seems unlikely that the pilot could have accomplished the required 3 takeoffs and landings given the information provided. Regardless of legality, it seems that the pilot was lacking in night recent experience and attempting a night, 20-knot crosswind landing was probably a flawed decision.


Photo Source: NTSB

Looking at this crash objectively, the pilot did not commit any egregious errors. Yes, it is likely that he did not meet night recent experience requirements, but he is not the first pilot to slide a bit on that. He did have a flight review and he met the medical requirements.

Lessons to be learned from this crash involve decision making. I have written much about our cognitive biases, especially illusory superiority and optimism bias, leading us down an unsafe path. In a written statement to the FAA, the pilot said that the wind was "noted by me but not critical." The pilot made a decision to attempt the landing with a crosswind somewhat in excess of the maximum demonstrated crosswind component of the Cessna 172. The manufacturer's demonstrated crosswind component is not a limitation and I know from personal experience that the airplane will handle a crosswind even a bit more than 20 knots. But was that a good decision based on the pilot's limited recent experience and the night conditions? Apparently it was not.

We know the importance of a stabilized approach. The pilot's narrative suggests that he was struggling a bit with the approach which would classify the approach as unstable. Continuing an unstabilized approach is never a good idea. Unless the airplane is sipping its last few drops of fuel, which was not the case here, it is best to apply power and get some altitude. Then an informed decision can be made as to attempt another approach for the same runway or choose a different runway or different airport. When things are not going well, please do not convince yourself that it will be okay "just this once."

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

broken image

Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

CEN21FA426 Accident Airplane

Photo Source: NTSB

This crash happened in Pennsylvania in November 2021. The 58-year-old, 196 hour, private pilot and his 13-year-old daughter/passenger were seriously injured. the NTSB accident report includes the following, "The pilot reported that he was returning to his home base under night, marginal, visual flight rules conditions. While enroute, he inadvertently entered instrument conditions and a sudden “snow squall.” He was blinded by the snow and tried to maintain wings level. The airplane gradually descended and impacted trees and terrain, which resulted in substantial damage. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation. He had received some instrument training; however, he was not instrument rated."


Photo Source: NTSB

The NTSB probable cause states, "The pilot’s decision to commence the flight in marginal visual flight rules conditions at night, and his failure to maintain a safe altitude once instrument conditions were encountered."


Phot Source: NTSB

Excerpts of the pilot interview included this information on the extent of the injuries to the pilot and his passenger, "He suffered a L1 vertebra fracture and foot injury. His daughter also suffered serious injury but is recovering." A news article published on stated, "[The pilot] had several broken bones and a concussion among other injuries, but is back home and walking. A portion of [the daughter's] spine was shattered. This week, doctors told the family, [the daughter] is developing scoliosis and may never walk again.


Photo source:

Lessons to be learned from this include the fact that while flying in MVFR conditions at night is legal, it is generally not a good idea. Night flying adds additional risk, but flying in marginal VFR conditions at night adds much greater risk. My advice for MVFR at night is do not do it. If possible and proficiency allows it, file IFR. If IFR is not an option, stay on the ground.

Many weather hazards, including snow squalls, are difficult if not impossible to detect visually at night. I was once making a night VFR flight from New England to central New York State in a Cessna 182RG. It was late December and clear weather was forecast. As expected, there was nothing but darkness below as I crossed the Berkshires. But, as I crossed the Albany, NY VOR at 8,500 feet, I noticed that no ground lights were visible. I turned on the landing light and sure enough, I was in a rather intense snow squall. Fortunately, I had IFR capability so I simply requested an IFR clearance and continued on my way without incident. I learned the lesson that it is easy to fly into instrument conditions without warning at night.

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.

We have all heard the phrase "No good deed goes unpunished." This 2,342 hour commercial-instrument-CFI received minor injuries when his Cessna 182 impacted the engineered materials arrestor system while he was completing his takeoffs and landings to comply with the night recent experience requirements of Part 61. The crash happened at Charleston, WV in September 2019. The NTSB accident report includes the following, "The pilot reported that, while performing landings for night currency, he misjudged the approach, and the airplane landed short of the runway and then impacted the engineered materials arrestor system, which was about 370 ft lower than the approach end of the runway."


KCRW 5unway 5 Arrestor System

The NTSB accident report also includes, "Archived NOTAMs for the date of the accident reported that the runway's visual approach slope indicator and end lighting were out of service."


NTSB Photo: Impact damage to the arrestor system

The NTSB probable cause states, "The pilot's improper approach path at night and his misjudgment of the landing point, which resulted in landing short of the runway and impact with the runway's engineered materials arrestor system."


NTSB Photo

In the Pilot/Operator Report submitted to the NTSB, the pilot states that he had received 7.2 hours of instruction about two months prior to the accident and that the instruction had included a flight review and instrument competency check. This was apparently all instruction during daylight hours. The pilot reported that he had one hour of night time in the 90 days preceding the accident. The pilot stated in the Recommendation section of the Pilot/Operator Report, "Night landing refresher training with instructor"

The pilot was within the regulations attempting to regain night currency while solo, but as he points out, taking a competent CFI along would have been prudent.

Questions arise from a study of this accident such as why was he landing so near the end of a 6,715 runway knowing the VASI and end lights were inoperative? How did he manage to descend 370 feet lower than the approach end of the runway on final? The crash occurred at 11:30 PM local time. Was fatigue involved? Did his age of 77 play a role? we do not know the answers to these questions, but the lesson to be learned is that night flying adds risk and we must take appropriate steps to mitigate them.

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

New Edition to the Aviation Safety Series

Aviation Safety Series by Gene Benson

Thoughts on Being a Better, Safer Pilot - Vol. 3 is now available in e-book format.

Click here to purchase on Amazon for $3.99

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