Tag: safety (page 2 of 6)


I think Dirty Harry said it best: a man’s got to know his limitations. Loathe as we may be to admit it, we all have them. Our bodies can only go so long without food, water, and sleep. The mind can only process so quickly, the memory retain so much, the senses absorb so much input before they cease to function properly.

Likewise, the equipment we fly has limits, too. Airspeed, temperature, pressure, altitude, RPM, weight, center of gravity, and other limitations must be understood and respected if we want our aircraft to respond in a predictable manner. This is something every pilot learns from the very first day of training, and those limitations look him or her square in the face on every flight. From color coded markings on the gauges to those annoying placards liberally distributed throughout the cockpit, you don’t have to look far to find an advisory or warning in the aviation world.

But let’s be honest, some of these limitations might get exceeded on occasion without major catastrophe. Perhaps it’s a slight overspeed on a fixed pitch prop during aerobatics. Flying a bit over gross weight. Exceeding a duty day limit. Extending the flaps a few knots above Vfe. Flying under VFR when the visibility hasn’t quite reached the requisite level.

Normally, these minor variances don’t result in disaster. The problem is, once you’ve ventured beyond that red radial line, you’re essentially a test pilot and the margin of safety built into the aircraft by the designer is now gone. How far can you push it before something bad happens? Nobody knows until it actually happens. I hope you’re as uncomfortable thinking about that as I am writing it.

Now if you actually are a test pilot — say, one flying an experimental aircraft during phase one — that’s one thing. You know what you’re getting into, and you have prepared for it with engineering data, specific training, contingency plans, and so on.

But if you’re a professional aviator flying passengers in a transport category airplane, your whole raison d’etre is to ensure the ship remains well within the documented limitations. I once got to see first-hand what happens when you ignore them. It was about a decade ago, and I was sitting in the lobby of an FBO at John Wayne Airport when a loud “boom” emanated from the general direction of the runway. Within a few seconds, thick black smoke wafted up into the air.

Once the smoke had cleared, I got a look at what happens when a jet’s brake system limitations are exceeded:

110907-hawker_jet_fire1 110907-hawker_jet_fire2

From the NTSB report:

On October 29, 2007, about 1400 Pacific daylight time, a Raytheon Corporate Jets Hawker 800XP, N800CC, was substantially damaged by a fire originating from the left main landing gear after the takeoff was aborted at the John Wayne-Orange County Airport, Santa Ana, California. The aircraft is owned and operated by CIT Leasing Corp. and was originating at the time for the 14 CFR Part 91 business flight. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The two airline transport pilots and six passengers were not injured. The flight was destined for Denver, Colorado.

The pilot reported to the responding Federal Aviation Administration Inspector from the Long Beach, California, Flight Standards District Office that the takeoff was aborted twice before the third attempt due to an engine warning light. All three takeoff attempts were made within about a 20 minute period.

Inspection of the landing gear found that the left main landing gear tires overheated and blew during the third takeoff attempt. The hydraulic line on the left main landing gear was severed and hydraulic fluid leaked out onto the hot surface and ignited.

Jet aircraft, with their 150+ mph takeoff speeds and higher weights, can place tremendous strain on the brakes in the event of an aborted takeoff. That’s why most aircraft in that class have a time limitation after an abort. The brakes must be allowed to cool for a specified period (or, if the aircraft has brake temperature sensors, until a specific temperature is reached) so that if the second takeoff attempt also ends with an abort, the brakes don’t overheat and fail.

I don’t know what the limitation is for the Hawker, but I would be surprised if three attempts were allowed within 20 minutes. The scary part is that the Hawker has a fuselage fuel tank aft of the trailing edge of the wing, right where the skin has been burned through.

I don’t know what happened to the flight crew, but if brake limitations exist and the PIC intentionally exceeded them, FAA sanctions might’ve been difficult if not impossible to avoid. Aviation is like that. You can fly safely for 20 years and with one moment of carelessness ruin a whole career.

Tough business, eh?

Ron Rapp is a Southern California-based charter pilot, aerobatic CFI, and aircraft owner whose 9,000+ hours have encompassed everything from homebuilts to business jets. He’s written mile-long messages in the air as a Skytyper, crop-dusted with ex-military King Airs, flown across oceans in a Gulfstream IV, and tumbled through the air in his Pitts S-2B. Visit Ron’s website.

Too Hot to Handle

fire_burn_flames_213827Lithium-ion (LI) batteries occasionally catch fire. That’s not news. The problems have been well documented early on with Boeing’s 787s having some serious battery overheat problems, to the point that they were grounded while a fix was implemented. More recently, Samsung’s latest smartphone has been self-immolating so frequently that they’ve been recalled and the airlines have asked that they are shut down during flight. In light general aviation aircraft, a cabin fire from an LI battery device could become immediately catastrophic.

UPS lost a 747 and its crew in Dubai in 2013 when a shipment of batteries caught fire. There have been a number of incidents on passenger flights where cabin crews have responded to douse an overheated device, but in light aircraft we often don’t have much space to resolve the problem. Some of us have had an iPad shut down at inconvenient times (see iPaddy Melt). I’ve had two overheats where the iPad behaved exactly as programmed—it went to sleep. But what to do if it occurs during an IMC approach and what if it should go into thermal runaway mode and catch fire?

The IFR approach issue is relatively simple to resolve: Carry some paper approach charts for the destination/alternate and have a backup device available in case the primary fails.

A thermal runaway is a much bigger challenge. Briefly, LI batteries have very high energy densities and under certain conditions can overheat, especially during charging. According to Battery University (there is such a place!), the LI battery has “…the potential of a thermal runaway. The temperature would quickly rise to the melting point of the metallic lithium and cause a violent reaction.

“The high energy density comes at a price. Manufacturing methods become more critical the denser the cells become. With a separator thickness of only 20-25µm, any small intrusion of metallic dust particles can have devastating consequences…Sony Energy Devices (Sony), the maker of the lithium-ion cells in question, says that on rare occasions microscopic metal particles may come into contact with other parts of the battery cell, leading to a short circuit within the cell. Although battery manufacturers strive to minimize the presence of metallic particles, complex assembly techniques make the elimination of all metallic dust nearly impossible…During a thermal runaway, the high heat of the failing cell can propagate to the next cell, causing it to become thermally unstable as well. In some cases, a chain reaction occurs in which each cell disintegrates at its own timetable. A pack can get destroyed within a few short seconds or linger on for several hours as each cell is consumed one-by-one.”

Caution areas: A short circuit within the battery itself or a faulty charger can create a runaway. Static electricity or a faulty charger can destroy the battery’s protection circuit and will be undetectable by the user. A battery with a failed protection circuit may function normally but cannot provide any protection if it’s damaged . Once the cell is in thermal runaway mode nothing can stop it once triggered.

Revelation! Consumer-grade lithium-ion batteries should never be charged below 0°C (32°F). Battery University, “Although the packs appear to be charging normally, plating of metallic lithium occurs on the anode while on a sub-freezing charge. The plating is permanent and cannot be removed. If done repeatedly, such damage can compromise the safety of the pack.”

