AOPA ASF Blog: Safety eJournal

The theory that wide open spaces generally preclude two aircraft from swapping paint or worse was put to the test this past weekend when a Cessna 172 collided in VFR conditions with a Cirrus SR22. Random events have been happening with some frequency (see last weeks blog) and yet they remain statistically unusual. In 2006 there were 6 midairs, in 2005 there were 10 according to ASF’s Nall reports.

As we tend to look at these mishaps a bit clinically, perhaps to maintain a level of objectivity and sanity, my condolences go to all - family and friends. These events are reminders of the responsibilities that we carry as PICs. This also applies to students since the C172 pilot was a student. Again, we are in the preliminary stages so little detailed information is available. The Cirrus was on an IFR flight plan, and had been in communication with ATC, planning to land at Rock Springs, Wyoming (KRKS). The aircraft was likely on a visual approach and had been released to the CTAF when it collided with the Cessna who was not on the ATC frequency, nor was he required to be.The parachute system on the Cirrus was partially deployed but it’s too soon to know if that was a function of the collision or whether the pilot activated it.

This midair fits the collision profile perfectly of being within a few miles of a non-towered airport in VFR weather. I’ve flown into RKS before. It’s not exactly high density traffic, which reinforces the point that other aircraft are where you find them, not where you expect them to be.

I’m a big believer in getting off the IFR communication line and on to the VFR CTAF party line as soon as possible. If neither frequency is too busy, you can multi-task by listening on both but it can get really garbled when both freqs are alive together. As IFR pilots, we operate in both worlds and have to play by two sets of rules simultaneously. It’s also too soon to tell if one aircraft ran down the other or turned inappropriately. That will be settled by NTSB.

There will probably be some comment regarding glass multi-function displays with traffic avoidance capability and parachute escape systems since the Cirrus was so equipped (parachute - yes; traffic display - maybe). These are intended as aids, not as replacements to the primary tenets of airmanship. I’ve used traffic avoidance systems to good effect on many occasions, but until we get all aircraft equipped with ADS-B or some equivalent, remember that VFR bogeys may not always show up on the glass. Transponder operation and radar coverage play into that. VFR or IFR - look (outside) and listen. It’s really important - even in Big Sky country (with apologies to Montana.)

“It was a random act of God for that plane to have zeroed into the smallest house around.” So said the owner of a vacation rental property in Gearheart, Oregon, a seaside community west of Portland, as quoted in media reports. Details are sketchy at this writing but it appears that a rental Cessna 172 took off from the Seaside airport with two people on board in the early morning around 0630.

As is usual for that part of the world, it was foggy. The Cessna crashed into the house about a mile from the airport and a three alarm fire resulted. So far, there are three survivors with injuries and three confirmed dead that were inside the house. The pilot and passenger are presumed dead.

Ground fatalities caused by light aircraft accidents are exceedingly rare, which is small comfort to those affected but it helps the rest of us understand the real risk. It’s way too early to cite specifics but here are some points for pilots to consider. An IMC takeoff requires thorough preparation and concentration. Close to the ground there are few options.

First, is the decision to go itself. Suppose the engine quits. It’s rare but it does happen - now what? How much ceiling and visibility would you like to have—just in case? Every hundred feet of additional ceiling yields maybe another ten seconds of maneuvering time to avoid obstacles. Likewise, forward visibility is at a premium. What if the primary flight display or the vacuum pump just packed it in? (See last week’s blog.) Are we ready for partial panel before even settling into the routine of normal instrument flight?

Statistically, it is more likely for the pilot to have a lapse or become distracted at a critical time. These are normal human failings and early climb is the place to be on guard. Nothing else matters but keeping the wings level and a positive climb flight attitude. Spatial disorientation is always a possibility for a variety of reasons. Open doors, open windows, ATC communications, passenger distractions, anything that takes away from gaining critical altitude is irrelevant.

I’ve had both lapses and distractions in my flying over the years and have learned from each one that there are better ways to deal with them then I did at the time. I suspect most of us have had a few along the way.

There is always tremendous pressure to speculate on accidents like this. In this case, mechanical or instrument malfunction, pilot lapse, spatial disorientation or incapacitation are all possibilities. I’ve been wrong way too many times to repeat that mistake.

The old joke about the fully automated airliner with no flight crew - just an automated cabin announcement that misfires - seems prophetic with last week’s NTSB announcement about massive display failure on Airbus aircraft. There were 49 failures on Airbus 319 and 320 aircraft including seven incidents where all six screens failed simultaneously. Didn’t think that was possible? Neither did the manufacturer, the FAA or the NTSB.

