A Tough Thanksgiving (and some hypocrisy)

December 7, 2011 by Bruce Landsberg

There were a number of fatal accidents over the Thanksgiving weekend, and while in my previous blog I lamented that we ought not to be speculating too publicly, the preliminary investigations do not bode well for pilot decision-making. Below are the facts that we think we know at this point.

1. Medical flight with five people on board crashes in Illinois – 3 fatalities. The flight went from GA to IL with only a few miles to go to destination.  Strong NW winds apparently slowed the ground speed aboard the Piper Navajo. From the Chicago Tribune, Pilot told air traffic controllers moments before, “We are out of fuel and we are coasting.”  NTSB noted there was no fuel in the tanks or on the ground. Fuel exhaustion?

2. Turbo Commander 690 on a beautiful VFR night slams into a mountain with 6 fatalities. The weather is reported as 26003 KT 20 SM SKC. There is speculation about configuration of Phoenix Class B airspace and the pilot attempting to stay below it to avoid ATC. Controlled flight into mountainous terrain at night while VFR?

3. A VFR pilot (according to the flying club manager) is returning his daughter in a Cirrus SR20 to college along with another daughter and a friend – 4 fatalities. Weather at the crash site is reported as 9 OVC 1 3/4 sm  -RA BR. VFR into IMC? No IFR flight plan has been located at this writing.

All the pilots involved were reasonably experienced and had been flying for some time according to acquaintances. Aftermath—Three pilots deleted from the already declining pilot population, 12 passengers who won’t be around for next Thanksgiving, multiple families and communities devastated by these losses, more negative publicity for GA.

Both the Foundation and the industry have been in ongoing discussion with FAA and NTSB on how to address GA mishaps like these.  Were these systemic failures or individual failures?

  • Is it possible that any of the pilots did not know the risks involved?
  • Have we in the industry not done a good enough job of explaining the risks?
    • Fuel is needed for engines and the rules require a reserve.
    • VFR at night runs the risk of not seeing mountains – there is no rule for avoiding mountains per se but you won’t be happy with the results.
    • Flying in the clouds is extremely hazardous unless you’ve been trained to do it—there are minimums for VFR flight.
  • Is it possible that despite all the warnings that people become complacent or ignore them – certain that they can some how succeed?

Some think more regulation is the answer. In two cases a violation of Part 91 seems highly likely. In the Phoenix accident should we make it against the rules to challenge a mountain?

Most of these questions are rhetorical. Friends within FAA and NTSB have privately acknowledged that “We can’t fix stupid.”, but by the nature of their positions they must continue to try.  Whether these incidents fall in to that category won’t be known for certain until the investigations are complete. Learning from past mistakes really is the best way not to become a statistic. Nobody sets out to kill themselves, their passengers or their loved ones. Teaching decision-making to all pilots seems like an easy non-answer because the absorption capacity and risk tolerance varies so greatly.

Is technology the answer? Fuel flow transducers are capable of predicting to the gallon when the engines will go silent. Synthetic vision and TAWS predict impact in time to avoid it and autopilots are capable of keeping aircraft under control when the pilot can’t. Can we change human nature? Can we make the aircraft foolproof? Does everyone need the same level of oversight and at what cost to personal freedom and bank account? While political correctness may dictate one answer, does reality provide another?

Constructive suggestions are welcomed.

Bruce Landsberg
President, AOPA Foundation

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22 Responses to “A Tough Thanksgiving (and some hypocrisy)”

  1. Bendrix Bailey Says:

    Hi Bruce,

    You know my position, and it is not for more regulation. I am in favor of more enforcement and harsher penalties for violations. As you pointed out, these guys were already in violation, its just that they were not caught violating before they killed planeloads of people.

    More enforcement means more ramp checks. How much fuel is on board at the termination of a flight, IFR or VFR? How hard would that be to check? It sure would turn up a lot of violations and it would raise awareness that running fuel low is not just a risk “that you can handle” but a risk to your ticket as well.