Other concerns: Wedging the device into a suitcase or flight bag ? Bad idea ! The battery becomes more vulnerable to failure if subjected to impact or crush, or high rate charging from high capacity chargers. Many off brand replacement batteries often don’t employ the same high safety standard as the original manufacturer. This is NOT an area to go cheap!

Some other common sense thoughts: Try to keep the devices out of direct sun and in an area with good airflow. Strategically directed air vents will help with garden variety overheating but not with a thermal runaway. If that rare and really bad luck situation occurs, use a fire extinguisher—but understand that it may not work! Equipment is available for airline and corporate aircraft that resembles a metal envelope to contain an overheated device but they are pricey—as in several thousand dollars. For light aircraft, until someone comes up with a better solution, perhaps a fire mitt used for grilling (anyone who’s ever had one of my steaks will understand immediately) may allow you to grab the smoldering device and heave it overboard. (Caution, however, in a thermal runaway the cab temperatures can reach 1,000 °F, so the standard grilling mitt may not work well.) I’ll deal with the open door or window! If the aircraft is pressurized, you’ll need another solution.

This problem shouldn’t be overstated—there are tens of millions of LI devices in use, and as pilots we depend on them. But low probability/high consequence events should not be ignored. As far as nonflight-essential devices are concerned, probably best to just turn them off. Passengers may need to become re-acquainted with that rare activity of looking at something like a magazine or book! Or, just enjoying the view from on high.

Data Driven? The Engine Failure Debacle and a Modest Proposal

detached cylinderClyde Cessna famously said, “If the engine fails you are due for a tumble and that’s all there is to it.” If you thought that the failure of such a critical component was closely tracked by the FAA you’d be mistaken. Despite all the minutiae that the FAA requires for certificated aircraft parts and pieces, understanding the reality of piston engine failures is apparently not that important. By now, you may have heard about the FAA’s mandate to replace ECI cylinders on big bore Continental and Lycoming piston engines. This storm has been brewing for years, and after a lot of back and forth the FAA has spoken. If your engine has been overhauled with certain ECI cylinder they must be replaced within a certain period—generally well before any recommended overhaul interval. AOPA, many of the type clubs, and people who know much about engines complained that this was unwarranted and ill-considered. Even the NTSB weighed in against the airworthiness directive (AD) as being overreaching, which means Hell just froze over!!! The FAA apparently didn’t want to be confused with facts, as presented by the aforementioned parties. Maybe that’s because there are very few failure facts available and the preponderance of the evidence would support watchful waiting. But who’s to know?

The cost to the general aviation (GA) community is estimated in the tens of millions of dollars!!! Don’t get me wrong—if there’s a legitimate safety issue it should be addressed, but the actual data was exceedingly sparse. By some estimates, the failure rate was .01 , well below the FAA’s own guidance on when to act. So let’s open up a dialogue on whether we should be capturing more data on piston engine aircraft maintenance and failures. A recent attempt to get at the facts was made by a joint industryFAA working group chartered by the General Aviation Joint Steering Committee (GAJSC). In 2014 it was noted that System Component FailurePower Plant (Engine Failures) was the third leading fatality producer in GA accidents. Turbine failure was almost non-existent but piston engine problems were significant.

From the GAJSC report: “Because the SCFPP Working Group focused on GA aircraft, some data limitations existed that made accident analysis difficult (and in some cases impossible). The working group acknowledges that the NTSB does not have the time, manpower, or resources to investigate every accident and must prioritize its investigations to benefit public interest. It is understood that this is why, even in fatal accidents of small certified piston or experimental aircraft, the NTSB sometimes chooses not to conduct onsite investigations. However, this made some of the reports supplied by the NTSB to the SCFPP Working Group unfit for analysis because they did not contain enough information to be useful.”

One of the interventions that the GAJSC suggested was a maintenance data exchange. When something breaks or is replaced because it’s about to, how about taking just a few minutes to document that in a centralized database? In GA, often the only time things get documented is when there’s an accident or through a Service Difficulty Report (SDR) system which has its own problems. The other time is when there’s a warranty claim, but the manufacturers don’t release that data. Bluntly, our maintenance data collection system is nearly non-existent. Granted, it might increase the cost slightly to implement some organized record keeping, but it would likely prevent this kind of overbroad AD that may cost individual owners as much as $14,000 to replace perfectly good equipment. The net gains could be significant across the board. Given the highly subjective nature and—in some cases—profit-driven motive of some shops to just replace things that may not need it, wouldn’t it be better and safer to base decisions on fact?

Probably the only way to make this effective would be some sort of incentive-based or, dare I say, mandatory methodology. That requires some additional thought. Perhaps expand the NASA Aviation Reporting System ( ASRS) database to specifically track engine and critical airframe parts. The core infrastructure already exists, and there wouldn’t be a need to establish a new FAA office. When an engine is put into service, overhauled, or annualled, it is logged in—make, model, serial number, time-in-service, airframe, etc. When a Framistan fails or is in the process of failing, the tech spends a few minutes describing the problem and part number. The FAA does not get to see the specifics. It’s all handled under the same parameters that we have for other safety or regulatory infractions. The FAA also has an information database, the Aviation Safety Information Analysis and Sharing System (ASIAS) that might be used. However it’s done, in aggregate, everyone is made aware of flight-critical maintenance problems.

The specter of product liability is often raised but I remain unpersuaded that the current head-in-the-sand approach is better. We’re already paying somewhere between 20 to 30 percent in manufacturer liability reserves today, and with the advent of far better engine monitoring and recording equipment, the odds of opportunistic lawsuits is gradually diminishing. If there’s a legitimate problem with an aircraft or engine, let’s fix it. If there isn’t, we shouldn’t be at the mercy of questionable decision making and gut feelings of a variety of entities that are unreasonably risk-averse or looking to make a buck! What’s missing here is the data-driven approach that the FAA claims to be driving their decision making.

Engine failures are the third leading causes of fatalities in GA. No one relishes the thought of one quitting right after takeoff, at night, in IMC, over mountainous terrain, or over water. In fact, the only place that might be even slightly tolerable is over Clyde Cessna’s Kansas wheat fields, and you now know what Clyde had to say about that! We can and should do better! Let me also clarify that this is my view only, and not an official AOPA position at this point.

What do you think?

Flying the Diamond Lane:Mass formation arrivals at OSH bring connection and camaraderie

Flying the Diamond Lane

Flying the Diamond Lane

After meeting and talking with participants from the mass arivals to Oshkosh, one thing is certain, the impetus for flying formation is connection and camaraderie. Whether Cessna, Bonanza, Cherokee, or Mooney, the goal is the same, to be able to train, fly and camp together. To celebrate general aviation and our ability to attend this iconic event as an aviation family.

Mooney Caravan Training, Jolie Lucas Wing

Mooney Caravan Training, Jolie Lucas, Wing

For those unaware, the process to fly the mass arrival to Oshkosh isn’t as daunting as you might think.

