Flight Safety
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Latches - August 2010
Gene Benson
Picture this. It’s a nice day for your planned flight with a couple of non-pilot friends to (fill in the blank: watch a ballgame, attend a wedding, do some fishing, go to a car show, etc.) You have thoroughly checked the weather, planned the flight, performed a weight and balance calculation, verified adequate performance, and completed a meticulous preflight inspection. Everyone is buckled in and has been briefed about emergency egress and on sterile cockpit procedures. You know that your friends are suitably impressed with your skill and expertise as you run the before takeoff checklist. You have verified that the runway and approaching traffic is clear as you taxi onto the active and push the throttle forward commanding the flight to commence. A feeling of satisfaction and pride washes over you as the engine smoothly comes to full power and the airplane accelerates as if anxious to claim its rightful place in the sky. Rotation speed is reached and a gentle tug on the yoke lifts the nose. Upward acting forces exceed downward acting forces, gravity is defeated and …
Something is wrong! Why is it so loud? What is that wind sound? The right seat passenger screams in terror and the aft passenger gasps. The terrified passenger on your right desperately leans into you knocking your hand from the throttle. The aft passenger has released his belt and is leaning forward and pulling on the front seat passenger. Oh! The right side cabin door has popped open. The right side passenger is hysterical. You have to close the door! Leaning in front of the terrified passenger you grab the armrest and give a firm pull. Nothing! Harder! Slam it harder! Nothing! Give it all you’ve got next time! Push it open and…
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows: A loss of control in flight due to the pilot becoming distracted by a cabin door becoming unlatched upon takeoff. A contributing cause is the pilot’s failure to ensure that the door was secured before flight.”
The smart folks who manufacture our airplanes provide latches to hold things closed. We find latches on cabin doors, baggage compartment doors, cowlings, and access panels. Some latches work better than others. Keeping some doors and panels closed is more important than keeping others closed. As a general rule, if the opening of a door or panel in flight would be catastrophic, a double latch of some sort is installed. For example, some multiengine airplanes have a nose locker opposite a propeller. If the door to the locker comes open in flight, the door strikes the prop and chances are good that the airplane will be lost. Those doors have a very positive latching mechanism as well as a key lock providing a redundancy. Cabin entry doors are usually not as critical to flight so they frequently have only a single latch mechanism. In some airplane designs, notably the Beech Sierra and Duchess series airplanes, cabin doors coming unlatched upon rotation is not uncommon. Startling? Yes. Dangerous? Not aerodynamically. Distracting? Need not be.
An obvious approach to dealing with any latch is to make sure it is secure. A good elbow to a door latch before engine start will go a long way toward preventing a surprise later. A firm tug on other compartment latches should reveal any that aren’t quite fully engaged. If a latch has a double mechanism, there’s a reason for that so make sure both stages are secured.
But nothing is completely reliable so it’s also important to be prepared for the unexpected. I have long been an advocate for developing and using “abnormal procedures” for general aviation airplanes. These are procedures to deal with events which are not immediately critical, but which can become critical if not handled properly or allowed to become a distraction. An unlatched cabin or baggage door is a perfect example of an abnormal situation. Most aircraft manufacturers address this in the pilot’s operating handbook. Reviewing those procedures isn’t a bad idea. Adding something to the preflight passenger briefing about the unlikely possibility of a door popping open isn’t a bad idea either. Of course, that part of the briefing should explain that the airflow will prevent the door from opening more than a couple of inches and there is no possibility of falling out, especially if secured by a seatbelt and harness.
So picture this. Our flight begins as described in the first two paragraphs up until the door becomes unlatched. Except that everyone, including the pilot, knows that it is not an emergency and that the airplane will fly just fine while retaining all occupants. The pilot recalls the basics: aviate, navigate, communicate. In other words, primary concern is to keep flying the airplane without losing control, find the way back to the active runway, and communicate intentions to ATC or over the CTAF as appropriate. Control is lost of neither the airplane nor the bladder.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Oh wait! There was no accident! Not a bad day after all.
