EAA CHAPTER 922

About the List

Regular visitors to this site know that I frequently write about general aviation accidents and that I believe that nearly all accidents are preventable. My conclusion comes from in depth study of virtually every reportable aviation accident that occurs in the United States involving airplanes.

The accidents are preventable because they are seldom caused by a factor not directly controlled by the pilot. Some accidents result from mechanical failure but most of these accidents could be prevented either by better pilot scrutiny of the airplane condition or by better preparation for dealing with an emergency. What about weather related accidents? Weather systems don't overtake airplanes; pilots fly their airplanes into weather systems. There isn't a weather system on the planet that can catch even the slowest airplane. Inflight breakup? Possibly. I know that there have been several in the past year but in only one case did the airplane simply come apart without help from extreme maneuvering, intentionally or otherwise.

Anyone wishing to refute my premise that pilots cause nearly all accidents will find a case to support an alternative argument. Yes, a very few accidents are probably not preventable. But I would strongly argue that the facts show that at least 99% of the general aviation accidents are preventable through improved pilot attitude, awareness, or training.

Each of these items in my "Top Ten" list is accompanied by at least one example accident or incident. There are many more accidents or incidents to support each premise.

#10 - Pilot's Lack of Assertiveness

We pilots have a reputation of being rather assertive. But sometimes pilots aren't assertive enough and accidents result. It is an open secret that many rental airplanes are not maintained as well as they might be. The FBO and flight school businesses are tough and there is a big incentive to cut costs wherever possible. I am aware of situations where a pilot questions something found amiss on a preflight inspection only to be assured by the operator that it is OK. If the pilot is inexperienced and the operator has been in the business forever, it is easy for the pilot to be intimidated.

The image at the left shows the recovery of a Piper Warrior that was involved in a 2005 fatal accident in Indiana. The flight instructor and student died following an engine failure on takeoff and an unsuccessful ditching attempt in a lake. The NTSB investigation found multiple, serious discrepancies with the airplane's maintenance and also with the fuel farm. The large number of discrepancies found by the NTSB indicates a culture of ignoring rules that are too costly or time consuming to comply with. It would be hard to believe that a flight instructor would not be aware of at least some of the unairworthy items. Another CFI interviewed as part of the NTSB investigation stated that the airplane maintenance had been "poor" in the past. The accident CFI had a total of 493 hours total flight time. The young, relatively low-time CFI trying to build flying time by instructing, would probably have not been very assertive about shoddy maintenance for fear of losing his job. We can't be sure what the instructor knew or did not know about the condition of the airplanes. But, if he was aware of the situation and had been more assertive he and his student might be alive today.

#9 - Inadequate Knowledge of Aircraft Systems

Cessna 206 rear door showing location of microswitch.

All pilots know the basics of the simple single-engine or light multiengine airplanes that they fly. For example, if the alternator quits the engine won't immediately follow but the electrical load must be reduced to provide the longest amount of battery time to power radios and other essential equipment. Or, at least basic information like this should be understood. But some airplanes have systems that are a little more elusive and require a thorough study of the POH.

Four people escaped injury in California when the pilot botched a no-flap landing. The airplane drifted off the runway and collided with an airport sign and runway lights.

Why the no-flap landing? It seems that the flaps would not extend when the airplane was in the traffic pattern. The airplane is equipped with a door/flap limit switch which prevents the flaps from being lowered when the rear door is open. This is necessary since the door opens directly into the area of the flap travel. On this flight, a rear seat passenger was leaning against the door with sufficient force to open the switch and prevent the flaps from operating. Had the pilot been aware of this system he could have asked the passenger to refrain from leaning against the door and the flaps would have operated normally. I'll leave the issue of proficiency in no-flap landings for another time.

Click here to view an article on "Abnormal Procedures".

#8 - Inadequate Initial Training for the Certificate, Rating, or Aircraft Type

Ballistic recovery system used on Cirrus airplanes. Inset shows the deployment handle.

Two pilots, co-owners of a Cirrus SR-22 were killed in a stall/spin accident in New York in 2002. They had purchased the airplane six days before the accident and had each received airplane-specific training. The airplane was maneuvering at about 5,000 feet AGL when it entered a right, flat spin. The POH for the SR-22 stated that the only approved and demonstrated method of spin recovery was the deployment of the parachute recovery system but there was no evidence that such deployment was attempted.

Somehow the airplane-specific training failed these two individuals. While entering a spin to prove that the parachute recovery system was the only way to recover is certainly not practical, training organizations and instructors must find a way to make students internalize the critical elements of the training. Stating something so critical in a classroom, even if it is tested verbally, is simply not enough when lives depend upon having a pilot follow a procedure that is markedly different from standard.

Training isn't the culprit in all accidents but there are a multitude of accidents where training obviously failed the pilot.