Last year I flew the Fisk arrival into OSH and happily landed on the yellow dot.  But  I was intrigued by the formation arrivals and wanted to be a part of it.  I was grateful to have attended a training in Chino, California. I wasn’t sure if I would have the skill set to fly so close to another airplane, let alone landing fast with no flaps while looking only at my Lead. I was so pleased when everything jelled on the second day and I was actually enjoying the formation flying. I hope you enjoy this bit of history about the various aircraft types who fly the mass arrival, and also consider flying the diamond lane into OSH17.

Bonanzas to Oshkosh

B2OSH en route to OSHTheir website

Each year in late July about 100 Beechcraft Bonanzas and Barons assemble in Rockford, Illinois and fly in the world’s largest formation of civilian aircraft, to the world’s greatest celebration of aviation – EAA AirVenture, in Oshkosh, Wisconsin.

Bonanzas to Oshkosh began in 1990 when Wayne Collins and a few friends decided the only way to ensure camping together was to arrive together in formation. Wayne Collins led Bonanzas to Oshkosh until 2001 when Elliott Schiffman took over the reins. During Elliott’s tenure B2OSH established a nation-wide network of regional training sessions. Organized practices led to ever improving B2OSH flights and added a wonderful layer to the social fabric. In 2007 Larry Gaines slid into the left seat.

Bonanza Mass Arrival OSH

Bonanza Mass Arrival OSH

Today their focus remains firmly fixed: pilots flying the best general aviation airplane camping together in friendship and camaraderie. The formation arrival is their means of accomplishment. The requirements are membership in EAA and a demonstration of basic formation competence in the preceding six months. They cannot stress too strongly that this event focuses on friendship, camaraderie and a grass-roots structure.

According to Larry Gaines there were 115 airplanes on the ramp at Rockford.  98 Bonanzas and 17 Barons.  They sent 1 Bonanza out ahead of the group as a weather scout to verify that thunderstorm movement from the west would not accelerate and affect the flight. 2  Bonanzas had maintenance issues after engine start (out of ordinary CHTs and alternator failure).  Both flew to Oshkosh later.
So, there were 113 airplanes in our flight this year,  counting the weather scout.

B2O Party



Mooney Caravan

Vita nimis brevis est tarde volo  [Life is too short to fly slowly.]

Their website


Mooney Caravan line up Madison, WI

The Mooney Caravan’s roots originate in a message posted on February 21, 1998 to a Mooney email list started by Doug Fields. Following is the text of the message from Akmal Khan (who flew a 252 and enjoyed taking goodhearted jabs at his normally aspirated brethren):

“I am taking my family over to Oshkosh this year. I know a number of you Northwest Mooniacs were planning on flying over this year. I thought it might be fun to organize a caravan of Mooneys to fly in together. I will have my speed brakes on so you can keep up :-). We could arrange for a couple of stops along the way and maybe do a formation flight into Oshkosh. What do you think?”

Through the efforts of a core group of volunteers led by Jonathan Paul, the first Mooney Caravan of 42 aircraft took off from Madison Dane County Regional airport on July 27, 1998 with Jonathan as lead and Dave Piehler as tail. During the months prior to the flight, the organizers including a Letter of Agreement with the FAA and the flight procedures, which were developed following consultation with Bonanzas to Oshkosh, worked out the Caravan logistics. Bonanzas to Oshkosh had been conducting formation Bonanza arrivals into Oshkosh since 1990 when the organizers recognized that the only way to camp together in the North 40 was to arrive together!

“I had not been into AirVenture and so many people commented on the madness of the Fisk arrival and the relative ease of the Caravan that formation seemed like a better option. Additional considerations were the opportunity to get an introduction to formation flying techniques and skills. Third, I was aware that the Caravan planes would park together and there would be opportunities for meeting Mooniacs.” –Robert C. (Bob) Belville. Based at Morganton, NC.


Mooney Caravan 2016

41 Mooneys arrived OSH in 2 plane elements (instead of 3 due to surface wind) every 15 seconds. There was a little congestion on the taxiways – arrivals to the airport had been backed up by the weather and by the next morning the field would be closed temporarily – no more parking space!

 “Friends don’t let friends fly the Fisk arrival” … overheard in the North 40

Cessnas to Oshkosh

Cessnas to OSH Pilot Brief

Cessnas to OSH Pilot Brief

As has been the case with other events in aviation history, the origin of the Cessnas 2 Oshkosh mass arrival can be traced back to a group of pilots searching for a way to fly and spend time together. In the summer of 2005 a small group of Cessna owners led by Fred Johnson and Rodney Swanson met in the North 40 during the celebration of EAA AirVenture – Oshkosh to figure out a way to fly in, camp and hang out together as a group under the wings of their airplanes in the North 40. The ultimate goal was to share their mutual passion for aviation and have a good time together during the week of Oshkosh.

C20 Landing 36L

C20 Landing 36L

C2O reports that eighty-five aircraft, arranged in thirty  elements, participated in the 2016 Cessnas 2 Oshkosh Mass Arrival Flight. This number represents an unprecedented eighteen percent increase in participation compared to the seventy-two aircraft in 2015 and even higher compared to the previous three mass arrivals: 54 in 2014, 42 in 2013 and 41 in 2012.


C20 group_2016

C20 Group 2016


Cherokees to Oshkosh


Cherokees to Oshkosh on Final 36L

Cherokees to Oshkosh began a tradition in 2010 which we are confident will continue to grow and promulgate. The enthusiasm that effervesced from the founding group will be the base, which stands the test of time, and encourage future Cherokees to Oshkosh members to make the choice to join us. If you decide to join us in 2017, be prepared to attend a mini-clinic of your choice, as well as coming in early to Waupaca to enjoy the family of aviators that are the essence of Cherokees to Oshkosh. Both venues will require effort on your part. However, if you take the time to speak with any of the pilots that flew with us in previous years, we are confident they will tell you the hard work paid off. That belief was evidenced upon landing at Oshkosh, as we did not observe one pilot exit their aircraft in the North 40 without a smile!

“2016 was the third time flying my airplane into Oshkosh for EAA AirVenture and it’s been an adventure each time. The first time I flew in was as a single arrival. To me the single arrival was more challenging and I believe more dangerous because you have no idea who is lining up with you over Ripon and It can be hectic The past two years I have flown in to AirVenture with the Cherokees to Oshkosh group. This group is very organized and there are minimum qualifications for the pilots. Cherokees to OshkoshOne of the requirements is all pilots must attend a mini clinic on formation flying that are offered around the country during the year. We all arrive in Waupaca, Wi about three or four days prior to the day we plan to fly the mass arrival. During those few days we fly training sorties in formation and practice different scenarios of arrival in case we are assigned a different runway or some other change. When we fly in you know who is on your wing and what to expect. It is much easier and safer way to arrive not to mention it is a lot of fun and looks really cool.”John Bova Based at KSBP, San Luis Obispo, CA

No matter the make or model everyone I talked to in the mass arrivals was happy to have completed the task.  Do consider a formation clinic in your region in 2017.  Most clinics welcome all brands of aircraft.  The skills you will learn will serve you well and formation flying has a strangely addictive quality.  It is not too early to start making plans for OSH17.  The fun, fellowship, and flying are hard to beat.  Plus you might get a super cool call sign to memorialize your participation.