Attention Needed! - July 2010
Gene Benson
I recently did an analysis of an accident that occurred in 2008 involving a Cessna 337A. Two people lost their lives and two more were seriously injured when the airplane, conducting a wildlife survey, crashed after the pilot mismanaged his fuel and the engines ceased to turn. I came upon this accident while looking for accidents involving pilot fatigue. The NTSB included pilot fatigue in the probable cause finding since the pilot was also the person tasked with keeping this airplane flying and he had been extremely busy with that task over the past few days. Note that I did not say he was responsible for keeping the airplane airworthy because that was not the case. There can be a big discrepancy between flying and airworthy.
Maintenance records for the accident airplane were sparse and conflicting, but a few facts were clear. The airplane had not had an annual inspection in almost six years. The emergency locator transmitter (ELT) was overdue by about four years in having the battery replaced, but the unit didn’t work anyway, so why bother? Except that in this case, the wreckage wasn’t located for four hours after the accident and the front seat passenger may have survived his injuries had medical attention been administered in a timely fashion. There was apparently an issue with the landing gear, so the pilot had just been flying around with it extended. The list goes on. In short, the airplane was a mess. The airplane was trying to cry out, “Attention Needed!”
But, ironically, the accident was not directly caused by any of the maintenance shortcomings. The pilot apparently forgot to add fuel to the main tanks after his previous four hour twenty-three minute flight and then mismanaged the small amount of fuel remaining in the auxiliary tanks. It seems safe to assume that there wasn’t much of a preflight inspection performed or the lack of fuel would have been evident. Perhaps the pilot knew that if he did a thorough preflight inspection on this airplane he would be afraid to fly it. The pilot had operated this airplane for the previous ten years, yet he apparently did not have a good understanding of the fuel system.
So we see evidence of complacency. The pilot was also rated as a maintenance technician and he had inspection authorization (IA). That means that he could work on the airplane and sign off on all repairs and maintenance, including annual inspections. The pilot had apparently become complacent about the condition of the airplane. In addition to the poor condition, the lack of maintenance records, which he could legally sign, also indicates complacency. A pilot who maintains and operates an airplane must be especially cautious of this slippery slope. With no input from other parties it is easy to let small things slide. Each time that happens without producing negative consequences, the likelihood of repeating that behavior is increased.
This pilot was destined to be involved in a serious accident. It was just a matter of time. It could have been any number of problems with this tired, poorly maintained airplane. It could have been his failure to do a thorough preflight inspection. It could have been his “press-on” attitude causing him to fly when he was fatigued. The NTSB probable cause finding listed fuel exhaustion and pilot fatigue. If a different set of circumstances had done him in, the probable cause might have listed different reasons. But the real cause was complacency.
We don’t suddenly become complacent. It is a gradual process in which we begin to take for granted things that are far from being a certainty. If we climb up on a ladder and look in the fuel tanks nine hundred ninety nine times and the tanks are always full, that has no bearing on whether or not the tanks will be full the one-thousandth time. But if we skip that check on our one-thousandth flight and we don’t have any problems, we are likely to skip that check again. The same will hold true for checking magnetos, not scud running, and many other tasks that our instructors tried to drive into our brains. It also holds true for meeting recent experience requirements, keeping our medical certificate current, and having the airplane inspected annually. If we stretch the envelope on any of these items and don’t get caught, we are more likely to stretch it farther in the future.
One way to avoid complacency is to stick firmly to the rules and safe practices that we have been taught. If we can avoid that first excursion over the line, we are less likely to make a second. Here’s another excellent idea that I recently got from Jim Lauerman, president of Avemco Insurance. He said to let our circle of aviation associates (pilots, line personnel, and maintenance technicians) know that we are open to suggestions. In other words, give permission to point out any areas in which we may be unsafe. If they know that we are receptive, someone might just speak up and point out something that we could be doing better. Flying is fun, but also serious business. We can use all the help that we can get.
