Archive for June, 2014

Black Swans and Checklists

Wednesday, June 25th, 2014

By HeartThe loss of a Gulfstream IV several weeks ago with all on board is tragic, and the cause seems obvious and yet a mystery. From what we now know or think we know, it appears that the big jet accelerated down the runway and reached rotation speed when the crew belatedly discovered that the flight controls were locked. There was no escape—no way to fly or to stop. They skidded for over half a mile on the remaining runway, into the overrun, through the localizer antenna, breached the airport fence, and down into a ravine where the G-IV broke up and burned.

The mantra about flight controls being ” Free and correct” MUST be done prior to every takeoff in every aircraft. It’s a killer item. So how could a professional crew with so much experience miss this most basic of before-takeoff checks? A friend brought up a key point point—that most factory checklists are absurdly long and too many pilots ignore them or significant parts of them. They are written to prevent lawsuits, not to help pilots prepare for flight.

With my usual caveat about speculation so early in an investigation, part of the answer may be perfectly obvious—complacency and/or distraction. It is present in almost every accident involving experienced pilots. We become complacent because we’ve seen or done this many times before and it’s always worked. One should never get too comfortable in an aircraft, which is never a totally benign environment.

Distraction means not putting first things first. Humans are no good at multi-tasking—it’s amazing that job-seekers still think this is a good buzzword to put on their resumes. In aviation, as in business, deal with the nearest biggest alligator first. If the first one gets you, everything else is irrelevant! Shorter, more relevant checklists perhaps?

Now to the mystery part. The G-IV designers, anticipating that humans make the most basic of errors, added a thrust lever interlock that would prevent engine thrust from being increased beyond taxi speed if the gust lock was engaged. That should have prevented takeoff power from being applied. Was there a “black swan event” (a one in a gazillion chance) that the interlock failed at the same time the crew failed to check the controls? Or, did the gust lock release mechanism fail to release the controls while releasing the thrust lever interlock?

How would a crew know if the interlock failed in routine operation because they always checked the controls and everything worked normally? Suppose a key human factors device became inoperative? And in the one in a gazillion times that the crew failed to verify flight controls “free and correct,” the safety backup would not be there to save them.

A good way to check flight controls: “Box them.” That means to move the yoke or stick all the way left, then pull it all the way aft, then all the way to the right, then full forward and finally back to neutral. Of course, you could go clockwise instead, if you’re of that political persuasion. Full control movement is needed, and please actually look to see that the controls did as commanded. There have been dyslexic mechanics who reversed rigged the system, and that will really mess your mind on takeoff. Let’s pare checklists down to essential items only and make it easy to check—there’s more to learn after this accident.

USA TODAY—Unfit to Write?

Wednesday, June 18th, 2014
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Image courtesy of Stuart Miles /

“Get your facts first, then distort them as much as you like.” So said Mark Twain. But sometimes a reporter distorts a crusade in search of something nefarious that just isn’t there or is a small part of the whole truth.

USA Today reporter Thomas Frank in a recent article interviewed families of general aviation aircraft accident victims and took carefully edited video clips to create a “compelling must-view” narrative on how unsafe GA flight is. The premise is that GA poses a huge threat that hasn’t improved over the years because manufacturers and the FAA have blocked safety improvements.

The aircraft or improper maintenance represents a small part of the accident picture, accounting for 10 to 25 percent depending on the year. Generally, it’s pilots who cause a crash. It’s the same, by the way, for all other forms of human-machine interaction. Mechanical faults—in cars, boats, motorcycles, and bathtubs—represent a very small proportion of accidents.

When Mr. Frank interviewed AOPA he asked about the accident rate and number of fatalities: They have dropped by 55% and 75%, respectively, over the last 40 years. It seems odd to exclude those salient facts from a balanced piece.

The Cessna seat slip problem, which might cause a pilot to lose control, was mentioned extensively. There was a design issue, but it was also very much a maintenance issue. In 30-year-old aircraft, or anything mechanical, parts (including seat tracks) wear out and they have to be maintained. If owners fail to heed guidance from the manufacturer on product changes and fixes even when warned in the direst of terms that it’s important, I fail to see how that is the company’s fault. In some cases an Airworthiness Directive is issued but there has to be solid statistical evidence, not isolated incidents.

Frank notes the 1994 General Aviation Revitalization Act (GARA) as being inappropriately rammed through an unsuspecting Congress to protect manufacturers from product liability. The act says that plaintiffs cannot sue manufacturers for airframes or any installed parts once they are more than 18 years old. If an aircraft has been flying safely for nearly two decades it’s highly unlikely that a systemic design problem would remain undiscovered. I’m not aware of any personal transportation product that is held to a comparable standard or judged retroactively by new standards. GARA also does not protect manufacturers from withheld, concealed, or misrepresented information—that wasn’t noted.