Buttercup, out.


Jolie Lucas Bio

Jolie Lucas makes her home on the Central Coast of CA with her mini-Golden, Mooney. Jolie is a Mooney owner, licensed psychotherapist, and commercial pilot. Jolie is a nationally-known aviation presenter and aviation writer. Jolie is the Region 4 Vice President of the California Pilots Association. She is the 2010 AOPA Joseph Crotti Award recipient for GA Advocacy. Email: [email protected] Web: Twitter: Mooney4Me


single-engine cessna airplane on the tarmac in St. George, Utah. Toned in Photoshop, taken with Canon 40D

A U.S. senator recently held a news conference to announce that he wanted the FAA to start conducting more ramp checks at GA airports. There had been eight accidents since the beginning of the year in his state. He was concerned that the number of ramp inspections in the last decade had fallen from 2,000 to 748, a 73 percent decrease. FAA personnel funding increased significantly during this period according to the DOT inspector general. Parenthetically, the senator noted that there might be no correlation but the FAA should ramp up ramp inspections to check for compliance, ostensibly, to stop the “surge.” 

A casual pass through this year’s NTSB preliminary reports for the state-in-question revealed the following:

1) A student pilot lost control on a touch and go, drifted off the left side of the runway despite reportedly applying right rudder, whacked nearby signage with each wing, breached both fuel tanks, and managed a successful off-airport landing after dodging two sets of power lines. No injury. That would have made an interesting social media post for sure.

2) A V35 Bonanza suffered an in-flight breakup from a reported vacuum system loss in IMC (discussed in one of my previous blogs).

3) A Stinson 108  ground-looped during a precautionary landing after the engine began to miss. The aircraft had an approved STC to use autogas—but not with ethanol—according to the preliminary report. The pilot reported that the engine had missed on several prior occasions. No injury.

4) A Cessna 172 stalled shortly after takeoff from a private grass strip that was just over 1,100 feet long. Two fatalities and one minor injury.

5) A Piper Cherokee lost power shortly after takeoff and crashed. Both occupants sustained serious injuries—the engine is being inspected.

6) A Cirrus SR-22 suffered a power loss in cruise flight and although the pilot switched tanks (both of which contained fuel), there was no restart. The parachute was pulled and no injuries resulted. A preliminary engine teardown showed valve strikes on the tops of all cylinders.

7) A Piper Cherokee suffered an engine stoppage at night during an instructional flight and ditched just off the shoreline.  The aircraft had flown 5.1 hours since the last refueling. There were three minor injuries and one presumed fatality.

8) A Cessna 152’s nosewheel impacted a snowbank just off the end of a runway. The aircraft nosed over and crashed on the runway, caught fire, and was destroyed. The pilot was uninjured.

It’s a typical potpourri of GA mishaps and tragedies. The usual disclaimer applies to these preliminary reports as no probable cause has been determined, although it seems at least somewhat self-evident in several cases.

Regarding the efficacy of ramp checks, in the skill-based accidents, they might have been prevented—but only if the inspector happened to observe poor airmanship just prior to the mishap and was able to flag the aircraft down.

In the maintenance arena, there might have been an opportunity to ground an aircraft if it had not had the proper inspections. But it’s a bit of a stretch for an inspector to determine if an aircraft has ethanol in the fuel or an internal cylinder condition. We are not required to carry maintenance logbooks onboard but the aircraft should be airworthy and safe to fly. Sadly, a few of our compatriots pay scant attention to maintenance and fly with bad tires, poorly rigged flight controls, inoperative instruments, etc.

So, there’s an effort to do something, anything by government and the regulatory hammer is often the tool of choice. In my view, the real opportunity is ongoing and proper education since it’s the pilot and passengers who arrive none-too-gently at the scene of the accident first. It’s also the rest of us who pay increased insurance, and there is litigation and bad PR.  Perhaps a ramp “check” isn’t the best tool but merely a courtesy “discussion” by inspectors since the FAA is moving into compliance, as opposed to enforcement these days. If someone is a consistently bad actor, then enforcement is completely appropriate.

On training: Touch and goes by solo students should be carefully considered. There’s a lot going on during both takeoff and landing, and to string them together occasionally overwhelms the new aviator. Directional control should always be stressed. Adequate fuel and runways are essential for all flight—seems we have to remind pilots of that. 

On maintenance: Unless you’re flying a sailplane or a balloon, a fully functioning engine is essential to repel gravity—there ain’t no shortcuts here. Unfortunately, a few of us don’t just believe in luck, we rely on it, usually to save a buck. It’s a false economy.

Looking back at this group of accidents, do you think GA pilots could do better?

Would additional enforcement make a difference? If not that, what? Let’s hear your thoughts.

Touch up your short field landings: At Nenana!

Some days are sunny, others have been wet, but there is no denying that summer has arrived.  With 21 hours and 21 minutes of sunshine today in Interior Alaska, it is time to brush up your take-off and landing skills–to see if you can still hit the mark, and get stopped in under ???? feet.  (You fill in the blank).  To confirm you can REALLY do that, why not use one of the practice runways around the state to test your skills?  For the past several years I have written about painting marks on the gravel runway (ski strip) at Fairbanks International Airport and other airports around the state (Practice Runway at FAI Ready for Use), however this year a new location joins the mix.  For the first time, a volunteer crew led by Adam White, painted the ski strip at Nenana (ENN), with assistance from the Fairbanks General Aviation Association, Midnight Sun Chapter of the Nine-Nines, EAA Chapter 1129 and others.  The twist is, unlike the gravel strips at other airports, this runway is turf.

Volunteers painting marks on the ski-strip at Nenana.

Volunteers painting marks on the ski-strip at Nenana.

After a rainy period leading up to the evening event, the sun made an appearance, allowing the project to proceed.  Adam’s family served pulled pork sandwiches to power the group, and the mosquitoes came out in full force to hasten the work.  (In the interest of full disclosure, I arrived after the painting was done, just in time to admire the finished product, and sample the pulled pork and cole slaw—all of which were excellent.)

Try it yourself…

Aerial view of the practice runway, looking north, at Nenana.

Aerial view of the practice runway, looking north, at Nenana. Paint marks denote a “runway” 25 feet wide, with marking at 100′ intervals.

ENN airport layoutIf you want to try something new, motor over to Nenana and give the sky strip a try.  Sandwiched between the paved runway and float pond, I would recommend starting by landing to the north (wind permitting) on Runway 4 Right.  If all goes well, and you want to up your game, try the other end—but beware there are some swales which make this even more realistic training for true off-field conditions.  If you arrive with a light fuel load, and want to see how additional weight impacts your performance, remember that Nenana has self-service fuel. So you can increase your gross-weight, and have enough gas to get home.