    More enforcement would mean checking the ratings and currency (logbook) of all GA pilots who land or operate an aircraft below VFR minimums. I told you about my friend who operated IFR for years, without a rating or properly equipped aircraft. In many cases he got “Special VFR” clearances into and out of IMC airports with towers. His radar track must have many times shown up when nobody was flying but on an IFR flight plan. He would have been very easy to check and should have had his ticket pulled. I have spoken with far to many VFR pilots who fly IMC either because they don’t want the trouble of getting rated, or because their fancy glass panels and autopilot appear to make it easy.

    You get the idea.

    The problem is that GA pilots are not part of an organization that includes self-enforcement as a part of the operating practice. In 121 or 135 operations, the pilot is only a part of the organization, and one that is managed and monitored closely. Part 91 standards of management and monitoring are so lax that it is a wonder we don’t have more accidents. That we do not is testimony to the integrity of the majority of GA pilots. The accidents due to wilfull violation that we do have is proof that relying on integrity is not enough.

    Best regards,

    Ben

  2. Sherif Sirageldin Says:

    Hi Bruce,

    Great article, great questions. Towards the end of the article you pose some questions. Here are my two cents… (for what they’re worth).

    – Relying on technology for fuel starvation seems to be a double-edged sword. I have two transducers on my Cardinal. But they can’t measure how much fuel with which I started my flight. Did that line-person put in the full 38 gallons on my receipt? Did a bunch spill? Did I measure to the bottom of the tank with my fuel stick? Could I have been off by 3 gallons per tank (a good 45 minutes of flying). On the rare occasions when I push my fuel to less than 1 hour on board, my brain starts stressing about such things (and that is really really unpleasant).

    – Relying on Synthetic vision and TAWS for terrain avoidance only works if the system knows the correct baseline barometric pressure. My onboard TAWS (MX20/GNS480/Jeppesen Terrain database) is surprisingly accurate and helpful… but also surprisingly unsettling when I experiment with the altimeter pressure setting. And it seems the only way to properly set that is based on the closest airport’s weather observation… but is that close enough? Is that airport 20 miles away in the middle of the mountains in an unusual pressure system relative to mine…?

    – Can we change human nature?… Yes, but it is a very sloooow process and not everyone will change.

    – Can we make the aircraft foolproof?… Yes… but not at a cost or timeframe that is affordable

    – Does everyone need the same level of oversight and at what cost to personal freedom and bank account? While political correctness may dictate one answer, does reality provide another?
    – These questions are very disconcerting… especially since they are most obviously being discussed by some who don’t mind the most restrictive freedom and most liberal use of funds.

    I typed this up quickly while working (gasp) so I do hope that these thoughts make sense.

    Best Regards and always a pleasure reading Leading Edge,
    Sherif

  3. Jim McCord Says:

    Bruce,

    It certainly was a frustrating period. I had the opportunity to lead a FAASTeam CFI workshop last week focusing on GA accidents (Nall report) and teaching risk management. We specifically looked at the Phoenix accident, not from a “fault finding” standpoint (since we don’t know what might have precipitated the accident) but from a “how would I teach my student to avoid hitting the mountains” standpoint. There is very favorable terrain to the Southeast, right after takeoff, clear of Class B, yet that’s not where the pilot went (for undetermined reasons).

    In the seminar we also looked at technology. It can certainly help the pilot that wants to use it properly but not if the pilot uses it to “trim” his or her safety margin even slimmer. As the saying goes – as soon as they make something foolproof, the make a better fool…

    Our FAA FAASTeam Manager summed it up nicely: this is not something that will change overnight, but just as with the impact that MADD has had on driving while intoxicated, over time we can change the culture of GA to be one focused on maintaining a larger margin of safety, and following the (existing) regulations.

    Thanks for helping.

  4. Jim Jordan Says:

    Bruce,

    Ever since a very rough night VFR flight into Reno below an overcast with lots of wind and turbulence trying to read a Sectional for the height of the local terrain, I have owned the current model of Garmin portable GPS with their “Terrain” function.  I am always amazed when I think about how many CFIT accidents could have been avoided by the pilots buying and using any of the Garmins I have used from the 296 in 2004 to the 796 today.   Of course, sometimes the answer would be cost, but I just went on eBay, and it looks like for a little over $500 one could probably buy a used 296.  In my bird at today’s prices that is just two tanks of gas, which is a cheap price for one’s life.