A Cessna 172 at 300 feet over Coney Island as depicted by MS Flight Simulator

Cessna 172 stall/spin crash at Coney Island, NY in 2005. (Official NTSB photo)

#7 - Inappropriate Conduct/Inadequate Flight Supervision by a Flight Instructor

An instructor and three passengers were fatally injured in 2005 while maneuvering at low altitude along the beach at Coney Island, New York. The Cessna 172 departed Linden, New Jersey on a "discovery" flight. It departed in an overweight condition and proceeded to Coney Island where it was observed maneuvering at low altitude along the beachfront. The airplane was also tracked by radar. The last radar return showed it to be at an altitude of 300 feet and at a ground speed of 60 knots. The airplane apparently stalled and entered a spin before it impacted the beach.

A "discovery" flight is supposed to serve as an introduction to general aviation with the hope of encouraging the passenger to enter flight training. While flying low over Coney Island might have seemed appealing to the young passengers, it would hardly set a good example for a prospective flight student.

There are far too many accidents where the CFI contributed to an accident by acting inappropriately or by failure to adequately supervise a flight.

#6 Failure to Maintain Proficiency

It's an easy trap in which to fall. A pilot works hard to earn a certificate or rating. He or she is sharp and proficient, though inexperienced, at the time of the checkride. Required procedures have been recently practiced and the pilot is spring-loaded for the examiner to simulate some sort of emergency or unexpected situation. It is easy to become complacent after the certificate or rating has been issued. Most flights work out as planned so the pilot just continues to exercise the privileges of the certificate or rating and accumulates more and more time since any emergencies or unexpected situations have been practiced.

Instrument pilots must maintain proficiency as illustrated by this accident in 2005. The white material is foam put down by the fire department. (FAA photo)

Emergencies would include an engine failure. This is actually more lethal if it happens in a multiengine airplane. A multiengine pilot who is caught unaware and less than proficient in dealing with an engine-out situation is more likely to have a fatal accident than the single engine pilot who only has one choice to make when an engine quits.

Unexpected situations would include the instrument pilot who is not prepared for an approach down to minimums. Perhaps the pilot hasn't practiced descending to minimums, recognizing that a missed approach is necessary, then executing the missed approach procedure. This is routine during training but there is no requirement that it ever be practiced again as long as the pilot continually meets the recent experience requirements of the FARs.

The accident example here is a Mooney shooting an instrument approach into Ithaca, New York. The weather had taken a turn for the worse dropping visibility and ceiling to near zero. The most recent weather given to the pilot showed the weather to be above the minimums for the approach. The pilot was cleared for the approach, descended to the minimum descent altitude (MDA), but failed to stop the descent. He continued about 300 feet below the MDA when he suddenly observed trees about 50 feet ahead of the airplane. There was no time to correct the situation. The airplane hit the trees and then slammed into the ground in the backyard of a house in an upscale residential neighborhood. Miraculously, the airplane careened between two houses while shedding parts, including a wing. Even more miraculously, there was no fire. The pilot escaped with very minor injuries and no one on the ground was injured.

This accident clearly illustrates a lack of proficiency. The pilot had not recently shot an approach to minimums and had to miss the approach. Proficiency could have been easily maintained or restored by a simulated or actual instrument flight with an instructor. A session in a flight training device (FTD) or PCATD also could have served the purpose.

Click here to view an article on Controlled Flight Into Terrain (CFIT) that includes more details and photos of this accident.

#5 - Inadequate Preflight Preparation

More than a few years ago the FAA had a pamphlet titled "Safety Must be Planned." It detailed the importance of preflight planning. Such a publication would seem rudimentary by today's standards but the message is still important. Far too many accidents are caused by a lack of planning. Most result from inadequate planning regarding fuel but some come from failure to make sure that there is a suitable runway, that the weather will be satisfactory, and few other causes. The following accident illustrates the importance of planning every flight, even the local training flights.

Preflight planning could have prevented this fatal accident in colorado in 2006.

Our accident example happened in 2006 in Colorado and involves a Beech turbocharged Bonanza. The pilot had recently purchased the airplane and was receiving type-specific flight instruction to comply with insurance policy requirements. He had accumulated 6 hours of instruction. The pilots declined his offer to refuel. According to the line serviceman, when he visually checked the airplane's fuel tanks prior to takeoff they were "half full." If accurate, the airplane had 18.5 gallons aboard at the initial takeoff. The airplane had been aloft for about 1 hour, 15 minutes, when it arrived at another airport and made 2 full-stop landings. On the next departure numerous witnesses reported hearing the engine "sputtering and coughing" and seeing the extended landing gear being retracted before the airplane struck a parked semi truck in a residential neighborhood. It exploded on impact and both the airplane and semi truck were consumed by fire. The pilot and 15,000 hour CFI were both fatally injured. The CFI had recently retired after a career as a professional pilot.