Thanks again to the volunteers that devoted their time, talents and resources to create this new practice runway, adding to our ability to hone our skills before heading to the back-country!

Speak up Early & Often

For pilots, a visit to an ATC facility often results in a mental sunrise on why things are done as they are and how to get the best service.

A local group of pilots visited an ATC facility and observed:

VFR flight following: At a moderately busy Class C facility, on a nice VFR Saturday morning, the amount of traffic was impressive—especially around the edges with clusters of aircraft who weren’t speaking to anyone.

At a satellite airport outside Class C airspace there were several VFR targets in the pattern or nearby. As an IFR Cessna 210 was picking up his clearance on the ground, the controller advised him of the nearby beehive. It got more exciting because although the winds were light, the 210 elected to depart against the prevailing flow—his prerogative. The controller advised of the nearest targets, altitudes, and that there was a Hawker jet setting up for an RNAV approach to the opposing runway. The 210 launched uneventfully and avoided everyone. We’ll catch up to him momentarily.

The Hawker was advised of “the hive” and the controller reminded him to cancel when appropriate. A thin layer of clouds precluded it right then and the controller asked for a pirep. Two minutes later the Hawker reported bases broken at 1,300 and canceled. The controller now had a better picture on what was going on and where a conflict might develop recognizing, of course, that everyone was adhering exactly to the prescribed cloud clearances. Right! Pireps are important—make ’em!

For pilots, the mantra is Aviate, Navigate, Communicate. For controllers it’s Safety, Efficiency, and Pilot Requests—in that order. Controllers may be working two or more frequencies, and we only hear one side of the conversation. Be patient since ATC’s highest priority is avoiding a paint swap before they can get to our request.

On an initial call for VFR flight following, just the call sign and possibly “flight following” is all that is needed. Don’t unload that you’re “a Buzzard 110 at 2,000 somewhere northeast of Mudville headed up to see Aunt Tilley who has a world class twine collection.” ATC will reply when they can with a squawk—and then it’s time to provide type, altitude, and destination.

The IFR Cessna 210 was headed northbound and assigned 7,000 but the Mode C readout showed 7,300 and climbing. The controller provided the altimeter setting and asked the pilot to check altitude. He reported level at seven and when the Mode C showed 7,700, ATC requested him to stop altitude squawk.

Meanwhile, an inbound RJ was descending out of 10,000, which the controller stopped at 9,000 just to be sure. The 210 was handed off to the adjacent sector and told to start squawk again, to ascertain the problem. The 210 showed level at 7,000, which points out that sometimes there are intermittent gremlins in the system. A good reason for the biennial altimeter/transponder check and the need to check anomalies in several locations/times. Perhaps in the distant future we’ll be using GPS-derived altitudes, at least in some airspace.

Approaching even moderate high density airspace, don’t wait until arriving near the boundary before calling. It’s a three-dimensional chess game of time, speed, and distance—the pieces are constantly moving. It’s even more complex when ATC has to anticipate what the non-participating players might be contemplating. ATC is managing considerable traffic 40 to 50 miles out from the Charlie or Bravo boundary of mandatory communication and typically up to 10,000 feet. So there is opportunity for unpleasant encounters even though communication is not required, as described in the accident below.

Arrival and departure gates are often a mystery to VFR pilots who sometimes believe staying clear of Charlie or Bravo airspace should eliminate any conflicts. Not so! The fast movers need to get into and out of the communication airspace (which AOPA works hard to keep as compact as reasonable). Choice of altitude becomes critical. A midair collision last year in the Charleston, South Carolina, area outside of Class C between an F-16 and a VFR Cessna 150 illustrates this point.

Minimum vectoring altitude, in this case, was 1,600 as the fighter was being guided to the final approach. The Cessna had just departed on a cross-country and was not in contact with ATC. While several traffic calls were made to the jet, the defensive approach would have been for the Cessna to level at or below 1,400 until establishing contact and to listen on the ATC frequency. It’s good to know those arrival and departure gate altitudes in areas where you fly a lot.

Some pilots are uncomfortable talking to ATC, being uncertain about what to say or that, somehow, there’s a violation lurking for the least little foul-up. As they say in Jersey, Fuhgettaboutit! ATC is there to help, and it’s seldom that controllers will be anything but helpful. Just tell them you’re a student pilot. I’ve used that to good effect in high-density IFR traffic in the Northeast, which always gets their immediate attention. (Just kidding!)

Say It Right-NEWThe AOPA Air Safety Institute’s recently updated Say It Right: Mastering Radio Communications is an excellent free online course to help you feel better about it. You’ll be talking like a pro in no time.

Post your thoughts about using Flight Following in the comments section:

a) I always use Flight Following – when available

b) I stay away from the busy airspace

c) My eyesight is excellent and I have lightning fast reflexes to see and avoid any traffic

d) Other comment

The Normalization of Deviance

Like many pilots, I read accident reports all the time. This may seem morbid to people outside “the biz”, but those of us on the inside know that learning what went wrong is an important step in avoiding the fate suffered by those aviators. And after fifteen years in the flying business, the NTSB’s recently-released report on the 2014 Gulfstream IV crash in Bedford, Massachusetts is one of the most disturbing I’ve ever laid eyes on.

If you’re not familiar with the accident, it’s quite simple to explain: the highly experienced crew of a Gulfstream IV-SP attempted to takeoff with the gust lock (often referred to as a “control lock”) engaged. The aircraft exited the end of the runway and broke apart when it encountered a steep culvert. The ensuing fire killed all aboard.

Sounds pretty open-and shut, doesn’t it? There have been dozens of accidents caused by the flight crew’s failure to remove the gust/control lock prior to flight. Professional test pilots have done it on multiple occasions, ranging from the prototype B-17 bomber in 1935 to the DHC-4 Caribou in 1992. But in this case, the NTSB report details a long series of actions and habitual behaviors which are so far beyond the pale that they defy the standard description of “pilot error”.

Just the Facts

Let me summarize the ten most pertinent errors and omissions of this incident for you:

  1. There are five checklists which must be run prior to flying. The pilots ran none of them. CVR data and pilot interviews revealed that checklists simply were not used. This was not an anomaly, it was standard operating procedure for them.
  2. Obviously the gust lock was not removed prior to flying. This is a very big, very visible, bright red handle which sticks up vertically right between the throttles and the flap handle. As the Simon & Chabris selective attention test demonstrates, it’s not necessarily hard to miss the gust lock handle protruding six inches above the rest of the center pedestal. But it’s also the precise reason we have checklists and procedures in the first place.
  3. Flight control checks were not performed on this flight, nor were they ever performed. Hundreds of flights worth of data from the FDR and pilot interviews confirm it.
  4. The crew received a Rudder Limit message indicating that the rudder’s load limiter had activated. This is abnormal. The crew saw the alert. We know this because it was verbalized. Action taken? None.
  5. The pilot flying (PF) was unable to push the power levers far enough forward to achieve takeoff thrust. Worse, he actually verbalized that he wasn’t able to get full power, yet continued the takeoff anyway.
  6. The pilot not flying (PNF) was supposed to monitor the engines and verbally call out when takeoff power was set. He failed to perform this task.
  7. Aerodynamics naturally move the elevator up (and therefore the control column aft) aft as the airplane accelerates. Gulfstream pilots are trained to look for this. It didn’t happen, and it wasn’t caught by either pilot.
  8. The pilot flying realized the gust lock was engaged, and said so verbally several times. At this point, the aircraft was traveling 128 knots had used 3,100 feet of runway; about 5,000 feet remained. In other words, they had plenty of time to abort the takeoff. They chose to continue anyway.
  9. One of the pilots pulled the flight power shutoff handle to remove hydraulic pressure from the flight controls in an attempt to release the gust lock while accelerating down the runway. The FPSOV was not designed for this purpose, and you won’t find any G-IV manual advocating this procedure. Because it doesn’t work.
  10. By the time they realized it wouldn’t work and began the abort attempt, it was too late. The aircraft was traveling at 162 knots (186 mph!) and only about 2,700 feet of pavement remained. The hydraulically-actuated ground spoilers — which greatly aid in stopping the aircraft by placing most of its weight back on the wheels to increase rolling resistance and braking efficiency — were no longer available because the crew had removed hydraulic power to the flight controls.

Industry Responses

Gulfstream has been sued by the victim’s families. Attorneys claim that the gust lock was defective, and that this is the primary reason for the crash. False. The gust lock is designed to prevent damage to the flight controls from wind gusts. It does that job admirably. It also prevents application of full takeoff power, but the fact that the pilot was able to physically push the power levers so far forward simply illustrates that anything can be broken if you put enough muscle into it.

The throttle portion of the gust lock may have failed to meet a technical certification requirement, but it was not the cause of the accident. The responsibility for ensuring the gust lock is disengaged prior to takeoff lies with the pilots, not the manufacturer of the airplane.

Gulfstream pilot and Code7700 author James Albright calls the crash involuntary manslaughter. I agree. This wasn’t a normal accident chain. The pilots knew what was wrong while there was still plenty of time to stop it. They had all the facts you and I have today. They chose to continue anyway. It’s the most inexplicable thing I’ve yet seen a professional pilot do, and I’ve seen a lot of crazy things. If locked flight controls don’t prompt a takeoff abort, nothing will.

Albright’s analysis is outstanding: direct and factual. I predict there will be no shortage of articles and opinions on this accident. It will be pointed to and discussed for years as a bright, shining example of how not to operate an aircraft.

In response to the crash, former NTSB member John Goglia has called for video cameras in the cockpit, with footage to be regularly reviewed to ensure pilots are completing checklists. Despite the good intentions, this proposal would not achieve the desired end. Pilots are already work in the presence of cockpit voice recorders, flight data recorders, ATC communication recording, radar data recording, and more. If a pilot needs to be videotaped too, I’d respectfully suggest that this person should be relieved of duty. No, the problem here is not going to be solved by hauling Big Brother further into the cockpit.

A better model would be that of the FOQA program, where information from flight data recorders is downloaded and analyzed periodically in a no-hazard environment. The pilots, the company, and the FAA each get something valuable. It’s less stick, more carrot. I would also add that this sort of program is in keeping with the Fed’s recent emphasis on compliance over enforcement action.

The Normalization of Deviance

What I, and probably you, are most interested in is determining how well-respected, experienced, and accomplished pilots who’ve been through the best training the industry has to offer reached the point where their performance is so bad that a CFI wouldn’t accept it from a primary student on their very first flight.

After reading through the litany of errors and malfeasance present in this accident report, it’s tempting to brush the whole thing off and say “this could never happen to me.” I sincerely believe doing so would be a grave mistake. It absolutely can happen to any of us, just as it has to plenty of well-trained, experienced, intelligent pilots. Test pilots. People who are much better than you or I will ever be.

But how? Clearly the Bedford pilots were capable of following proper procedures, and did so at carefully selected times: at recurrent training events, during IS-BAO audits, on checkrides, and various other occasions.

Goglia, Albright, the NTSB, and others are focusing on “complacency” as a root cause, but I believe there’s a better explanation. The true accident chain on this crash formed over a long, long period of time — decades, most likely — through a process known as the normalization of deviance.

Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety. People grow more accustomed to the deviant behavior the more it occurs. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

This concept was developed by sociologist and Columbia University professor Diane Vaughan after the Challenger explosion. NASA fell victim to it in 1986, and then got hit again when the Columbia disaster occurred in 2003. If they couldn’t escape its clutches, you might wonder what hope we have. Well, for one thing, spaceflight in general and the shuttle program in particular are specialized, experimental types of flying. They demand acceptance of a far higher risk profile than corporate, charter, and private aviation.

I believe the first step in avoiding “normalization of deviance” is awareness, just as admitting you have a problem is the first step in recovery from substance addiction. After all, if you can’t detect the presence of a problem, how can you possibly fix it?

There are several factors which tend to sprout normalization of deviance:

  • First and foremost is the attitude that rules are stupid and/or inefficient. Pilots, who tend to be independent Type A personalities anyway, often develop shortcuts or workarounds when the checklist, regulation, training, or professional standard seems inefficient. Example: the boss in on board and we can’t sit here for several minutes running checklists; I did a cockpit flow, so let’s just get going!
  • Sometimes pilots learn a deviation without realizing it. Formalized training only covers part of what an aviator needs to know to fly in the real world. The rest comes from senior pilots, training captains, and tribal knowledge. What’s taught is not always correct.
  • Often, the internal justification for cognizant rule breaking includes the “good” of the company or customer, often where the rule or standard is perceived as counterproductive. In the case of corporate or charter flying, it’s the argument that the passenger shouldn’t have to (or doesn’t want to) wait. I’ve seen examples of pilots starting engines while the passengers are still boarding, or while the copilot is still loading luggage. Are we at war? Under threat of physical attack? Is there some reason a 2 minute delay is going to cause the world to stop turning?
  • The last step in the process is silence. Co-workers are afraid to speak up, and understandably so. The cockpit is already a small place. It gets a lot smaller when disagreements start to brew between crew members. In the case of contract pilots, it may result in the loss of a regular customer. Unfortunately, the likelihood that rule violations will become normalized increases if those who see them refuse to intervene.

The normalization of deviance can be stopped, but doing so is neither easy or comfortable. It requires a willingness to confront such deviance when it is seen, lest it metastasize to the point we read about in the Bedford NTSB report. It also requires buy-in from pilots on the procedures and training they receive. When those things are viewed as “checking a box” rather than bona fide safety elements, it becomes natural to downplay their importance.

Many of you know I am not exactly a fan of the Part 121 airline scene, but it’s hard to argue with the success airlines have had in this area. When I flew for Dynamic Aviation’s California Medfly operation here in Southern California, procedures and checklists were followed with that level of precision and dedication. As a result, the CMF program has logged several decades of safe operation despite the high-risk nature of the job.