    Jim

  5. Bruce Says:

    When traveling, not just joy riding, and especially with passengers, all pilots should be strongly encouraged to file IFR flight plans. That’s right! File IFR. If you are not IFR rated, then the recommendation should be to get rated. VFR is simply not safe for air travel given airspace restrictions, weather and air traffic. VFR is for sightseeing, joy riding and practicing flight maneuvers, not for serious traveling.

    IFR weather, comms and system skills are required for safe air travel.

    Every pilot should be or should be becoming IFR rated.

  6. Mike McGowan Says:

    Psychological testing should be incorporated in the licensing process to reduce the number of idiots allowed to pilot aircraft.

  7. Steve Westcott Says:

    On the first point, my car, which to the best of my knowledge has never left the ground, gives me, at a glance, the number of miles to my destination and the number of miles of fuel left in my tank. If it economical enough for my truck why not hours and minutes to destination, hours and minutes of remaining fuel on an airplane?

    On the second point you can’t see the mountains at night! OK sometimes when the moon is right you can but even then the view is deceiving. Pilots need more instruction for flying in or near the mountains. The altimeter can’t tell you that the slope of the mountain is rising faster than you are climbing, there is wind shear, even the temperatures are unpredictable where it can be warm over the valleys and cold over the peaks. Flying the mountains in a small aircraft is exhilarating and dangerous and that’s during the day.

    On the third point we need more training and more reminders about our Plan B. I think we have all pushed it when we “HAVE to get back”. The plane is rented and must be back, the spouse, who may already be somewhat less than supportive of the whole flying thing is expecting you NOW, and so on and so forth. I have not flown for an overnight trip to my favorite island resort because they are notorious for unpredictable weather that grounds all planes for 2 or 3 days (no practical plan B). We are not taught, but we should be, that if there is no practical plan B then don’t go!

    That’s how I see it. Thanks for asking

    Steve

  8. AL Says:

    The question is not IFR or VFR, the question is adhering to the rules of whatever level you are approved. I know IFR pilots who spent the time and the money and never used it again and not current legally. Some of them are not good VFR pilots because they rarely fly. A ramp check can detect gas levels, it cannot uncover or predict the particular mindset, reaction or decision making of pilot in some future scenario look at the final analysis of Flight 447 they filed IFR…………follow the rules.

  9. Cary Alburn Says:

    I think many accidents can be answered by “pilot complacency”–I’ve done it this way before, it worked then, it’ll work now. Unfortunately, technology, gadgets, training, doesn’t do away with the pilot who thinks somehow all those darned “rules” don’t apply to him/her, because “I’ve done it this way before, it worked then, it’ll work now.” Whether it’s running too far into the reserves but always before having enough to make it, or flying at night in mountainous but familiar terrain, or flying a tecnologically well-equipped airplane in marginal weather but without either the skills or the rating to allow it to be done legally, or whatever scenario that is overly risky, being complacent because “I’ve done it this way before, it worked then, it’ll work now” applies too often.

    One thing I learned as a CFII many long years ago is that teaching judgment, overcoming years of development of a student’s innate nature, was pretty close to impossible. Some folks just can’t be trained out of their fundamental beliefs, especially complacency.

    It seems that maybe more enforcement of existing regs might have some of the answers, but I doubt it will materially affect the over-all pattern. We just can’t police fools successfully. Of course, I guess that’s a form of complacency, too: We’ve tried it this way before, it didn’t work then, it won’t work now. :)

    Cary

  10. Steve 2 Says:

    After 40 years of dreaming, I got my pilot’s license a couple years ago. One of the things that has impressed me about the GA community is the level of common sense that most of the community operates under. While there are a few regulations that seem written because someone’s wife yelled at them that morning, for the most part the current regulations are there for practical reasons. The industry as a whole seems to understand that the GA community lives (collectively and physically) only if there is a working balance between rules and common sense.

    There will never be enough regulations to cover every scenario and the regulations we have already address every common scenario that can be dealt with in a rule. The schools and instructors have great material and courses available to be able to give prospective pilots the tools they need to fly safely all of their lives and still have fun doing it. Technology continues to advance and give incredible benefits to the pilot, touching almost every aspect of flying.