Summer Fun - June 2010
Gene Benson
Well, here we are once again. It’s that small window in time between Memorial Day and Labor Day. It’s traditionally the peak-flying season for those of us in Upstate New York. Our use of small, general aviation airplanes allows us to take daytrips that are the envy of our land-borne friends. Pancake breakfasts are so plentiful that we have several choices every weekend. And of course, we can load the family in an airplane and take a week or two to vacation just about anywhere in this great land.
But our peak-flying season is unfortunately our peak accident season also. The accident rate when compared to hours flown is probably not any higher during the summer than any other time of the year. But, if we are going to do more flying, we are naturally being exposed to more risk. So let’s review a few things to see how we might manage that risk.
A few obvious summer hazards come to mind. Thunderstorms immediately loom large. Let’s make sure we get a good weather briefing, keep an eye on the sky for changing conditions, and avoid any active cell by at least twenty miles. That distance will help to protect us from encountering any hail that might be tossed out the top of the cell and carried by the wind. It also helps us to avoid the effects of microbursts produced by the cell.
Performance sapping high temperatures also jump out as summer hazards. I wrote a previous column for CNY Aviation in July 2009 on that subject called, “Feeling the Heat” so I won’t dwell on that subject. (You can find that article in the archives.)
The additional traffic produced by this terrific season can also be a hazard. Vigilance is the watchword for collision avoidance. Scan the sky methodically from right to left (or left to right) stopping about every 10 degrees to focus. Be aware of empty field myopia, a condition in which we think we are focusing in the distance but in fact are focusing only a few feet ahead. This is most likely when flying in reduced visibility such as summer haze when the eyes have nothing in the distance to provide a point of focus. Occasionally focusing on a wingtip may help to stimulate the eyes and help avoid this condition.
Don’t assume anything. Don’t assume that other pilots will make radio calls or that all pilots will choose the same runway at non-towered airports. Always scan both directions and in the air as well as on the ground before crossing any runway or taxiway. (Yes, airplanes have been known to land on taxiways.) Avoid flying low or shallow final approach paths because they make your aircraft hard to see by pilots awaiting takeoff. Also avoid spending any unnecessary time on a runway, even if it isn’t the active runway. Finally, take advantage of ATC flight following service whenever it is available.
Give special attention to fuel management when on those summer trips. Our area has already had its first fuel exhaustion accident of the season; let’s make it be the last one as well. Avoid the so-called “GPS Accident” where the pilot relies solely on the GPS for navigation without tracking time and fuel consumption. For more on avoiding fuel related accidents, read my article “Too Much Air” in the CNY Aviation archives from July 2008.
So let’s get out there, turn some fuel into noise, and have a safe summer flying season.
Turning Luck into Experience - May 2010
Gene Benson
We always try to learn from accidents. Sometimes we feel that we “lucked out” and narrowly avoided a mishap ourselves. Maybe there is a way to turn our luck into experience. After all, it has been said that a new pilot starts out with a full bucket of luck and an empty bucket of experience. The trick is to fill the bucket of experience before the bucket of luck runs out. This month we will look at a way to help that happen.
The latest advance in the promotion of safety is the safety management system or SMS. An SMS encompasses every aspect of an entire organization, treating all elements as an integral part of a system rather than as separate entities. This could be considered as the next generation of Crew Resource management (CRM). Most major airlines in the U.S. have adopted this approach. Canada presently requires all commercial aviation operators to have SMS in place. Eventually all aviation operations holding an FAA certificate will be required to follow suit. This will include charter operators, approved flight schools, and repair stations.
So how does this concern the general aviation pilot flying a single-engine or light multiengine airplane? Nobody will be required to create an SMS to fly a Cherokee around for personal or business use. Developing an SMS for that kind of flying would be a formidable task. But, whenever something new comes along it’s worthwhile to see if it can have any benefit to us. One core part of SMS can easily be accomplished and might just make flying safer.
Any SMS system will have a means of gathering information not only on accidents and incidents, but also on any situation that could have produced an accident or incident. The NASA Aviation Safety Reporting system (ASRS) has been doing that for many years and we can learn by studying their publications. But just as the SMS has to be specially tailored to the operator, we can learn something by examining our own close encounters with bent metal.
