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Vectors For Safety - September 2022

Safety Initiative Update

Don't Do It!

Allow anyone to exit or enter the airplane with an engine running that is. Again, a passenger departed an airplane and was struck by the spinning propeller and killed. This one happened in Kentucky on August 7 of this year.

Verify it!

Correct fuel that is. This should never happen, but somehow it does at least once per year. A Beech 58 Baron was incorrectly fueled with jet fuel and crashed shortly after takeoff seriously injuring the pilot. An excerpt from the NTSB accident report says it all: "The airplane was fueled before the flight. The fueler reported that he incorrectly fueled the airplane with Jet A fuel instead of Avgas. He added that he did not notice the “Avgas only” label adjacent to the fuel port, and that he did not follow the company’s fueling checklist while fueling the accident airplane."

As I have written many times before, personally observe the fueling of your airplane if possible and always check to make sure you received the quantity and type of fuel requested.

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

Set it!

An example that is. This is a special note to flight instructors. It is not enough to tell students what they should do. We must set the example of doing it ourselves. They decided to perform a landing at a 1,720 foot private grass strip. The temperature was about 88 degrees F. The NTSB accident report includes the following: "During the takeoff, after the airplane became airborne, and the last recollection the student pilot had was that the airplane was not climbing due to “low airspeed in [the] high heat [and] high humidity.” Subsequently, the airplane impacted the runway about 100 feet from trees at the departure end, which resulted in substantial damage to the fuselage and wings. The student pilot reported that they did not complete performance calculations prior to the takeoff. Takeoff performance calculations based on the takeoff distance chart in the airplane owner’s manual revealed that a ground roll of about 1,022 ft and a takeoff distance of about 1,792 ft was required to clear a 50-ft obstacle at the airplane’s maximum allowable gross weight. The chart (and the checklist procedure) indicated that the maximum performance takeoff was to be performed with the flaps in the retracted position." Both the student and the CFI were seriously injured. As a flight instructor, we must insist that regulations be followed including those requiring takeoff calculations to be performed. Even if this takeoff had been successful, the student would have learned that the calculations are optional. As it turned out, the student learned the lesson the difficult way.

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

Review it!

Midair collision avoidance that is. A tragic collision occurred on August 18 in the traffic pattern at Watsonville, California, resulting in the death of three people. Details are still sketchy as of this writing, but it appears that the collision happened in the traffic pattern at the non-towered airport. Click here to download an FAA advisory circular regarding non-towered operations which also provided additional links. Click here to view our YouTube video, "Avoiding the Midair Collision."

Enroll in it!

Our free course valid for Wings credit that is. Runway excursions happen daily and most are easily avoidable. Our course, "Many Happy Returns," is based on a webinar we presented last year. But even if you watched the webinar or took the course then, a refresher might be a good idea and you can refresh those Wings credits also! The course, sponsored by Avemco Insurance, is valid for one credit for Basic Knowledge Topic-3 and one credit for Advanced Knowledge Topic-2. It also qualifies for the Avemco Safety Rewards Program. Click here for complete information and to enroll for free.

Avemco Insurance sponsors Gene Benson
Gene's Blog

Decision: Go or Stop?

The NTSB database has many accidents that happened during an aborted takeoff. Those mostly result in property damage to the airplane, sometimes substantial damage, but minor or no injuries. The database also has many accidents that happened in the first half-minute or so after becoming airborne. Those frequently include reports of serious injuries or fatalities. Have you ever aborted a takeoff? Has an instructor ever provided experience in aborting a takeoff? If so, was the abort near rotation speed or was it done at around 30 knots? Practice high speed aborts are very hard on the brakes but probably should be practiced, under the supervision of a competent flight instructor, during a flight review. Why? Nearly all consumer vehicles on the road now have at least anti-lock brakes and often even more sophisticated stabilization systems. Want to stop? Just press hard on the brake pedal. Most small GA airplanes have the old simple hydraulic brakes that will simply stop the wheel from rotating when sufficient pressure is applied. Pilots need to recognize and practice the technique of applying the necessary pressure to slow the airplane without skidding the tires.