Frank cites several anecdotes in his article. But somehow he misses one of the most egregious product liability cases of all time: In 1983, a 1970 Piper Super Cub, with a sailplane in tow, collided with a van driven onto the runway to block the takeoff. A crude (and illegal) camera mount replaced the Cub’s front seat and there were no installed rear-seat shoulder harnesses where the pilot sat. They were not required, although the pilot could have chosen to add them. The pilot suffered massive head injuries from the camera mount and Piper was sued for lack of non-required shoulder harnesses—you can read more in this case study.

Comparing a new 2012 Cessna Skyhawk to an early 1970’s vintage would see substantial improvements: Fuel injected engines to eliminate carb icing, re-engineered seat tracks, better door latches, a full annunciator panel, dual vacuum pumps, airbags, shoulder harnesses, etc. Somehow none of that made the cut either.

Using an automotive metaphor, if you drove a 1957 Chevy (a great year) there would be no seatbelts, no airbags, no crush zones, a solid metal dash instead of padded, etc. The public, the NTSB, the NHTSA, and presumably Mr. Frank would have no expectation of similar safety to a late model Chevy.

Likewise, comparing airline operations to GA is absurd. No one would think to compare the safety record of intercity busses to personal vehicles. Frank used NTSB former chair Debbie Hersman’s non-sequitur comparing GA operations to the airlines—I’m disappointed. She knows that’s jumbling the fruit basket.

NTSB investigations do sometimes leave something to be desired, and in some cases they don’t even send an investigator to the scene. But in many cases the investigation is spot on, but the probable cause findings are not allowed in court—merely a quirk in our justice system to let an unbiased third party present its findings?

The general aviation community takes safety very seriously, which is proven almost daily in print and online. The Air Safety Institute conducts 200 free safety seminars annually and has the largest GA safety website in the world. None of that was mentioned.

So, with apologies to the many responsible video journalists, writers, and editors who strive for accuracy, this particular writer and editorial team deserve three Pinocchio’s for deliberately distorting the facts. They don’t get four because there are a few truths contained in the story, but to finish with another Twain quote,“When in doubt tell the truth. It will confound your enemies and astound your friends.” I am neither confounded nor astounded. Perhaps we’re expecting too much from USA Today.

It’s Storm Week

Wednesday, June 11th, 2014

Storm WeekEvery year GA loses a few aircraft and their precious human cargo to nature’s equivalent of a thermonuclear bomb.

Looking back 20 years, on average, there were about five GA thunderstorm accidents per year. Surprisingly, that hasn’t changed much in two decades! That corresponds roughly to one accident per month during T-storm season. In the grand scheme of things, that’s not a lot. But unlike landing accidents where almost everybody walks away (not my definition of a good landing), a thunderstorm tangle has a 75 percent fatality rate. Also, every flight has a landing, but not that many flights encounter CBs. Confounding factors make comparable assessments difficult!

So the numbers are flat, but my statistically unproven hunch is that we are doing much more flying in thundery weather thanks largely to datalink. In-cockpit weather—displayed on portable or panel-mounted devices—has revolutionized the ability to see and avoid boomers. Use the tool intelligently lest optimistic interpretations lead us where angels fear to tread. On board radar is also a tremendous help in-close, but it also has to be used smartly.

One of my favorite mentors, Captain Bob Buck who wrote the book on weather flying, gave the big storms anthropomorphic characteristics. He described them as “treacherous.” Why? Because while having similar characteristics, no two storms are exactly alike. To misquote Forrest Gump’s mother, “You never know what you’re going to get.” What looks like something you’ve seen before may be quite different. Bad can go to worse to impossible literally within a mile.

True skill lies in avoidance. We’re kidding ourselves upon escape from an encounter that it was due to airmanship. Lady luck merely smiled.

Enough philosophy! Cruise over to the Air Safety Institute Storm Week page for an all-inclusive look at a multitude of courses, case studies, and quizzes. There’s also a webinar registration for Wednesday, June 11 at 7 p.m. EDT to join Dr. David Strahle and me for a look at in-cockpit weather with an emphasis on datalink. It will be recorded if the timing doesn’t work for you. AOPA President Mark Baker and I took a looong trip in a Cessna Caravan from St. Louis to Frederick and we discuss the tools used in this “Flying the Weather: T-storm Toolbox” video.

There were a lot of storms! This year—let’s try to reduce the CB encounters and accidents to an all-time low. We want and need you flying with us next year.