The fuel selector was positioned to the left tank which was apparently run dry causing the loss of power. There may or may not have been fuel remaining in the right tank but it is doubtful that switching tanks following a loss of power at low altitude on takeoff would have restored power in time anyway.

"The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
the pilot's inadequate preflight planning/decision by not having the airplane refueled prior to takeoff, and allowing the engine to be starved of fuel because he failed to switch the fuel selector valve. A contributing factor was the flight instructor's inadequate supervision of the flight."

This accident could have been avoided by planning the flight and the associated fuel consumption. The plan must include having enough fuel and when to switch tanks if the airplane does not have the capability to feed from both tanks.

#4 Failure to Maintain Situational Awareness

Maintaining situational awareness is important in many aspects of life. We need to be aware of our surroundings while walking through a mall parking lot after dark. While driving we need to be aware of the car approaching from the side street. Flying an airplane requires even more attention to the events happening around us because of the greater speed involved and the addition of a third dimension. Many of the flight factors having a safety impact can't even be seen so they must be tracked by indirect means such as an alert from a controller.

The EMB 145 was to land on runway 36C and the Baron was to land on runway 36R. Note the wind direction.

The accident example illustrates how the failure to maintain total situational awareness can lead to disaster. The pilot was given two warnings of possible wake turbulence but failed to plan his approach to compensate for the wake of a regional jet that he probably never saw.

The accident happened in Memphis in 2003. A Beech Baron 58 was approaching the airport after a flight from Tampa. An EMB 145 regional jet was also in the vicinity of the airport. The weather was very good VFR with the wind out of 290 degrees at 5 knots. The EMB 145 was to land on Runway 36C and the Baron was to land on Runway 36R. The Baron pilot was given a vector to intercept the Runway 36R localizer and was warned of possible wake turbulence from the arriving EMB 145. He was told that he would be 4 miles in trail. He was cleared to land by the tower and again warned of the possible wake turbulence.

Official NTSB photo

The EMB 145 had landed and exited the runway before the Baron approached. The Baron's approach was completely normal until it was about 15 feet above the runway. Witnesses observed the airplane make a sharp roll to the left and impact the ground between the two runways.

"The National Transportation Safety Board determines the probable cause(s) of this accident as follows: An encounter with wake turbulence on approach, which resulted in the pilot's inability to maintain control and subsequent in-flight collision with the ground."

This tragedy was completely avoidable. Every pilot is taught about the dangers of wake turbulence and how to avoid them. But to avoid this and other invisible dangers pilots must be aware of their surroundings and always think ahead of the airplane.

Click here to view an article on wake turbulence that features more details and graphics of this accident.

#3 Failure to Have/Execute an Alternate Plan

Many things in life, from a football game plan to a flight, require a "Plan B" in case the situation changes. The most changeable element of aviation is the weather. Many accidents have been caused by pilots pushing the envelope when it is important to reach the destination but the weather has deteriorated.

Official NTSB photo

This accident example involved a Lake LA-4-200 amphibian that crashed into a hill while scud running in New Hampshire in 2004. The proposed route of flight was from Platsburgh New York to Concord New Hampshire. The pilot was instrument rated but not current for instrument flight. He received a weather briefing that indicated marginal VFR conditions all along the mountainous route. He departed VFR and flew above the clouds at 9,000 feet until, nearing the destination, he spotted what he believed to be a hole in the overcast. He descended into the hole but reported that the hole closed at about 3500 feet MSL and that he stayed on instruments at that altitude for awhile. He learned that the ceiling at Concord was 1400 feet and he apparently began a descent in an attempt to get below the overcast. The airplane impacted mountainous terrain at an elevation of 2490 feet MSL. The pilot's passenger, his son, died in the accident but the pilot survived.

"The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's continued VFR flight into IMC conditions, and his failure to maintain terrain clearance, which resulted in a controlled flight into terrain. Factors in the accident were the low cloud ceiling and the pilot's lack of recent instrument time."

It was reported that the purpose of the flight was to return the pilot's son to school. If this is true, there may have been some perceived urgency in making the flight. Perhaps an important exam or meeting was scheduled. In many weather-related accidents, the perceived importance of the trip is directly proportional to the degree of risk taken by the pilot.

Many accidents could be avoided if only an alternate plan had been formulated. A plan that would allow the desired outcome to be accomplished without the need to fly in poor weather or with a known mechanical defect would greatly lessen the perceived importance of the flight. The time to travel by car from Plattsburgh to Concord is about 5 hours.

Click here to view an article on Controlled Flight Into Terrain (CFIT) that includes more details and photos of this accident.

