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Vectors for Safety-September 2020

Safety Initiative Update

Northeast Virtual Aviation Safety Stand Down

Be sure to register for and attend this event. We have some dynamic speakers lined up. A brief Q&A session will be held after each presentation.Attendance and participation at the event may qualify you for all three FAA wings credits at the basic level. This event primarily features presenters from the Northeast, but most topics apply to flying anywhere. Everyone is welcome to join the event! The virtual event will be on Saturday, September 12 from 9 AM till 1 PM Eastern time. For more information and a registration link, click here.

What's going Around?

One of our local TV stations here in Rochester, NY used to have a weekly feature titled, "What's Going Around?" It ran primarily during the school term and usually involved an interview with a pediatrician who would provide updates on the childhood illnesses that were most commonly being treated that week. Though there should be nothing contagious about aircraft accidents and incidents, we do seem to have a higher incidence of one kind of accident for a few weeks and then something else becomes more popular. It is easy to get a quick snapshot of what kinds of accidents are happening on a daily basis by looking at the ASIAS report that are issued each weekday. Click here to check out the most recent contenders for most popular.

Being Responsible

On July 31, 2020, a Piper PA-12 collided with a DHC-2 (Beaver) near Soldotna, Alaska. Six people aboard the Beaver and the pilot of the PA-12 died in the crash. The NTSB preliminary report says that a witness stated that the PA-12 impacted the DHC-2 on the left side of the fuselage toward the back of the airplane. The NTSB also states in the preliminary report: "According to information on file with the FAA Civil Aeromedical Institute, the pilot of the PA-12 was denied medical certification in June 2012 by the Alaska Regional Flight Surgeon due to vision problems. The denial was appealed and sustained in July 2012." News reports show that the 67-year-old pilot of the PA-12 was an Alaska state lawmaker.

We do not know what the NTSB will determine as the probable cause of this accident and we do not want to make false assumptions regarding whether or not the PA-12 pilot's vision played a role. The question here is not whether this pilot was legal to fly on that day, but whether he was safe to fly. Let's all take responsibility for making sure we are fit-to-fly. We all need to be responsible in our behavior.

Avemco Webinar Series for Fall Resumes October 8

Our first webinar in the series is titled, "Autumn Scenery Safety." Autumn offers unique opportunities to view some spectacular autumn scenery or just some general sightseeing. We can be safer if we are aware of some additional hazards and take steps to mitigate the risks. This live webinar will address some of those hazards and provide practical risk mitigation strategies. Like all events in the series, attendance is valid toward the Avemco Safety Rewards Program. To accommodate time zone differences, we are offering the same program on two live sessions. Attendance is valid for one Basic Knowledge-3 wings Credit. Click here for more information or to register.

Learning from Near Misses

Much has been written about learning from our mistakes. Accident analysis is all about learning from the mistakes of others. But we can kick that up a notch by also learning from the accident or incident that was narrowly avoided. Read more on the "Being Better Blog."

Beware of CO Poisoning!

We will soon be experiencing cooler temperatures, especially in the northern latitudes. That might give us reason to reach for that cabin heat knob. But Beware! In most single-engine airplanes and some light multiengine airplanes, cabin heat is derived by circulating outside air through a shroud around part of the exhaust system. If there is a crack in the exhaust pipe, carbon monoxide can be delivered into the cabin. It seems prudent to do three things. First, have a competent technician inspect the exhaust and cabin heat systems for any problems. Second, use a CO detector. The inexpensive cards with a patch that turns color in the presence of CO have been around for years. The must be replaced periodically and they are better than nothing. But reliable, portable CO detectors suitable for aircraft use can be purchased for a little more than one-hundred dollars.

Our first accident analysis this month illustrates the issue.

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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.

Accident Analysis #1

This accident involved an Aeronca 7AC. The pilot and sole occupant died in the crash. The NTSB accident report contains the following: "The private pilot departed for a local personal flight on a winter day with an outside air temperature of about 6°C. About 1 hour after takeoff, the pilot's brother saw the airplane maneuvering near his home, which was in a rural area about 31 miles from the departure airport. The airplane did not return to the departure airport, and the accident site was located in an open field 2 days later, about 4 miles from the pilot's brother's home. Examination of the accident site revealed wreckage and impact signatures consistent with the pilot losing control of the airplane. Examination of the engine's exhaust muffler revealed cracks in several locations, and the muffler's shroud contained a layer of exhaust residue. Six months before the accident, the pilot and the mechanic who had previously performed an annual inspection on the airplane became aware of a crack in the muffler near a weld that the pilot had performed. The pilot had purchased a replacement muffler, but it was not installed before the accident. A carbon monoxide detector was not on board the airplane."

The NTSB accident report also includes the following: "Toxicology testing of the pilot's blood revealed a carbon monoxide level of 40%, which was more than enough to severely impair the pilot. The carbon monoxide likely entered the airplane's cabin because of the cracked engine exhaust muffler."