When the decision to continue a takeoff or to abort is needed, it is an urgent decision allowing just a few seconds. We will look at two scenarios that each require a decision. We will then look at some ways to minimize the chance that we will need to make a similar decision.

Scenario #1

We leave the ramp area, taxi to the run-up area of a non-towered airport and diligently go through our before takeoff checklist. We mentally perform our before takeoff briefing, check for traffic, make the customary call on the CTAF, and line up with the runway. After a final glance at the windsock, we smoothly apply full power along with a little pressure on the right rudder and begin our takeoff roll. As we gain some speed, we check “airspeed alive” and expect to see an indication of about 25 to 30 knots. But the airspeed indicator has not yet been awakened from its snooze against the peg. Urgent decision time! A shot of adrenaline races through our system enhancing our alertness and our readiness to act. Should we continue the takeoff or should we abort? Our training, experience, as well as the positive and negative aspects of our unconscious mind, all clamor for a vote.

Our brain, hopefully functioning at its best and not hindered by fatigue, illness, alcohol, medications, or something else, has a kaleidoscope of facts and questions to sort in just a couple of seconds.

  • Do I really need the airspeed indicator?
  • Will tapping the glass make it come alive?
  • How long will it take to get the problem fixed if I abort?
  • How much runway do I have remaining?
  • Did I forget to remove the pitot cover?
  • How important is this flight?
  • Will I be able to reschedule?
  • Can I make a landing without the airspeed indicator?
  • What if there is an airplane on short final behind me?
  • Can I still stop on the remaining runway?

We all like to think that we are superior pilots and that we will make the correct decision instantly. But the clear truth is that our brain will go through its own kaleidoscope of facts and questions before making a decision but we will not be aware of it on the conscious level.

Decision and result: Of course, an unresponsive airspeed indicator, noticed at low speed on an adequate runway, would be a prudent reason to abort the takeoff. Most of us would make that decision within a couple of seconds. We make the announcement on the CTAF and taxi back. After shutting down and securing, we notice a mud dauber nest in the pitot opening and we make a request to have the maintenance folks clear it.

Scenario #2

Let’s look at a different scenario. A pilot is making a takeoff from a relatively short runway at a relatively high density altitude. The airplane is still not airborne as the half-way point of the runway zips by. The pilot gets a queasy feeling as trees at the end of the runway appear to get larger and the rising terrain directly ahead appears to get steeper and higher. The pilot now has an urgent decision to make. Should I continue or should I abort? The same adrenaline rush is noted and the pilot’s own kaleidoscope of facts and questions appear.

Decision “A” and result: The pilot decides that there is little chance of being able to clear the trees and the rising terrain. Throttle is closed and hard braking is applied. Tires squeal and the brakes smoke but there is too much energy to be dissipated. The airplane departs the runway, bounces over some very rough ground as the nosewheel finds a softer area of terrain to sink into. The nosewheel breaks off and the airplane flips into the inverted position, crushing the vertical fin, bending the prop, and stopping the engine. The pilot, uninjured and suspended by the harness, unbuckles, turns off ignition, master switch, and fuel selector valve before exiting the airplane.

Decision “B” and result: The pilot realizes that the airplane cannot be stopped on the remaining runway. The pilot decides that after many years of flying, accumulating a great amount of experience and skill, the airplane can be finessed over the trees and turned before reaching the rising terrain. The pilot did fly the airplane precisely to achieve the best possible climb performance with the existing conditions and cleared the trees by a few feet. But with the rising terrain looming, a shallow left turn was initiated. Whether or not influenced by the breeze descending down the rising terrain producing a mild downdraft, the airplane stalled and the left wing dropped. The airplane impacted terrain in a slightly nose down, left wing low attitude. The left wing separated from the airplane and the fuel tank was breached. Somehow, as much of the remaining airframe was bent and torn, a spark was generated and fire engulfed the wreckage with the pilot still inside.

The Big Question: To Abort or Not to Abort?

That is a very big question but not an easy one for pilots of small general aviation airplanes. The airlines have it down to a fairly precise science with computers analyzing a multitude of factors. For them, a speed is calculated at which they cannot stop and must fly. Pilots of small GA airplanes do not have that information. An internet search will find many pilots weighing in on the question of when an abort is prudent, with several offering formulas or guides. In my opinion, there are far too many variables to be considered once the takeoff roll has begun.