Here’s an exercise to run through on a non-flyable day. Sit down and compile a brief synopsis of any time you came even a little close to having a mishap. Was there a time when you landed with very little fuel aboard? Was there a time when you were concerned about clearing the trees at the end of the runway on takeoff? Did you ever question whether or not you were going to be able to maintain control after touching down in a strong crosswind? Has another airplane ever come close enough to pose a collision risk? Have you ever forgotten to switch fuel tanks? Did the gear warning horn ever save you from a gear-up landing? Have you ever inadvertently descended below minimums on an instrument approach?
Next, add to your list any close calls that any of your pilot friends have shared with you. Finally, go to the ASRS website and read as many issues of their “Callback” publication as time permits, taking notes to add to your list.
Now go back to the beginning of your list. For each close call, write a brief statement of how that situation could have been avoided. Take whatever action is appropriate to make sure you avoid a similar situation in the future. That might be as simple as making a mental note or it might be a little more involved such as making a change to a checklist or developing a set of personal minimums.
Maybe we can take some of the luck we have used in avoiding mishaps in the past and convert it into experience to use in the future.
Tidbits - April 2009
Gene Benson
Let’s do something a little different this month. Let’s look at a variety of items instead of focusing on one theme. I have a whole bag of tricks that can increase safety or decrease our workload. Most of these will not be new to a pilot who has flown with several different instructors or who has been diligent in keeping up with the aviation publications. But we all need a refresher once in awhile so here we go.
Once lined up with the runway for departure, check the magnetic compass and heading indicator to make sure that they agree with each other and with the runway heading. If the heading indicator and compass read, for example 220 degrees and you are planning to depart from runway 28, something is wrong. This simple procedure would have prevented the tragedy in 2006 when a Comair crew attempted to depart from the wrong runway in Lexington, Kentucky.
When extending the landing gear, keep your hand on the gear selector until the “down and locked” indication appears. This will keep attention focused on the gear until it is safe and prevent other tasks from interfering with verification.
After landing, avoid moving any knobs or switches till the airplane has exited the runway and is stopped on a taxiway. This allows the pilot to focus on the important task of completing the landing roll. It will also help avoid inadvertent gear retraction by allowing more opportunity to verify the flap handle versus the gear handle. There are many cases in which a pilot grabbed the gear handle rather than the flap handle right after touchdown. If the flaps need to be retracted on the runway due to gusty winds, consider that to be an abnormal situation and take special care.
Here’s one more thing about operating the retractables. In many airplanes, there is more drag produced when the gear is in transit than when the gear is down. So when making a departure where obstacles are a factor, leave the gear down until clear of the obstacles. This will result in a slightly steeper climb angle with the same airspeed and power.
Never move the fuel selector after doing the engine run-up. If there is a problem with fuel flow it might show up just after rotation. If the fuel selector needs to be moved after the run-up has been completed, run the engine at a relatively high RPM for a few minutes to make sure the engine is running from fuel in a tank rather than just fuel in a line. How long the engine should be run at a high RPM depends on the airplane. Generally, the bigger the airplane the longer the fuel lines will be.
Avoid practicing maneuvers at the traditional five hundred foot increments such as 2500, 3000, 3500 feet, etc. That’s where everybody else is flying. If you want to practice holding altitude during slow flight, do it at 3700 feet rather than 3500 feet for example. This won’t eliminate the collision hazard but sure decreases the number of airplanes operating at our altitude.
Never leave the towbar connected to the airplane. It is more common than one might think to have a pilot attempt a takeoff with the towbar still attached. This will almost certainly hit the prop at some point and could have a really bad outcome. Disconnect the towbar as soon as the airplane has been moved, even if it will be needed again soon. It you are not ready to stow it, place it on the ground near the pilot’s door so that it can be seen upon entry.
These are just a few tips and there are many more. Not every technique will work for every airplane and every pilot and nothing substitutes for quality, professional refresher training.
Please fly like your life depends on it!