Photo Source: NTSB

The NTSB Probable Cause Finding states: "The pilot's impairment due to carbon monoxide poisoning from a known cracked engine exhaust muffler, which resulted in a loss of aircraft control. Contributing to the accident was the pilot's decision to continue flying the airplane without properly repairing the exhaust muffler."

Gene's Blog

Mise en Place

by Gene Benson

I am an incredibly lucky man. My wife likes to cook almost as much as I like to eat. Since she retired, my wife has taken on cooking as her main hobby. Her specialty is creating healthy yet delicious meals and snacks. Her approach to cooking reminds me of how a professional pilot performs on a continuous improvement program. She takes courses, reads articles, watches videos, and of course watches cooking shows on TV. She plans a full day of meals calculating total calories, cholesterol, sodium, and several other parameters. If one of the parameters is out of the target range, she makes adjustments as needed. She also estimates total prep time so that the meals can be served at the desired time.


When it is time to begin the actual meal prep, she practices something called “mise en place.” The simple translation is “everything in place.” She gathers the utensils, cookware, ingredients, and whatever else she will need before she begins. The method works. Her meals are flawless, tasty, and prepared with a low level of stress.


That is where we can adapt a procedure from the culinary world for use in aviation. If we make the effort to thoroughly plan our flights and make sure that everything is in place before we start the engine, we can be safer and operate with less stress.


Having the necessary utensils would translate to having an aircraft that is legal and that is capable of adequate performance considering anticipated density altitude, terrain, runway lengths, airspace and more. Having the necessary ingredients might mean having sufficient fuel including generous reserves, needed charts whether paper or digital, water to stay hydrated, and whatever else the flight might require. Of course, we must not forget a main ingredient, a pilot who is competent, current, not stressed or fatigued, and healthy.


Many accidents and incidents could be avoided if the pilot had done a little more planning. Lacking a key ingredient part way through preparing a meal does not reflect well on a chef. Running out of fuel or having any other problem caused by a lack of planning does not reflect well on the pilot.

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.

Accident Analysis #2

Any aircraft crash that results in serious injury or death is sad. Many are also disturbing when they are so easily preventable. I find this crash disturbing on a couple of different levels and I will get to that after we look at what happened.

The accident involved a Piper PA28-140 which had been modified via STC to a pseudo PA28-180 (NTSB phrase). The 36 year-old pilot survived, but with serious burns. His mother, his aunt, and his 14 year-old nephew perished in the crash. Nthe NTSB reported that at the time of the crash, the pilot had a total of 148 hours flight time including 70 hours as pilot-in-command. He had completed a flight review in a Cessna 172 just 23 days prior to the crash.

The NTSB report states: "On the day of the accident, the pilot conducted two flights with passengers at 68FD. On the first flight, he had one adult male and two small children on board. On the second flight the pilot also had three passengers on board but, this time the passengers were a young male, and two adult females.

The takeoffs at 68FD were performed by the pilot on runway 27, which was a turf-covered runway. Trees existed at the departure end of the runway that were part of a heavily forested area, which extended to the west of the airport."

The following note is made under the Airport Information section of the NTSB report: "Runway 27 was turf, and was in fair condition with areas that were sandy and devoid of turf. The total length was 5,280 feet long and 50 feet wide. At the time of the accident only 2,600 feet of its 5,280 foot runway was available for use due to flooding. Obstacles in the form of 70-foot-tall trees, and electric power transmission lines existed on the departure end of the runway. Examination of runway 09 revealed that a clearway devoid of obstructions existed beyond the departure end."

The NTSB report continues: "According to witnesses, during the second flight's takeoff, after a ground roll of approximately 1,200 feet, the airplane rotated and the pilot had the "nose up pretty much." One of the witnesses who observed this began to verbalize that the pilot should "get the nose down." When the airplane reached the trees at the end of the runway, it cleared them. Moments later the witnesses observed that the airplane had begun to sink into the tops of the trees and then roll to the right. It then disappeared from sight, and the sound of impact was heard. Black smoke then rose up from behind the trees."

Like many accidents that I analyze, this one includes the word "tailwind." The investigation determined that there was approximately a 3 knot tailwind and states that a tailwind can increase takeoff distance by ten percent for each two knots of tailwind. Based on that information takeoff distance would have been increased by about 15%. Much of the NTSB's accident analysis is based on a video recording taken by a rear seat passenger and another taken by a person external to the airplane. The video taken from inside the airplane captures the windsock indicating the tailwind during the takeoff run.

Two important factors call into question the pilot's runway choice. One factor is the tailwind and the other is the lack of obstacles had the opposite direction been chosen for takeoff. Convenience often plays a role in the takeoff direction, especially in a very light wind condition. We do not know what factors entered into the pilot's decision regarding direction of takeoff.