In my non-scientific study of accidents, it appears to me that in general, the likelihood of serious injury or death is less if a takeoff is aborted than if the airplane becomes airborne and then crashes. It is important to recognize that if the pilot notes a problem, elects to continue, and does not crash, no report is filed so our data is solely based on the negative outcomes and the success stories are omitted.

Partial Solution

There is no definitive answer or formula to tell us whether to continue a takeoff or to abort when we sense a problem. Obviously, if we are at a low speed early in the takeoff and we have plenty of runway ahead of us, an abort on the runway is the best course of action if something does not seem right. So, let’s try our best to avoid a situation in which we must make a stop or continue decision during a takeoff roll. We can never completely eliminate some situations in which we will have to make the decision. Some of those might be wildlife running onto the runway, a vehicle or pedestrian straying onto our path, or an obscure and unforeseen maintenance problem.

But here is a partial solution, not to provide guidance regarding the decision to abort a takeoff, but to help us avoid the need to make that decision. That partial solution is due diligence in planning and preparation. Here are a few items to assist us in our due diligence:

  • Always do thorough takeoff performance calculations including as many variables as are available.
  • Know and mentally prepare for wind conditions during takeoff.
  • Ensure that the airplane is well-maintained, reducing the risk of something maintenance related rearing its head during the takeoff roll.
  • Verify that all latches on cowlings, access panels, and baggage compartments are secure. Key lock if possible.
  • Brief passengers regarding the need to keep free of controls, including pedals, and to not touch any switches or levers.
  • Brief passengers on sterile cockpit procedures.

My grandmother told me many times that an ounce of prevention is worth a pound of cure. That was sage advice when it comes to making takeoffs. We might say that a few minutes of planning is worth the reduction of risk.

Reprinted from NASA CALLBACK

I encourage all pilots to subscribe to the "NASA CALLBACK" publication. I never miss reading an issue because it often provides a look at a situation which could have been an accident, but worked out successfully. These can help us learn from the mistakes or near-misses of others. Click here for the subscription form. It's free!

The following article is reprinted from the NASA CALLBACK PUBLICATION #511 of August 2022.

The Green Half-Mile

This C152 pilot experienced a common assortment of hazardous, hot weather factors that combined to produce an insidious, but predictable situation and potential disaster.

■ After landing at MRC for fuel, we elected to take off using the grass runway. The winds had been relatively calm, and despite training numerous soft field takeoffs and landings for private and commercial ratings, we had never actually used a grass runway. We spoke with some of the regulars in the FBO, who said that the turf condition was good, and they provided some tips for using that particular field. We had two pilots in the aircraft, which put the C152 within 3 pounds of maximum gross weight when full of fuel. We back-taxied the length of the field to reposition and test the smoothness of the turf. At the end, we turned a 180 and conducted a rolling takeoff without coming to a stop.

The plane reached rotation speed after about 1,000 feet (1,800 feet available), but on climbout, it became apparent that we would not clear the power lines and trees on the far side of the airport. With no more power to give, the aircraft already in clean configuration, and the stall horn starting to sound, I cut power and put the plane back on the runway, resulting in the plane coming to a stop in the grass after the end of the turf runway across Runway 24 and the taxiway. There was no damage to the plane or facility, or any injuries, but we were definitely two shaken up pilots after a close call.
A combination of factors contributed, most of which were related to operating at maximum gross weight on a hot summer day. Application of soft field considerations (not coming to a stop) over short field considerations (max power before releasing brakes) reduced the amount of available runway to less than full length.
The performance charts indicate we needed a total of 2,020 feet to clear a 50-foot obstacle with approximately 1,000 feet of ground roll. We had 1,800 feet of runway plus another 900 to 1,000 feet of clear climbout space before the first obstacle, which should have been more than adequate, but was not enough on that day.

We suspect the combination of flying a 40-year-old airplane with pilots relatively new to the C152 also significantly reduced aircraft performance from the best-case numbers in the published charts. The biggest lesson learned is that when close to the margins on gross weight and high density altitude, always take the longest runway winds will allow.