Oh, not that again! - March 2010
Gene Benson
Remembering way back when airplanes were still chiseled out of stone and I was a student pilot, I recall that my instructor was a fanatic about slow flight. I was learning to fly because I wanted to go fast and do maneuvers like what I saw at airshows. But as soon as we had climbed to a safe altitude my instructor would say something like, “OK, slow to 40 miles per hour, keep your altitude at two-thousand five hundred feet and keep the compass on south.” The airplane was a J-3 Cub so 40 mph was a reasonable speed for slow flight. Just as soon as I got the airplane all set up he would instruct me to turn right or left forty-five degrees while reminding me to maintain my altitude. I had a couple of years yet before I would be old enough to solo and the Cub was eventually replaced by the state-of-the-art Tri-Pacer. Now I was expecting to fly cross-country at blistering speeds in excess of 100 mph. Nope. We still did slow flight except that it was now done at 70 mph instead of 40 mph. My skill must have improved because now I had to move the airplane up a hundred feed and down a hundred feet while maintaining heading and sometimes while making slow turns. I also had to hold different airspeeds while strictly maintaining an assigned heading and altitude.
No matter what the main objective of the lesson, an ample dose of slow flight was always included. I remember thinking, “Oh, not that again!” when my instructor would start a sentence with, “Slow to…”
Why was my instructor so determined to include slow flight in every lesson? Was he trying to run up the Hobbs meter? Hardly. Those airplanes didn’t have Hobbs meters. Lessons were billed according to “tach” time. The slower the engine ran the slower the tachometer turned and the less the student paid for an hour in the air. My instructor was of the “old School” persuasion. He believed that the instructor’s job was to teach and to make the student as good a pilot as he could be. He knew that repeated slow flight practice was much like multiplication table drills. It might not be very exciting, but the end result is mastery of the task. Slow flight amplifies any subtle errors such as coordination or over-controlling. It therefore teaches, with proper coaching from the instructor, finesse and precision. It also teaches the art of making small corrections and waiting for them to work. It is an excellent skill builder in preparation for instrument work.
Many modern primary curricula neglect slow flight. Many instructors now teach either cruise flight or minimum controllable airspeed (MCA), but nothing in between. (My gripe with scenario based primary training where a student is taken on a cross-country flight on the first lesson can be the subject of a future rant.)
So here’s a thought that just might increase safety. Let’s go out and practice slow flight at various airspeeds and at various airplane configurations. Practice holding altitude and heading and while varying the airspeed between maneuvering speed and MCA. Practice adding and retracting flaps while maintaining a specific airspeed within the flap operating range. Pick a speed and practice making 90 and 180 degree turns while maintaining airspeed +/- 5 knots. Practice moving the airplane up or down 100 feet while maintaining a particular airspeed and heading. Make good use of trim and of course keep a good lookout for traffic. Practice slow flight at an altitude no less than what you would use to safely practice stalls, just in case.
We see way too many accidents that result from inadvertent stalls in the traffic pattern. Practicing slow flight will sharpen the skills needed to maneuver the airplane around at reduced airspeed. It will provide greater precision and greater confidence.
Even though I had many “Oh! Not that again!” moments during my flight training, I’m grateful to my instructor for making sure my basic skills were solid.
Mental Gears - February 2010
Gene Benson
A friend of mine is a retired career firefighter and is still active in our local volunteer fire department. A recent conversation turned to the subject of how automobile accidents have changed over the years. He was explaining that arriving at the scene of a serious accident thirty years ago almost always involved extricating bodies. A good day was when the injured were extricated and whisked away to the hospital. Today it is common for the first responders to find the occupants standing outside their mangled cars talking on their cell phones.
What has changed? Automobile design has greatly changed and great emphasis has been put on “crashworthiness.” Cars now have airbags hidden just about everywhere and they are designed with “crumple zones” to absorb the energy of a crash before it reaches the occupants.
I know very little about the automobile industry or about safety initiatives to prevent accidents. I know that the inclusion of anti-lock brakes and stability control systems are helpful but I’m not sure how many accidents are being prevented by this technology. I also notice the lack of any significant safe driving campaigns. So perhaps the auto industry, the National Safety Council, and the Department of Transportation have given up on accident prevention and are concentrating on accident survivability. That’s outside my area of expertise so I can’t make an informed judgment as to whether or not that’s the best way to decrease highway deaths and serious injuries.