As light GA manufacturers rush into glass cockpits, is it unseemly to ask what assurance we have that there will not be a catastrophic failure or at least a significant failure in our less robust systems? Several years ago I had the privilege of getting a demo in one of the early all-glass light aircraft which suffered a total flight display meltdown. It wasn’t an issue since we were in good VFR and there were backup instruments. Still, this isn’t what’s supposed to happen.

After one flies enough and sees enough equipment break - some of it harmlessly and some of it at the least opportune time - a sense of caution or perhaps cynicism sets in. Duplication of hardware on critical things like comm, nav and flight displays means less fancy footwork on the pilot’s part when something goes south.

I suspect the record keeping on Part 91 flights flown in light aircraft when a flight display dies is not very accurate, even though NTSB Part 830 requires, somewhat vaguely, pilots to report the in-flight failure of electrical systems that require “sustained use of ….backup power to …retain flight control or essential instruments.”

Has anybody had, or know of someone who had, a major glass malfunction and did it get reported and to whom? The purpose is not to rat out the manufacturers but to insure that weak points get fixed before someone is hurt.

Many accidents, while not boring to the participants, have a predictable regularity - Crosswind landings or gear-ups, for example. There’s not much we don’t know about the cause and cure for either. They get cataloged in Air Safety Foundation’s database where they form the basis for topic and initiative areas for future education or awareness. But others pique our curiosity.

What brought this to mind was a fatal Cessna 441 accident in Oregon last week. Obviously, it’s way too soon to know why things went sour but a normal landing in light winds turned into a disaster. Witnesses saw the Conquest porpoise a few times and then saw what looked like an attempted go-around. What’s unusual about this? Two things: First, pilots flying turboprops usually know how to land especially without confounding factors, such as night, IMC, short runways or adverse winds. Secondly, how did what is usually just an embarrassing, if somewhat expensive, incident become a fatality.

The coding on this accident for our database will be challenging because the initial event occurred on landing, from what we now know. The fatality occurred on go-around which is five times more likely to result in a fatality than landing where there are seldom any serious injuries. The NTSB also has difficulty with this and we sometimes code something differently if we think there is compelling logic

We don’t yet know the pilot’s background or training but this accident is now on the ASF Watch List. When more information comes in we’ll revisit to see what may be learned and passed along.

As communications becomes more encompassing - web for example - I ‘d invite your thoughts on the watch list. Is there a better way to communicate the lessons learned than what we’re currently doing?

A friend and ASF donor took me to lunch in his brand new Eclipse yesterday. As you’ll read in the August issue of AOPA Pilot, Editor-in-chief Tom Haines also earned his EA-500S type rating. I have three observations after the ride.

1. The FAA and Eclipse do not give away the ratings - it is a thorough and rigorous process involving simulation, lots of ground training and mentoring on actual trips until the experienced mentor jet pilot in the right seat thinks you’re ready. My friend is multi-thousand hour Baron pilot and has a Citation type rating but no real jet time. He is a meticulous and cautious engineer - a perfect mind set for this and he agreed with Haines that his plate was full.

2. Higher Power Aviation, who does the training for Eclipse, follows a well-defined process to prepare customers for the check ride. In flying fast airplanes the profile is everything. Plug in power settings, and configuration and shazzam, the aircraft falls into predictable performance on the descent, on the ILS, in holding etc. However, to make the speed differential less daunting and to get people through the type ride, the training profile bears little resemblance to what real world ATC needs.

As it is currently being taught, fly the approach at Vref plus 10 knots from the final approach fix inbound. Try that any busy airport with appreciable jet traffic and you’ll hear words you never heard in the bible as controllers and the pilots behind you try to resolve the ensuing traffic tie-up. In the real world, it’s often 150-170 knots to the marker. To be fair, this how the airlines teach their new hires and then when everyone gets on the line, the realities take over. The mentor pilot for my friend gently explained how things were and proceeded with his reprogramming. Seems to me, even if it takes a little longer, we should teach real world profiles right from the beginning. One set of numbers to remember and more practice in getting right.

3. Despite the marketing claims to the contrary, at least with early versions of the VLJ, it looks much like jet flying to me in terms of single pilot workload. Not too bad in low density airspace or at altitude and really intense on short legs or in high density. It’s good they don’t give the type ratings away.