Then there was the pilot's decision to take off with the flaps retracted. Was he flying a PA28-140 or a PA28-180? Though guidance on the use of flaps for a soft or rough field takeoff varied slightly between the Pilot Operating Manuals for the two models. The PA28-140 manual states "Soft Field, Obstacle Clearance" takeoff flaps should be set to 25 degrees. The PA28-180 manual states, "short field takeoffs and for takeoffs under difficult conditions such as deep grass or on a soft surface, distances can be reduced appreciably by lowering flaps to 25 degrees." So it seems that manufacturer guidance recommended a flap setting of 25 degrees.

Finally, the NTSB report addresses the carburetor heat control. The following is included in the NTSB accident report: "The video showed that, during the takeoff, the engine tachometer indicated an rpm of about 2,000, which was less than the published minimum static rpm of 2,325 for the engine at its maximum throttle setting. While the accuracy of the tachometer's calibration could not be verified due to damage sustained during the accident, one potential cause for this discrepancy was the position of the carburetor heat selector handle. Video and statements from the airplane's owner suggest that the pilot had left the selector in an intermediate position, although the appropriate position for the takeoff phase of flight was the off position. Taking off with the selector in an intermediate position would potentially result in a loss of engine performance consistent with that observed on the tachometer." Under a section reporting on the onboard video recording, the following is noted: "Green colored painter's style tape was visible over the carburetor heat control lever. The lever appeared to be secured by the tape in a position somewhere between mid-range and the lever's travel towards the off position." The pilot was questioned about the tape. Here is his response as presented in the NTSB accident report. "When asked why there was tape covering the carburetor heat control lever, the pilot stated the airplane owner advised that the linkage for the carburetor heat may not have been working, and that a friend told him "don't use it."


According to the NTSB report, the calculated density altitude at 68FD was approximately 1,900 feet. Review of an FAA Koch chart indicated that due to the density altitude the airplane would have incurred a 20-percent increase in normal takeoff distance, and a 10 percent decrease in rate of climb.

In the accident report section regarding the airplane owner, the NTSB reports the following: "According to the airplane owner, he was an airframe and powerplant mechanic and he maintained the airplane. He stated that the weight and balance form was not up to date. When he bought the airplane it had a Lycoming O-320 in it, and they just worked off the old weight and balance form. He also stated that there was nothing wrong with the airplane, and that the tape over the carburetor heat control lever was to remind the pilot "not to mess with it" as "it was a little stiff" and that the pilot "did not need it as Lycoming suggests not using it unless you need it," and that "it would travel both ways, it was just a little stiff."

ERA14FA255 NTSB Photo

Photo Source: NTSB

The NTSB Probable Cause finding states: "The pilot's decision to depart from a soft runway with a tailwind and toward obstructions, and his failure to follow the manufacturer's recommended procedures for the takeoff. Contributing to the accident were the degradation of airplane and engine performance due to the high density altitude and the pilot's failure to properly configure the airplane's carburetor heat."

Yes, the pilot-in-command is ultimately responsible for the safety of the flight. There is no question that the pilot should have done some things differently. But let's consider some important factors. The pilot was inexperienced having only 148 total flight hours and only 70 hours of P-I-C time. What was the quality of the pilot's flight and ground training? Did he complete a thorough ground school course or did he simply study test questions and answers? Was he aware of the regulatory requirement to calculate takeoff performance before executing a takeoff? Did he understand the aerodynamic principles regarding takeoff procedures and the importance of best angle of climb and best rate of climb airspeeds? Did he realize the detrimental effect of any application of carburetor heat on engine performance? And finally, what about flying an airplane with a known maintenance issue? It simply does not seem like his knowledge and good operating practices could have deteriorated in so little flight time.

Inexperienced pilots tend to adopt the behaviors they see modeled by more experienced pilots. We do not know what behaviors the pilot had seen modeled in the past. The accident airplane owner modeled at least one of these poor behaviors by flying an airplane with a known maintenance discrepancy, the taped carburetor heat control. We should all strive to model safe practices to inexperienced pilots.

We can also take it to the next level by informally mentoring new pilots. When we become aware of a pilot moving from student pilot to simply pilot, we can reach out in a friendly way and offer to be available for any questions or problems that might arise in the future. We should not appear to be the know-it-all who wants to show off skill and knowledge. We can use a simple phrase such as, "I am always available if you want to run any questions by me." We never know when a pilot will ask a question or opinion and we might just safe a life by steering the pilot in a safe direction.

Safety Initiative Support

There are many costs associated with the operation of our Safety Initiative. Those costs include a webinar subscription, website hosting, commercial email service, software subscriptions, and more. We want to thank our readers who have made financial contributions to help defray expenses and we also especially thank those of you who have set up a monthly contribution through PayPal. We want to thank and applaud Avemco Insurance for their support of the FAASTeam and also for their sponsorship of our recent Pilot Talk webinar series which will resume in October.

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