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 runway excursion happened in Oklahoma in August of 2020. It involved a Piper PA28R (Arrow) with four people onboard none of whom were injured. The NYSB accident report includes the following: "The pilot planned to depart from a 2,435-ft-long runway, and reported that, with the three passengers and the amount of fuel onboard, the airplane was about 127 lbs below the maximum takeoff weight and required 1,700 to 1,800 ft of runway for takeoff. The pilot began the takeoff roll about 117 ft from the takeoff end of the runway with the wing flaps retracted for a normal takeoff. During the takeoff roll, the pilot noticed a sound and vibration from the engine, then about 5 seconds and 668 ft later he reduced engine power to abort the takeoff. He was unable to stop the airplane on the remaining runway and it continued off the end of the runway, over a road, and into trees. The airplane sustained substantial damage to the left wing."

The NTSB report continues: "Postaccident performance calculations revealed that the takeoff roll was greater than that calculated by the pilot; about 2,1000 ft. A postaccident examination of the engine and airframe did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation. The recorded engine and GPS data did not reveal any anomalies. The data showed that the pilot likely began to abort the takeoff, about 547 ft from the end of the runway, and likely only applied the brakes and began to significantly slow the airplane about 304 ft from the end of the runway, which was not sufficient distance to stop the airplane before exiting the runway surface."


NTSB Photo

The NTSB Probable Cause finding states: "The pilot’s incorrect takeoff performance calculations and delayed aborted takeoff, which resulted in a runway excursion and collision with trees."


NTSB Photo

The 34-year-old private pilot had a total flight time of 222 hours total flight time, including 35 hours of night time, with 10.8 hours in this make and model. He reported that he had 5 hours of training in this make and model from a CFI.

As we said in the blog post above, proper planning and preparation can prevent us from having to make the urgent decision regarding the need to abort a takeoff. We do not know where the pilot went wrong in the takeoff performance calculations, but the airplane should still have been capable of making the takeoff. The pilot probably should used one notch of flaps as indicated for a short field takeoff, that is irrelevant because he decided to abort the takeoff due to a noise and/or vibration rather than a perception of insufficient runway ahead.

What was the noise/vibration? We will likely never know. We must consider the possibility that it was the phenomenon known as "automatic rough" that sometimes affects low-time pilots when flying at night or over water. However, passengers reported hearing the noise also.

From a human factors perspective, The pilot reported that he had flown to the area, competed in a rodeo event, attended a gathering of friends, and arrived at the airplane for the return trip at 1:00 AM. That seems like a rather full day which could lower pilot capabilities a bit. Perhaps making a night departure from a relatively short runway with a heavy load in these circumstances was not a prudent choice.

The big question is, did the pilot make the correct choice to abort the landing or should he have continued? In my opinion, he absolutely made the right choice. Yes, there are several things he could have done differently, but they were all prior to accelerating down the runway on the takeoff roll. At the moment he had to make the decision, that was all history. The airplane was substantially damaged, but the pilot and his three passengers escaped injury. Had he continued the takeoff he might have avoided the accident all together. But, he might also have have crashed for any one of a variety of reasons after becoming airborne. That would likely have resulted in serious injuries or death.

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 58-year-old, 91 hour total time private pilot, his passenger, and their dog all escaped injury when the Beech C23 they were operating was destroyed when it exited the runway during an aborted takeoff. The accident happened in Nevada in 2017. The NTSB report includes the following: "The pilot reported that two private airports were near each other, and he mistakenly landed at the wrong airport. He added that, once he realized his mistake, he referenced the Federal Aviation Administration (FAA) chart supplement and visual flight rules sectional chart and observed a published runway length of 2,600 ft for departure. The pilot reported that he referenced the Pilot's Operating Handbook (POH) and noted that the calculated takeoff distance was 1,350 ft."

The report continues: "The pilot reported that, during the takeoff roll, he decided to abort the takeoff with about half of the runway remaining because the airplane had not reached the speed he expected. During the aborted takeoff, the airplane pulled to the left of the runway centerline "slightly" when the brakes were applied, and the left wing struck two fence posts along the runway. The collision with the fence posts pulled the airplane off the runway surface to the left and into a ditch and a barbed wire fence."


