April 1 , 2010
In this Issue
SAFETY OUTREACH STATUS

I have slowed things down a bit on the outreach front to allow for some vacation and other travel. April will continue to be sparse but I hope to pick up the pace again in May.

But, I have managed to do a few activities. I ran a webinar on March 8 concerning fuel related accidents. That event carried an apparently excessive fee of $3.95 and drew only 11 attendees. A free event was held March 25 on maneuvering flight. It was marketed to the remaining half of the FAA Eastern region and drew 208 attendees. (The other half was covered by a Feb. 25 event.)

March also saw the completion of the third round of my recurrent ground school. I managed to get make-up sessions online to accommodate folks who have to miss a session. I am waiting to schedule more webinars and the next round of the ground school till I get a couple of personal schedule items worked out. I hope to be scheduling more events by mid April to occur in May. Click here to be notified when the recurrent ground school is scheduled.

I have added a new FAA accredited course to my online offerings. In addition to getting the CFIT courses online as I reported in March, I now have approval to offer a course titled, "The Psychology of Approach and Landing." It is valid for one Wings Knowledge-Elective-Master Credit and has a fee of $9.95.

I have now presented webinars to well over 2000 people. The mailing list for this newsletter passed the 1000 mark with this issue. I am grateful to all of you who have shown interest in my safety outreach and who have participated in events. I am especially grateful to those of you who have participated in the fee-based events and/or have purchased online courses or products.

OPERATIONAL TIP

We recently passed through Chicago's O'Hare Airport while traveling via airline between Rochester, NY and Tucson, AZ. Thousands of people hustle through the concourses making their way to and from the various gates. The vast majority of those folks move along keeping to the right side of the concourse as they would if driving on the highway. But, there's always the exception. One person was standing stationary smack in the middle of the high traffic pedestrian lane with suitcase aligned perpendicular to the concourse and having an animated mobile phone conversation. I thought how glad I was that that person was a passenger and, as far as I know, not a pilot since absolutely no evidence of situational awareness was present.

We have all been taught the importance of maintaining situational awareness when we exercise the privileges of our pilot certificates. But telling a pilot to maintain situational awareness, or simply SA, is like telling someone to drive safely when they leave the house. Most people have the intention to drive safely and most pilots have the intention to maintain SA. The lacking element is in telling someone how to drive safely or how to maintain SA.

Maintaining situational awareness is easier in a multi-crew environment when we can keep tabs on each other. It is more difficult in the single pilot operation and that is what we will focus on here.

There isn't one silver bullet for maintaining SA but there are some things that a pilot can do to help prevent the loss of SA. One of those is to maintain a high level of proficiency. Another is to be proactive in avoiding flight while fatigued. A relatively minor distraction is much more likely to lead to a loss of SA when the pilot is suffering from fatigue. Be well-rested if possible. Practical considerations sometimes interfere with that so insist on a snack and a 15 minute nap before flight. Recent evidence points to very significant benefits to the brief power nap.

Yet another technique is the use of the 5P model. It should be used before flight and then every 10 to 15 minutes during flight. The 5 P model works like this:

  1. Plan—planning, weather, route, fuel, publications, ATC reroutes/delays.
  2. Plane—mechanical status, database currency, automation status, backup systems.
  3. Pilot—illness, medication, stress, alcohol, fatigue, eating.
  4. Passengers—pilot or non-pilot, experienced or inexperienced, nervous or calm, etc.
  5. Programming—GPS, autopilot, PFD/MFD, possible reroutes requiring reprogramming.

Red flags raised and corrected by using the 5P model during flight planning can go a very long way toward preventing loss of SA during flight. Obviously, once in flight, items such as database currency, medication and alcohol shouldn't play a role but fatigue, stress, and eating should be re-evaluated as the flight progresses.

Let's look at some things that might signal a diminished situational awareness:

  • confusion or a gut feeling that something isn't right
  • a temptation to depart from standard procedures or regulations
  • unresolved discrepancies (two or more pieces of information do not agree)
  • fixation or preoccupation
  • failure to achieve expected aircraft or navigation performance

Immediate corrective action should be taken as soon as any one of these conditions is noted. The nature of the corrective action must depend on the situation. It is critical to maintain aircraft control and remain clear of terrain and obstacles regardless of what else is going on. If SA is in doubt during an approach, whether VFR or IFR it might be prudent to execute a missed approach or go-around to provide time to get back into the game. Sometimes attempting to state the problem out loud can help organize thoughts.

If a loss of situational awareness has been experienced and corrected, it might be wise to land at the nearest suitable airport and spend some time decompressing before continuing the flight. As already stated, fatigue and stress are frequent thieves of SA. A 15 minute power nap, a snack and some water can do wonders to provide a fresh start.

There is much more to be said about situational awareness in the single pilot environment. Look for a complete course in the future.

Accident Discussions
Accidents discussed in this section are presented in the hope that pilots can learn from the mistakes of others and perhaps avoid repeating those mistakes. It is easy to read an accident report and dismiss the cause as carelessness or a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
VFR Accident NTSB Record: WPR09CA120

This accident illustrates a loss of situational awareness caused by a distraction. The pilot and sole occupant of the Piper Comanche was uninjured but the airplane was destroyed by a post-crash fire.

The pilot reported that during departure on a local night flight, the airplane's door popped open. He turned to downwind and attempted to close the door. While on downwind, the airport's pilot activated runway lights turned off. The pilot then had to reactivate the runway lights and he landed the airplane without extending the landing gear. Subsequently, the airplane caught fire and was consumed.