    In short, we have all the tools and rules we need to stay active and safe available to us right now. My hope is that we are still able to stave off the p.c. calls for more regulation, which will NOT make anyone safer, and continue to strive and reach for calling every pilot to the higher standard of operation that must be in place if our freedom to fly is to continue.

  11. Steve 2 Says:

    Well said, Cary.

  12. Wilson Riggan Says:

    Bruce,

    Thank you for your insightful post. You have hit on a subject that is going to play a large role in the future of general aviation – decision-making. The topic is familiar to those of us in positions of responsibility in aviation. It’s maddening to hear about competent, intelligent, capable pilots knowingly flying their aircraft into situations from which they cannot escape.

    The judgment that most of us have developed has come from “experience.” By that I mean having experiences that could have had similar outcomes, but either we saw it coming soon enough or we just got lucky and it didn’t quite kill us. Either way, from those experiences we developed the chutzpa to stick to choices we knew to be safe. Sometimes the choices are so clear that we already know what to do, but just require the gumption to stand up to whatever external pressure there is to cut corners.

    Personal example: Years ago, when I was the chief pilot of a mid-size Part 135 operation, I was chastised routinely by the company owner for my guys (and me) landing back at home with “too much” fuel. You see, when we buy fuel on the road, it’s at retail, but when we buy it at our home FBO, it’s at wholesale. I always insisted on at least an hour’s fuel on arrival as a minimum, but the boss thought that was “too much,” as the FAA said we only needed 45 min. We never could resolve the conflict, so we ended up agreeing that he and I were not a good fit, which required that I leave and find another job.

    Less than two years later, as he was returning from a charter in one of his Navajo Chieftains, he ran out of fuel about 45 minutes from home, bellied the airplane into a golf course and hurt all aboard. Thankfully, no one was killed, as I recall. Of course he lost the business and presumably everything else he’d worked for as a result.

    I believe that we need a major focus on decision-making. We have sufficient rules. We have procedures designed to keep us safe. We have incredible tools at our disposal. We have all kinds of delivery methods for knowledge and learning. What we need now is the human connection. We must reach our people (pilots of all levels) with the message that each of us is the last link in the chain that either leads to an accident or that is broken before it gets that far. It is a conscious choice for each of us every time we strap into an airplane – whether it is a Cessna 182 or a Boeing 767 (both of which I do), or anything in between.

    Thanks, Bruce, for being willing to talk about something that most would rather not think about.

    Best Regards,

    Wilson Riggan

  13. Steve Kittel Says:

    As a recently minted pilot, I cant imagine that self preservation would not be first and foremost on any pilots mind, especially if you are flying loved ones. Some of the items discussed are the most basic things:

    * Fly at least 1000ft above the highest object within a 2000ft radius (no reason NOT to talk to ATC). when planning my x-country flights, I look at the height of obstacles along my route and plan my cruise altitude carefully. There was no reason for the pilot of the arizona flight to be as low as he was. Im sure the mountains are on the sectional. His altimeter setting had to be way off if he was less than 1000ft above the mountains.

    * Dont rely on technology for fuel burn or quantity. Have at least 1 hour fuel reserves at day or night – even then you cant be sure the aircraft was level when visually checking the fuel on the ground during preflight, so believe the reserve doesnt exist. If Im flying for 2 hours, you bet I have more than 3 hours of fuel, if not a fuel tank (if taking people makes my fuel quantity to low, then I dont go).. Winds not as Forecast, improper leaning, and deviations can all eat up what fuel you thought you had.

    * Unless you are staying local, file a flight plan and contact ATC for flight following!

    In response to the comment above that all pilots should be IFR rated and that VFR is for joy riding… I do perfectly fine flying VFR cross country at night… I use VOR radials, GPS, and whatever tools I can, and contact ATC for flight following. I am handed off between Atlanta Center, RDU, Washington Center, Norfolk, etc. so Im in constant contact and know what traffic and terrain/obstacles are around me. The system works for VFR pilots IF you use it. The pilot in command has the responsibility to the safe operation of the aircraft. We had an IFR rated club member go down from fuel exhaustion after a long flight from New England to Virginia…just because you are IFR rated, doesnt make you immune. Things happen because people exceed limitations set by SOPs and regulations. Set limitations for yourself and adhere to them!