Whether you’re flying friends & family, pallets of cargo, or the general public, we all have the same basic goal: to aviate without ending up in an embarrassing NTSB report whose facts leave no doubt about how badly we screwed up. The normalization of deviance is like corrosion: an insidious, ever-present, naturally occurring enemy which will weaken and eventually destroy us. If we let it.

Ron Rapp is a Southern California-based charter pilot, aerobatic CFI, and aircraft owner whose 9,000+ hours have encompassed everything from homebuilts to business jets. He’s written mile-long messages in the air as a Skytyper, crop-dusted with ex-military King Airs, flown across oceans in a Gulfstream IV, and tumbled through the air in his Pitts S-2B. Visit Ron’s website.

The Day After the Holiday: Flying Home Safely

The day before a holiday, given there are blue skies, is a silly, noisy day in the airpark. People are on the move. My pilot neighbors who have decided to fly to family are loading up and heading out, sometimes en masse, wisely using their aircraft to avoid what can be dangerously packed highways of travelers, and miserably packed commercial airline flights.

Funny, I don’t worry so much about them on the day they leave out of here. The day after the holiday, though, I admit to fretting a little. Why? Statistics.

Weather is the great delineator on the flight home after a holiday.

Weather is the great delineator on the flight home after a holiday.

It is much easier to decide to stay home for the holidays when you are still in your driveway, contemplating the weather, than it

is to imagine staying on at Aunt Fran’s or Grandma’s, where you may be packed into an expensive hotel room, or maybe the basement spare bedroom (probably no wifi down there, either). The NTSB annals are full of accidents and incidents that happen on the backside of the holiday curve, when people are saturated with food, family, good times, and sometimes rushing to get back for work, school or other ordinary pressures. Suddenly pilots everywhere feel that pinch at the base of the neck and catch themselves almost universally thinking, “Well, maybe the weather isn’t really that bad. Maybe the ice won’t be there, maybe the thunderstorms will drift off the route… and maybe the winds aren’t as strong as they are forecasting.”

That is the essence of get-home-itis, and there is not a one of us immune to it. Pilots can, however, allow common sense to sit on the other shoulder and balance such musings. For every “maybe the forecast is off,” one has to imagine “yeah, it could be turn out worse than what they are saying.” After all, a forecast is only a guess of how the weather gods will play out the day. A sophisticated guess based on lots of data, but a guess, nevertheless.

For every “I have got to get home and be at work tomorrow,” there has to be, “this is what personal days and telecommuting are made for.” Building a weather day or two into holiday vacations can alleviate all of these ruminations. I do it as a matter of course. The plus is that if I get home the day I expected to get home I have a day to decompress before ordinary life reaches out and grabs me again. And if I need the extra day because home or en route weather is bad? Well, I’ve got it.

Another good hedge is a back up plan, such as refundable airline tickets (yep, pricey, but only if you need to use them), or a car rental that you can cancel last minute. I’ve used them both to get where I needed to be when the weather prevented me from flying myself.

And what about the “look-see” approach to flying on marginal or worse weather days? 14 CFR Part 91 leaves pilots a lot of leeway on planning flights when the weather might not be at minimums upon reaching the destination. I’m pragmatic on this one. If you are a current pilot in a well-equipped aircraft who has lots of experience with the type of weather you’d like to “look-see” well, run it through your common sense rubric. If it passes, plan the flight with several “outs,” places you’ll divert to if needed. The go ahead and give the flight a try. Weather is a dynamic beast, and conditions may be better than forecast, or worse. You’ll know when you are up there, hopefully deviating around it or diverting to avoid it. Good luck.

Ultimately the key to short circuiting the day-after get-home-itis syndrome in aviation is proper planning, preparation, and of course, a realistic understanding of your aircraft and your own capabilities. Pilots, know thyself. Fly safe out there!

Amy Laboda has been writing, editing and publishing print materials for more than 28 years on an international scale. From conception to design to production, Laboda helps businesses and associations communicate through various media with their clients, valued donors, or struggling students who aspire to earn scholarships and one day lead. An ATP-rated pilot with multiple flight instructor ratings, Laboda enjoys flying her two experimental aircraft and being active in the airpark community in which she lives.

See & Avoid Doesn’t Work

Contemplate the worst scenario that might confront a pilot during a flight. What comes to mind? Fire? Flight control failure? Engine failure? Perhaps it’s flight crew incapacitation, explosive decompression or severe structural damage.

No doubt about it, those all fall into the Very Bad Day category. But there’s one that can be even worse: a mid-air collision. That’s because it can involve all the problems listed above — at the same time. And since the parties involved aren’t aware of the impending crunch until it’s too late, the mid-air is usually accompanied by a violent element of surprise, confusion, and initial denial.

You might think fatal mid-airs are rare events, and from a purely statistical standpoint I’d have to agree. According to the 2010 Nall Report, a fatal mid-air occurs about once every 8 million flight hours. Think of it as the roughly the same odds as winning the lottery or being struck by lighting. Doesn’t sound so bad, does it? A typical GA pilot might accumulate but thousand or so hours over a full lifetime of flying.

So what’s there to worry about? Plenty. The “big sky” theory may sound good, but it doesn’t hold up very well under close scrutiny. It’s true that the navigable atmosphere over the United States alone is massive — about 20 million cubic miles — and there are relatively few airplanes in the sky. Even on those occasions where a collision is possible, modern tools such as radar, TCAS, VHF communication, and anywhere between two and four sets of eyeballs almost always succeed in averting the disaster. If aircraft were equally distributed throughout the atmosphere, the “big sky” idea would be pretty comforting.

But airplanes cluster near airports, large cities, and on thin slices of the sky known as “airways”. For the VFR types, airspace and terrain often crowd planes into small swaths of the air in places like the Santa Ana Canyon or Banning Pass. The sky is much like the ground: vehicles stick to relatively confined spaces and that makes collisions a serious hazard.

Since we’re on the topic of statistics, let me give you a few of my own: I personally know two people who have been struck by lightning, and a winning lottery ticket was recently sold not 300 feet from my front door. Hey, crazy stuff happens. But unlike lighting strikes and golden tickets, we’re not all facing the same odds. The risk profile varies widely depending on the type of flying you’re doing.

For example, flight instruction is frequently a factor; thirty-seven percent of mid-airs occur with a CFI on board. Many instructional flights happen near airports, and as previously mentioned, that’s where other airplanes tend to congregate. On the other hand, if you fly airliners, your risk of a mid-air is rather low because the aircraft itself is large and easy to see, you’re always flying IFR, and the most sophisticated traffic avoidance hardware available is always installed. Airliners also spend most of their time in cruise and are in constant radar contact with ATC.

Midair collisions are almost as old as powered flight itself.  This B-17 collided with a German fighter over Tunisia in 1943.

Midair collisions are almost as old as powered flight itself. This B-17 collided with a German fighter over Tunisia in 1943.