The Lancair experimental aircraft: beautiful, fast and having what the FAA calls a “disproportionate” number of fatal accidents. There have been 7 fatals since February including the most recent, which occurred this week. Here are some preliminary FAA statistics running from October of last year:

Lancairs make up just over 3% of the amateur built ( AB) fleet yet have over 10% of the fatal AB accidents. Keep in mind, however, that they also tend to fly significantly more than the typical AB local flights. These are cross country machines.

Over half the Lancair accidents in this small sample were fatal while the rest of the AB fleet is just slightly above the overall GA fleet fatal accident ratio of 1 fatal mishap for every 5 accidents. Here’s what’s interesting - unlike the typical high performance aircraft that have fatal weather encounters, the Lancairs are generally in VFR conditions and involve loss of control - i.e a stall/spin.

A couple of observations: High performance aircraft may be squirrelly in stalls but not always. The certificated Columbia ( now Cessna) 350/400, which has ties to the Lancair early in its history, has a good stall/spin safety record. “Experimental” means that aircraft handling is left up to the designer and the extent of flight testing is entirely at the designer’s discretion. It may be very thorough or not. Factory built aircraft must meet specific construction and performance standards and are FAA tested for compliance. That’s one of the reasons for the cost differential.

There may also be variability in the building process. The designer suggests that it be built this way and the builder thinks he has a better idea or just isn’t adept at putting the machine together.

A few aerodynamic realities: Small wings and big engines make for very fast aircraft with high wing loadings and glide ratios not much better than the proverbial brick. If the engine stops for whatever reason, the crash dynamics are often not very good.

I believe that pilots should be able to build and fly their own aircraft. Extra training is one way to compensate, although not always successfully, with “hot” aircraft. There’s lots of history on that. Comparative statistics on any aircraft model’s safety are complex until you’ve accumulated enough accidents to say there’s a problem - the hindsight approach - and the denominator (exposure) factor is always squishy. Government crash testing, as done on automobiles, just doesn’t seem feasible for aircraft.

Your thoughts?

With apologies to Lyricist George Gershwin and singer Billie Holiday, the livin’ ain’t so easy as density altitude climbs. In the last few days we’ve had a couple of accidents that sure look like density altitude, although it’s too soon to say for sure.

Whenever I see high temperatures and high terrain I’m suspicious. When a high performance aircraft that is typically a strong performer at lower density altitudes is fully loaded, I’m almost ready to put money on it.

The two fatal accidents that appear to fit the DA profile both happened on June 29: In Santa Rosa, NM a Cessna 206 with 5 passengers was lost shortly after takeoff. One state over, at the 7,000 foot of a mountain close to North Las Vegas, NV, a Cherokee 6 also with five passengers crashed. We’ll learn more as the investigation goes forward but if this is the case, to lose 10 people in one day because the pilots forgot that sea level performance doesn’t exist in the summertime is sad, expensive, and really unacceptable.

My experience with hot and high makes me conservative on who and how much to carry. Trip legs are frequently shorter as fuel load is lightened and I really study the route carefully so as to be at altitude before getting to the high terrain, if that’s possible.

Some years ago when taking a mountain flying course, while pausing at Leadville, CO to get the certificate for being at the highest airport in the U.S. , I watched a fully loaded Cessna 172 almost do the deed. The airport picture makes it look deceptively easy. The Skyhawk is not exactly a ball of fire with all seats full at sea level. With a runway of 6,400 feet, that’s less than the field elevation of 9,927 feet msl the Cessna pilot clearly did not understand what he was up against. With four people on board the Cessna rolled and rolled and rolled. It sagged off the ground, caught its breath in ground effect and then sagged some more into the the cool thin morning air. That coolness was the only thing that saved them because by early afternoon there would have been no climb at all - only forward and down.

If you haven’t done much high terrain flying recently take a look at ASF’s mountain flying course.

As we did in talking about near fuel accidents, share your experiences that you or a “friend” had in learning about density altitude beyond the academic view. Is there a way we could be teaching this more convincingly?

More than a decade ago there were five GPS manufacturers making IFR-approved units. ASF asked for a group meeting, along with FAA, to discuss some level of input standardization. No two units worked the same way so we suggested that core IFR-essential functions be somewhat standardized.

The core functions were Direct To or selecting a bearing from a fix , setting up an approach, missed approach procedure, and holding. Everything else would be left to the manufacturer to innovate. A pilot, once trained on core functions, could fly any box in the IFR system without extensive retraining although they might not be able to use all the clever or advanced features that were built in to every system.