OK, I’m into the fourth paragraph and it’s time to make the connection with airplanes. How about crashworthiness in our airplanes? It’s not so good. Most of the general aviation airplanes flying today were designed in the 1950s or 1960s. Crashworthiness for airplanes back then was not a high priority just as it was not a high priority for the automakers. The newer airplane designs that include composite materials are probably more crashworthy than the older aluminum models but the accident reports still show lots of fatalities in the modern airplanes. Some advancement has been made in the installation of shoulder harnesses containing airbags. Of course there are still lots of airplanes flying around without any shoulder harnesses at all.
The advent of the ballistic parachute is perhaps the aviation equivalent of anti-lock brakes and stability control systems on cars. They are there to help mitigate the result of an operator (pilot or driver) failing to plan ahead for the conditions. The difference being that the ballistic parachute doesn’t prevent the accident but it can increase the probability of surviving.
So why haven’t airplanes become as crashworthy as cars? Let’s remember that the average general aviation accident probably happens at around twice the speed of the average automobile accident. That means lots of additional energy must be absorbed somewhere. Let’s also remember that most cars are built from steel and most airplanes are built from aluminum. An airplane designed to protect its occupants from, let’s say, a stall/spin accident at 500 feet AGL, would have a serious reduction in performance if it would fly at all.
So as pilots we have to shift our mental gears. It’s not a good idea to be driving in freezing rain, talking on the phone and eating lunch at the same time, but many drivers do it or something similar. Many of those careless drivers will have accidents and will survive thanks to the vehicles they are operating. We need to be in a different gear range when we get into the airplane. We need to plan the flight, make sure the airplane is safe, maintain our recent experience, and do whatever else we can to avoid having an accident. The airplanes we fly will probably not protect us from our carelessness as well as our cars so it is critical to take every possible precaution to avoid the accident.
Increments - January 2010
Gene Benson
How did Peyton Manning become one of the best quarterbacks of recent time? How did Jay Leno become one of the best comedians of the last 20 years? Did they wake up one morning and realize that talent had suddenly been bestowed upon them? Were they struck by lightening and somehow skill-enhanced? Probably not. They each started out with an interest and worked very hard to learn their craft and develop their abilities through study and practice. They improved in increments.
We can become better pilots by also improving in increments. As we begin a new year let’s all agree to be incrementally better pilots by the end of the year. Here’s a few ideas on how to accomplish that goal.
If not already participating, enroll in the FAA Wings Pilot Proficiency Program and complete a phase. If already enrolled, complete the next level, advanced or master, as appropriate.
Fly for at least one and a half hours with an instructor you have never flown with before. Ask around to get recommendations from other pilots. No matter how much we might like “our” instructor or how loyal we might be to him/her, there is always something to be learned from a different perspective. This time can be used as part of the Wings program.
Participate in a recurrent ground school course. There are some online and, as a shameless plug, I offer one as a live webinar event. Recurrent ground school is different than initial ground school in that the emphasis can be on information that is practical rather than on what is needed to pass the exam.
Read over the handbook for the kind of airplane that you usually fly. Pay particular attention to the section on systems operation. Many accidents and incidents could be avoided if the pilot had understood more about how the systems function.
Resolve to take four additional online courses. That’s only one every three months. Plenty are available for free. FAAsafety.gov has an ever increasing selection (I just authored the new “Aeronautical Decision Making” course which is a core requirement for the Wings program.) The AOPA Air Safety Foundation has a selection of very good free courses and you don’t have to be a member to use them. My website also has some free courses.
Read one additional aviation magazine each month. Even articles that aren’t intended to be safety related frequently have content that produces an “Oh yeah!” moment.
These are just a few ideas but it is a starting point. Chose one, or two, or all, or come up with some ideas of your own. We won’t become super pilots overnight but we can move incrementally toward that goal.
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