  14. Mike Schaffrinna Says:

    More training or more rules may seem like the solution but will not change the outcome. People are human and will make bad decisions. From an engineering perspective the answer is to develop systems that make it more difficult for the human GA Pilot to make an error. Just like the low fuel light in a car, technology can be leveraged to provide advanced warning and enhance the human interface between man and machine.

  15. Brian Lynch Says:

    Although I fly for a living I do, on occasion, fly a small airplane so that my family can experience the joy of flying. That having been said, the difference between the planning/preparation I complete in my flying job and the preparation I witness others doing, or not doing, when flying for leisure is staggering. The ‘kick the tires and light the fire’ mentality seems to prevail in the small plane world. And efforts to push others towards a more thorough planning process usually meets with resistance – an ‘aviation libertarian’ mentality, if you will.

  16. Ken Says:

    There are enough rules and enough training. Unfortunately, the pilots that need it the most don’t take it. While these types of events are a tragedy, the consequences of trying to eliminate them will forever change general aviation. I for one am not willing to pay the price. We all know the risks – we all accept them.

  17. Stefan Werner Says:

    Great article on the biggest issue we all face as pilots. Because we all get the sideways looks when “we make the news”, and we all have to deal with one or more family members that is convinced flying in small airplanes just ain’t safe.

    To me the number one item on the list has to be fuel exhaustion. All the things do have a hard to reduce minimum number of occurrences per year in my opinion. We can get is lower with lots of investment in training and equipment but never down to zero.

    However none of us should ever run out of fuel, unless we have a major mechanical problem that siphons fuel overboard in flight or someone shot 3″ holes in our tanks.
    Do electronics help ..partially. The electronics in the car someone mentioned do give you a miles remaining number…..to a point. Then it simply turns off. Because the manufacturers want to avoid someone claiming the car said such and such and I ended up short…at the side of the road.
    The best systems can measure quantity in the tank with weight cells so there is no mistake to be made entering the fuel data, but a good pilot always has a backup plan….and that is as old as flying powered aircraft. How much does it burn in an hour and how much is in there. At that point all you need s a watch and possibly a calculator.

    I was attending a seminar not too long ago themed “what went wrong” and in one of the interludes the FAAST rep related a story of her CFI days when she ran a Warrior out of gas on an instructional flight because she “forgot” to check the fuel before setting of. And she related it with way too much laughter for my taste.

    I almost never like punishment… But I think a mandatory 6 month suspension if you do run out of gas should be a really good deterrent.

    However, ramp checking a Part91 VFR flight is only marginally helpful because you can legally arrive with less than 30/45 minutes in your tanks…you just need to be able to prove that you planned with due diligence and mother nature simply did not comply with the forecast….remember the flight plan has to show you arriving with that reserve….not the actual flight.

    Happy Flying…and for heavens sake check the fuel and land short if in doubt. It really does not take that long to fill up.

    Stefan

  18. Pat Joffrion Says:

    As is often the case, a complex problem has a simple solution. Case in point… My personal Thanksgiving daytime flight to KJKA to KHDC in beautiful VFR conditions. Landed at predominantly abandoned Hammond, Louisiana airport. Zero security personnel and gates unlocked. After a long evening with family, we were planning for the 1-hour flight back to Alabama.

    First thing I did was drain fuel, then climb the wing to “stick” the tanks. My wife asked, “Why are you doing that? We just landed eight hours ago with plenty of fuel!” I reminded her that the FBO facility and the tarmac were deserted, and that it was possible for someone to siphon fuel right out of our tanks. That didn’t happen, but without checking, if it had occurred, we could have simply run out of fuel during our night flight home. Had the fuel been removed by a thief, our computer still would have displayed over four hours on board. On more than one occasion, I had over twenty gallons stolen from my plane when it was not parked in my hangar.