Obviously, we didn’t prevail in what I still think was a common sense human factors approach. Innovation was the goddess of the day and there is certainly merit to that argument. However, there is much to favor in commonality where flight critical operations are concerned. Many pilots do not have a monogamous relationship with an aircraft. Renters, CFIs, club pilots, pilot examiners and other assorted vagabonds who fly multiple aircraft got saddled with a complex and expensive training barrier.

“Legacy” units that are either orphaned by a defunct builder or one who has left the old boxes behind often have scant or way too much documentation. Personally, I find 200 page manuals daunting - especially for an aircraft that I may only fly every few months. It’s tough to find good computer-based simulation to practice or even a CFI who knows how to run an earlier generation unit, let alone teach it. Most installed avionics have a life span of 15 - 20 years and unless one has a generous allowance for upgrades, we’ll be living with a very mixed fleet for some time.

As it stands today, pilots who wish to fly glass models of classic aircraft will spend many hours and perhaps thousands of dollars to get back into the cockpit of an old friend. Flight management systems are wonderful devices that were originally designed for two pilot flight decks, a strong training infrastructure, and the cost is usually on someone else’s nickel.

As we start to see some maturity in the GPS market and even a few new players coming back in to broaden the field, is it time to ask the same question again or should market forces continue to hold sway?

Click here for my column on the topic.

Would appreciate your comments and experiences.

Tired of hearing about fuel mismanagement accidents? So am I. We’re losing, on average, several aircraft every week as pilots rediscover that adequate fuel and/or proper configuration of the fuel system is not optional.

I won’t bore you with the usual rants about stupidity, forgetfulness, or wishful thinking. So what’s left to discuss? First, BRIEFLY describe a bout you had with the fuel mismanagement virus and how close to the edge you got.

My story: Years ago, returning from the upper peninsula of Michigan to Wichita Kansas in a Cessna Turbo 210, as front seat passenger, I was party to some bad decision making. My PIC boss, flight planned a non stop IFR trip with the required 45 minute reserve - barely. The weather was good VFR but the prevailing southwesterly breeze took its toll on ground speed. The DME told the tale for over an hour as we fell below the minimum required speed to make the reserve numbers work. Several stops were passed up on the way into Cessna Field in Wichita and we landed with an estimated 20 minutes of fuel remaining. The fuel gauges were abundantly clear that this was dumb. Neither one of us hung around for the fuel truck driver to tell us how close we’d come to explaining to Cessna’s chief pilot why we’d forced landed a brand new Centurion next to the little house on the prairie.

Secondly, how should Air Safety Foundation raise the awareness for all pilots on this most basic and yet one of the most prevalent accident or incident causes? The folks who are running out of gas don’t come to ASF seminars or visit our website so to make a dent, we need to go well beyond the “choir.”

Here are some resources that might be helpful but we need distribution beyond the routine channels.

Two fuel Pilot Safety Announcements were developed last fall and we’ve been showing them at seminars - click on the links to see and to forward.

Click here to view our Fuel Awareness safety advisor.

ASF is promoting the “Golden Hour” of reserve. Had that advice been followed in 2006, we’d have 86 more aircraft that would have arrived uneventfully with no injuries or fatalities to pilots and passengers.

Fuel may be expensive but it’s dirt cheap compared to wrecking airplanes. Your thoughts are welcomed.

There was no shortage of thoughtful response and opinion to last week’s blog on how to enter the traffic pattern at non-towered airports when approaching from the opposite side of downwind. My informal analysis of the more than 120 responses showed you were split just about down the middle between the “Crossovers” and the “Crosswinders” with a very slight edge to Crosswinders.

This is almost identical to the response we got years ago when ASF first published the safety advisor on Operations at Non-towered Airports. We consulted both with FAA Flight Standards and with Transport Canada. We looked at accident statistics on midair collisions and found by far, the most dangerous place is on final approach, not the downwind leg.

Both sides were passionate that their way provided the best separation, spacing and view of other traffic.

There were several recurrent themes of the string :

1. Communication is the most important element, as well as LOOKING
2. Some treated the AIM as gospel, others saw it as guidance and NOT regulatory.
3. Pilot judgment is crucial.

Getting to the bottom line, obviously, the idea is not to swap paint. Clearly, based on your response, one size does not fit all, despite personal preferences. A thought - think like ATC - look for ways to avoid conflict, be courteous, orderly and flexible.

Next week, we’ll try to get beyond the traffic pattern. Thanks to all for participating.