Think it can’t happen to you? Think again. Some very talented, capable, and well-respected pilots have been involved in mid-air collisions. I know a guy who was involved in one while flying a large-cabin, TCAS-equipped business jet under Instrument Flight Rules. Alan Klapmeier, the founder of Cirrus Aircraft, was in one too. Richard Collins, famed Flying columnist, was in a mid-air. Speaking of Flying, the recent Editor-in-Chief owns a very nice Cirrus SR-22 which was in a mid-air. And lastly, a decade ago I was in a mid-air collision myself.

I’ll save the blow-by-blow (no pun intended) on that for another day. The point I’m trying to make is that the odds of a mid-air are probably greater than you think, especially if you live in a populated metropolitan area and fly VFR. If you’ve ever had a close encounter with another airplane in flight, you were only separated from “those who have” by nothing more than a miniscule sliver of plain old luck.

Think about that for a moment.

This may be hard to believe, but there is some good news. For one thing, mid-airs are not always fatal. It seems intuitive that most collisions would involve fatalities, but all the people I cited above survived, including (obviously) myself. Also, technology is rapidly advancing, from cheap TCAD boxes to airframe parachutes to super-bright LED exterior lighting.

The question we should all be asking ourselves is how we avoid ending up in a mid-air, fatal or otherwise. If you refer to official guidance from the FAA, the answer is to simply look out the window and spot the other airplane before it hits you. This technique, referred to as “see and avoid”, is still considered adequate for preventing collisions. Here are a couple of passages from Chapter 1 of the Airplane Flying Handbook:

The “See and Avoid” concept relies on knowledge of the limitations of the human eye, and the use of proper visual scanning techniques to help compensate for these limitations. The importance of, and the proper techniques for, visual scanning should be taught to a student pilot at the very beginning of flight training.

Proper clearing procedures, combined with proper visual scanning techniques, are the most
effective strategy for collision avoidance.

Other FAA publications, ranging from the Aeronautical Information Manual, to Advisory Circulars like AC-90-48 (“Pilot’s Role in Collision Avoidance”) will give you the same spiel: “see and avoid will keep you safe”. And it will! Until it doesn’t.

From my perspective as someone who’s been in a mid-air and who was using proper clearing and scanning techniques at the time, I take it as gospel that “see & avoid” won’t always do the trick. I’m just one guy, of course. But many others — some institutional in nature — just happen to agree with me.

For example, a couple of years ago Canada’s Transportation Safety Board issued an accident report on a mid-air collision between a Beech V-35B Bonanza and a PA-28 Cherokee over northern Virginia. Canada was tasked with performing the investigation because the pilots of the Bonanza were employees of the NTSB while the Cherokee was piloted by an employee of the FAA.

I won’t keep you in suspense. The conclusion from the TSB was that the “see and avoid” concept was inadequate. They even quoted a 1991 report produced by the Australian Transport Safety Bureau which provides an overview of the major factors that limit the effectiveness of the see-and-avoid principle in preventing mid-air collisions, as well as a 2005 scientific study published in Aviation, Space, and Environmental Medicine which came to the same conclusions.

The main points:

  • Cockpit workload and other factors reduce the time that pilots spend in traffic scans, and even when pilots are looking out, there is no guarantee that other aircraft will be sighted.
  • Visual scanning involves moving the eyes in order to bring successive areas of the visual field onto the small area of sharp vision in the center of the eye. The process is frequently unsystematic and may leave large areas of the field of view unsearched.
  • A thorough, systematic search is not a solution as in most cases it would take an impractical amount of time.
  • The physical limitations of the human eye are such that even the most careful search does not guarantee that traffic will be sighted.
  • The pilot’s functional visual field contracts under conditions of stress or increased workload. The resulting ‘tunnel vision’ reduces the chance that an approaching aircraft will be seen in peripheral vision.
  • The human visual system is better at detecting moving targets than stationary targets, yet in most cases, an aircraft on a collision course appears as a stationary target in the pilot’s visual field.
  • An approaching aircraft, in many cases, presents a very small visual angle until a short time before impact.
  • Complex backgrounds such as ground features or clouds hamper the identification of aircraft via a visual effect known as ‘contour interaction’. This occurs when background contours interact with the form of the aircraft, producing a less distinct image.
  • Even when an approaching aircraft has been sighted, there is no guarantee that evasive action will be successful.
  • Because of its many limitations, the see-and-avoid concept should not be expected to fulfill a significant role in future air traffic systems.
  • Transportation Safety Board of Canada aviation investigation report A06O0206 identified that there is a high risk of mid-air collisions in congested airspace when aircraft are not alerted to the presence of other aircraft and rely solely on the see‑and-avoid principle.

There’s one more area of the TSB report which is worth of quotation. In it, they reference a British Royal Air Force study into mid-air collisions. If you’re keeping score, that’s the third sovereign agency to reach the conclusion that “see and avoid” is inadequate. Yet our own FAA, which oversees about 80% of the world’s aircraft and almost all of the high traffic density airspace, still officially proclaims that one can look out the window and see everything that needs to be seen.

This accident has demonstrated yet again that relying solely on the see-and-avoid principle to avoid collisions between aircraft operating under visual flight rules (VFR) in congested airspace is inadequate.

A number of international studies have addressed the overall issue of the effectiveness of the see-and-avoid principle, as well as the risks of collision associated with this principle. All acknowledged the underlying physiological limitations at play and that, when mid-air collisions occur, “failure to see-and-avoid is due almost entirely to the failure to see.”

One study stated that “our data suggest that the relatively low (though unacceptable) rate of mid-air collisions in general aviation aircraft not equipped with TCAS [traffic alert and collision avoidance system] is as much a function of the ‘big sky’ as it is of effective visual scanning.”

A British Royal Air Force study into mid-air collisions, which were deemed to be random, found that the probability of conflict is proportional to the square of the traffic density, and recommended avoiding altitude restrictions that concentrate traffic.

Measures such as improving aircraft conspicuity, pilot scanning techniques, and pilot traffic awareness can reduce risks, but they do not overcome the underlying physiological limitations that create the residual risk associated with a see-and-avoid method.

It’s obvious that “see and avoid” cannot, by itself, ensure our safety. If it could, there’d be no need for TCAS or most of our controlled airspace (both of which came about because of high-profile mid-air collisions, I might add!). I’m not necessarily in favor of mandating any additional equipment, airspace, or restrictions, especially on general aviation. But it’s clear that serious changes are needed in how collision avoidance is taught, especially as it concerns “see and avoid”. The concept has serious limitations which must be understood so the pilot-in-command can make educated decisions about how — or even if — they want to mitigate those risks.

I sincerely hope our nation’s regulatory and safety organizations will eventually acknowledge what we all know to be true: “see and avoid”, while a good start and certainly a vital part of collision avoidance, is simply not sufficient to ensure traffic separation.

Ron Rapp is a Southern California-based charter pilot, aerobatic CFI, and aircraft owner whose 9,000+ hours have encompassed everything from homebuilts to business jets. He’s written mile-long messages in the air as a Skytyper, crop-dusted with ex-military King Airs, flown across oceans in a Gulfstream IV, and tumbled through the air in his Pitts S-2B. Visit Ron’s website.
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