The pilot lost situational awareness (awareness of the airplane configuration) due to the distraction of the door popping open. A distraction such this is a common cause of loss of situational awareness. How can we maintain situational awareness in the face of a distraction? One way is to think through and perhaps write down some procedures to be used in abnormal situations. The airlines have "emergency procedures" and "abnormal procedures." (For more on creating your own abnormal procedures, click here.) This airplane would have flown just fine with the door ajar so the situation was "abnormal" rather than "emergency."

Another way to help maintain situational awareness is to avoid flying when fatigued. We don't know if fatigue was a factor in this accident, but it was a night flight. What had the pilot's day been like? A short 10 or 15 minute nap can restore alertness for three to four hours.

Click here to read the full accident report.

IFR Accident NTSB Record: DFW08FA080

On March 10, 2008 at about 2023 local time a Cessna T210 suffered loss of control and collided with terrain while conducting an instrument approach to Lafayette, Louisiana. The commercial pilot and his passenger were fatally injured.

No abnormalities were discovered with the airplane, the engine, or any systems. The conditions at the time of the accident included dark skies, light to moderate rain and light to moderate turbulence.

The pilot had started the day by flying two passengers to a business meeting, departing at 0754. On the return flight, he dropped one passenger off at Baton Rouge and departed for Lafayette at approximately 1948 local time. ATC had first vectored the airplane for a visual approach to runway 29, but the pilot did not visually acquire the runway and subsequently accepted an Instrument Landing System (ILS) approach to runway 04R. The last radio transmission from the pilot was his acknowledgement for a heading of 335 degrees. Radar plots displayed the airplane turning through the assigned heading of 335 degrees while in a clockwise turn. The pilot did not respond to subsequent ATC directions. The last radar plot at 2023 shows the airplane heading approximately 046 degrees at an altitude of 1,600 feet and a ground speed of 207 knots.

The pilot's "time-on-duty" had been about 12 hours 29 minutes. It is unknown when the pilot ate and how long he rested during the day of the accident. The pilot's wife reported that he normally went to bed between 2030 and 2130. Fatigue is a leading cause of lost situational awareness. The accident occurred after a long day and at about the time that the pilot usually went to bed. He had been flying in dark, rainy, turbulent conditions which are more likely to produce fatigue than day VFR conditions.

By all accounts, this pilot was proficient and cautious yet he was pilot-in-command of a flight with a tragic ending. We can't know for sure, but the evidence points to loss of situational awareness mainly due to fatigue. How can we avoid ending up the same way? We can make sure that we are rested before a flight, especially one involving single-pilot, night, IFR operations. We have to be pilots first and foremost. Regardless of the external pressures we must insist on rest, food, and water before we depart.

Click here to read the full accident report.

COMMENTARY

This issue of "Vectors for Safety" includes an article about how to help prevent or deal with a loss of situational awareness. That article presupposes that a pilot is making a diligent effort to be safe. There are pilots among us (though I'm sure not among the readers of this publication) who do not make safety a priority. I can't be sure but I can guess that these pilots would also be inclined to text while driving, ride a motorcycle without wearing a helmet, chisel stone without eye protection, or replace an electrical outlet without switching off the power. FAA publications discuss personality types and how some may be inclined toward risky behavior. Beyond those personality types we find that some people simply believe that they possess sufficiently superior skill and knowledge to avoid accidents. Some have gotten away with progressively greater safety deviations and have become complacent. Still others are simply too lazy or to frugal to be safe.

No single pilot group has a lock on being complacent about maintaining situational awareness. A March 18 report from the NTSB tells the story of the Northwest Airlines flight crew who, in October of 2009, significantly over flew their destination after being out of radio communication for about an hour and seventeen minutes. Why? They were distracted with a discussion about new bidding procedures and were using their laptop computers contrary to company policy. The flight attendants had more situational awareness than the flight crew and ultimately got their attention. So much for a "professional" flight crew.

GA pilots also did not escape NTSB scrutiny. On March 9 a hearing was held regarding the disappointing safety results from the introduction of glass cockpits into general aviation. A final report on the extensive study is still pending but data cited during the hearing shows that airplanes with glass cockpits were actually more likely to be involved in loss of control and controlled flight into terrain (CFIT) accidents. I'm guessing that the report will show that both kinds of accidents involved VFR pilots flying into IFR conditions. Again risky behavior is showing. Perhaps pilots are falsely relying on the technology to provide situational awareness. The technology can help increase SA but it can't solely provide it. The NTSB also addressed the fact that many pilots are attempting to use the advanced equipment without sufficient training on the specific system.

The NTSB will ultimately make recommendations to the FAA. The regulators are watching. The insurance companies are watching. The media is watching. If this small group of risky behaving pilots continue to make the evening news with their misdeeds we will all pay the price in terms of greater regulation and higher insurance premiums. Perhaps if we are not afraid to speak up when we hear or see something that seems contrary to safety we can help turn the tide.

I also write a monthly safety column for cnyaviation.com. Click the banner below to visit that site.

CNY Aviation

 

Disclaimer:  Material contained in this newsletter and in this section is for informational purposes only.  It should not be construed as directive, doctrinal, or instructive.  Individuals should consult with their flight school management, certificated flight instructors, aircraft manufacturer recommendations and directives, Flight Standards District Office (FSDO) and/or appropriate FAA publications including the Aeronautical Information Manual (AIM), the Federal Aviation Regulations (FARs), and applicable FAA Advisory Circulars (ACs) for specific guidance relative to any information or before employing any recommendations contained in this newsletter.  Further, nothing on this web site or in this section is intended to contradict or be in disagreement with any official FAA rule or regulation, nor should such material be interpreted or construed as such.  This web site is intended exclusively to promote general aviation and to increase awareness of current events in aviation.
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