    Now for the solution… It would only take a few visits by FAA personnel to watch pilots preflight their aircraft, and then question the pilot on fuel quantity once he enters the cockpit. Same again for landing airplanes… Have an inspector request a stick gauge reading for remaining fuel on board.

    Another step would be to have FAA personnel perform impromptu logbook examinations on all planes landing or preparing to depart in IMC. While this would not stop unqualified pilots from scud running in and out of private small strips, the word would get out soon enough. We all know the two fastest means of communication: Telephone and Tell-A-Pilot.

  19. Mike Says:

    Thanks Bruce,
    Experienced pilots who failed to use good judgement, and failed in observing the regulations, is sad and frustrating.

    -Enhanced technology may help with the problem (but could this lead to an over-reliance, in lieu of appropriate preparation and sound decision making.) Terrain doesn’t move from where it has been depicted on the chart. Know where it is, know where you are. Standard equipment facilitates this.
    -Increased regulations or stiffer penalties: may not solve the problem as effectively as suggested …
    -”If you do not use the safest decision making, comply with the regulations and excercise the best judgement both before and during the flight, … you may die and kill all those on the flight.”

    Is there a greater motiviator for observing the regs and using good judgement with the safest, conservative decision-making, than the consequence being death?
    Is there a greater enforcer for adequate planning, exercising caution, and operating as safely as possible, than reminding the pilot that they are responsible for the lives of those on board?

    By sharing these stories, it raises the awareness of this ultimate consequence. If there are any new requirements to consider, and to avoid complacency, perhaps reading accident reports and the analysis, should be compulsory.

    “Learning from past mistakes really is the best way not to become a statistic. [i]Nobody sets out to kill themselves, their passengers or their loved ones.[/i]”

    Thank you. Keep up the helpful work providing the educational reminders.

    May those who suffered, rest peacefully. Prayers for, and condolences to, their friends and familly. respectfully,

  20. Bob Downs Says:

    As one who knew the pilot of the 690A that ran into the mountains and I flew for the company at one time, I am still grieved beyond belief that he and his three kids died in this inexplicable accident. I did read in a newspaper account that his autistic son was acting up so the father was in the back with him. If true, that explains a lot. But it doesn’t change the fact that night VFR departures, especially in mountainous areas, require as much study as an IFR depature. Probably an IFR flight plan should have been filed or at least a contact with Phoenix approach, but you can get out of Falcon Field VFR safetly and stay beneath the Class B if you plan the exit route. bobd

  21. Thomas Boyle Says:

    I disagree with those who think increased enforcement of the regulations wouldn’t make much difference. It would. It would make dealing with the regulations an even bigger hassle, and make nightmare enforcements even more common. We already have regulations up the wazoo. There are “gotcha” regs almost everywhere – have you read John Yodice’s column?

    When considering whether increased enforcement of the regulations would improve flight safety, the regulations that matter are already enforced by the laws of physics, and they ALWAYS catch you. If guaranteed detection and guaranteed punishment aren’t enough, good luck with that 90-day suspension: you’re dealing with someone who either has terrible judgment or who (as many of us have) just plain made a mistake. The fix isn’t to make life more of a hassle for people who aren’t trying to violate the laws of physics.

    The fact is, we’re already well past the point where we have to rely on our regulators to exercise some good judgment about which regulations they enforce! (Often that works; sometimes not).

    Fuel quantity is a hard problem… Aviation fuel tanks are shallow and flat. Small depth measurement errors translate into big fuel quantity measurement errors in a shallow tank; small tilts of the tank give rise to substantial depth changes at the measurement point (true no matter where you put it); and even if you have quite a bit of fuel in the tank, with some tilting of the tank you can unport the fuel pickup. In a cube-shaped tank, or even better a tall, thin tank, measuring fuel quantity is much easier. Electronics help by avoiding a different problem: the pilot who departs knowing the tank was full, but estimates the contents over time using a “gallons per hour” estimate that is wrong (either completely wrong, or wrong for the power setting or mixture setting). But directly measuring the tank contents is a hard problem.

  22. Patricia Andrews Says:

    You CAN fix stupid. All of us who are CFIs have an ethical responsibility to look for and correct faulty ADM. Where it cannot be corrected, we have a responsibility to withhold our recommendation.

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