#2 Failure to Follow Accepted, Safe Practices

This pilot killer is so pervasive that it is difficult to select a single representative accident. Accidents in this category include buzzing, failure to follow a checklist, neglected maintenance, flying without proper training and certification, and a host of other causes.

In 2006 a pilot was fatally injured and his grandson passenger was severely injured and burned when the pilot landed his Cessna 180 on a residential street and attempted to takeoff.

There is probably not a representative accident for this category but the following case illustrates an apparent lack of regard for accepted, safe operating procedures. In 2006 a pilot was fatally injured and his grandson passenger was severely injured and burned when the pilot landed his Cessna 180 on a residential street and attempted to takeoff. The airplane struck powerlines running parallel with the street, crashed and burned. A witness reported seeing the airplane flying low. It disappeared behind a house and the witness heard a loud noise which was the airplane striking a street sign as it landed. The witness drove down the street and observed the airplane taxi back, make a 180 degree turn, and begin a takeoff roll. The airplane struck the street sign for the second time and continued the takeoff roll. It became airborne and drifted off the center of the road where the left wing came up under the wires. The airplane rolled across the wires, impacted the ground in a near vertical descent and burst into flames.

The physician-pilot was a long-time resident of the Oklahoma town in which the accident occurred so it is unlikely that he mistook the street for a runway. Even if he did make that error, his decision to takeoff from the street is inexcusable. Taking off from a residential street certainly does not constitute following safe practices. Up until the takeoff the total damage was a bent street sign and a dented leading edge. After the accident, the damage includes the death of the pilot, months of hospitalization, numerous surgeries, and permanent disfigurement for the young passenger, and a destroyed airplane.

"The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's selection of unsuitable terrain, a residential street, for both takeoff and landing, which resulted in a collision with a static wire and terrain during takeoff-initial climb."

Accepted, safe practices have all evolved from accidents or close calls. They are the ultimate examples of learning from the mistakes of others. They exist for a reason and should be followed.

#1 Failure to Exercise Due Diligence

"Due Diligence" is a legal term but has real meaning in the practical sense. It simply means that a person attends to required tasks and issues with the necessary standard of care. All pilots must accept a responsibility to perform due diligence in all aspects of their flying. Just as a patient who requires surgery trusts his or her life to the surgeon, passengers and others on the ground trust their lives to the pilot. This applies to the pilot of the smallest airplane as well as to the captain of a large airliner.

Making a heading check, following a taxi diagram, and observing company safety procedures would all be considered as exercising due diligence.

This example shows how a professional airline crew failed to exercise due diligence and directly caused 49 deaths and one serious injury. The captain was among the fatalities and the first officer was the only survivor. The accident occurred in Lexington, Kentucky in 2006. The crew of a Comair CRJ-100 attempted to execute a takeoff on the wrong runway. They had been cleared to taxi to and takeoff from Runway 22 but instead lined up on Runway 26 which was not long enough. The takeoff was made in pre-dawn conditions. Runway 22 was well lit while Runway 26 was dark. Company procedures require a "sterile cockpit", or no conversation not directly necessary for the operation of the aircraft, below 10,000 feet. The cockpit voice recorder (CVR) revealed that casual conversation about their families continued as they taxied to the runway.

Every instrument pilot and most private pilots are taught to make a final heading check before beginning the takeoff. This very basic check confirms that the heading indicator is correct and that the airplane is on the proper runway. This check, required of every instrument flying student, was obviously not performed by either of these (supposedly) professional pilots.

For several years now the FAA has put great emphasis on runway safety. A key component of the FAA program is the use of a taxi diagram. It is hard to imagine that an airline crew could have avoided exposure to this program in some form.

Making a heading check, following a taxi diagram, and observing company safety procedures would all be considered as exercising due diligence.

Why would any pilot fail to exercise due diligence when lives are at stake? Most pilots don't consider themselves as daredevils. Most pilots want to be thought of as being safe. Failure to exercise due diligence is an insidious problem. It creeps into a pilot's psyche a little at a time. A hurried preflight inspection, a skimpy preflight plan or a single incidence of a skipped heading check all increase the probability of more carelessness each time they occur without consequences. Each time a pilot is careless and gets away with it, that behavior is reinforced and is more likely to happen again. We can't allow ourselves to fall into that trap. We must treat every aspect of every flight with the diligence it deserves.

Summary

Nearly all accidents are preventable. Most are easily preventable. Pilots have a responsibility to themselves and others to, "Fly like your life depends on it."

EAA CHAPTER 922

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Tuesday, September 28, 2010

EAA922

Sunday, September 12, 2010

September 12, 2010 Meeting

Sunday, September 5, 2010

40I Red Stewart Fly-in

Friday, September 3, 2010

Top Ten Killers

Monday, August 16, 2010

August 8, 2010 Meeting

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July 11, 2010 Meeting

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