NTSB Photo (courtesy of pilot)

Interestingly, though not a factor in the accident, the published runway length was incorrect. The NTSB report states: "The FAA Aeronautical Information Services Office was asked by the National Transportation Safety Board investigator-in-charge to evaluate the published runway dimensions at the accident airport. Upon review, the FAA determined that the runway dimensions provided for the airport should have been 2,483 ft by 25 ft rather than 2,600 ft by 25 ft. The FAA submitted the revised dimensions to the National Flight Data Center for publication."

The report also includes: "According to takeoff performance calculations with the FAA Koch Chart, the airplane would have likely experienced a 60% increase to the normal takeoff distance. When factoring in this increase with the airplane's POH takeoff distance chart, the ground roll required was about 1,808 ft, and the total distance to clear a 50-ft obstacle was 3,128 ft. Numerous trees were located at the end of the runway. The distance to clear the 50-ft obstacle exceeded the published runway length and revised runway length."

The NTSB Probable Cause: "The pilot's inaccurate takeoff performance calculations and failure to maintain directional control during an aborted takeoff."


NTSB Photo

This is not the first time a pilot has landed at the wrong airport and not been able to takeoff under the existing conditions. It has happened to airline pilots and military pilots as well as low-time GA pilots. One obvious solution is to verify, beyond doubt, that it is the correct airport. But once the deed is done and the airplane is safely on the ground, all sorts of red flags should go up regarding a takeoff. Our cognitive biases can have a field day convincing us that we must takeoff and bending our perception of the situation. What caused this pilot to make such a gross error in the calculations? Was his aeronautical knowledge training inadequate or did his unconscious mind influence his calculations and therefore his decision?

But when we consider the pilot's decision to abort the takeoff, he most likely saved the lives of all aboard. The NTSB report refers to tall trees to be cleared. Had the pilot continued the takeoff and collided with those trees, or attempted a low speed, high angle-of-attack turn to clear the trees, the result would have been much worse.

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 accident supports our statement in the previous accident analysis that the laws of physics are always at work and they do not care how much ink is on the pilot certificate or in the logbook. The accident resulted in the destruction of an Aeronca 11AC. It happened in June 2017 in Michigan. The student pilot received only minor injuries and the 8,500 hour commercial pilot/flight instructor was not injured.

The NTSB accident report includes the following: "The flight instructor reported that, during the takeoff climb from a grass runway with the student pilot flying, about 25 feet above ground the "climb rate became stagnant." He added that he instructed the student to "lower the nose slightly," but after "several seconds the airplane did not resume a normal climb rate." The flight instructor took the flight controls and noticed that they were "sluggish" and it felt as if the airplane was caught in "wind swirls" and downdrafts. Subsequently, the flight instructor made a "small left turn" toward a small gap in the tree line ahead and the airplane impacted a heavily wooded/treed area."


The NTSB accident report also includes the following: "According to the flight instructor, the airplane departed "loaded at gross weight." The student pilot reported that the flight instructor did not discuss weight and balance with him before flight. During postaccident interviews with the National Transportation Safety Board investigator-in-charge, the student and flight instructor each reported their personal weight and a total of 10 gallons of fuel on board at takeoff. Based upon the information provided, the takeoff weight was 1,389 pounds, which was 139 pounds over the maximum gross weight (1,250 pounds) published in the airplane Pilot's Operating Handbook. The airplane's center of gravity for takeoff was within limits at 18.65 (12.4 to 22.0)."

The NTSB Probable Cause finding states, "The flight instructor's inadequate preflight planning, which resulted in a takeoff over maximum gross weight from a turf runway in high-density altitude conditions and the airplane's inability to attain a climb rate and subsequent collision with trees."


According to the NTSB calculations, the airplane was loaded about 10% over it allowable weight. Flying with more weight than allowed by the manufacturer's documentation is never a good idea. But flying 10% over the allowable weight in a high density altitude environment is really asking for trouble. Perhaps some complacency was at work here along with the laws of physics.

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

Books by Gene Benson

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