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Chain Of Events

Lufthansa Aerial Solutions is working with UAS-maker DJI to develop new uses for drones. DJI
Gemini Sparkle

Key Takeaways:

  • A fatal Cessna 172 accident resulted from a power interruption caused by water-contaminated fuel from a leaking tank, leading to an aborted go-around and hard landing.
  • The pilot's fatality was largely due to not wearing his seatbelt and shoulder harness, an omission possibly linked to pre-landing distractions and an incomplete checklist, making an otherwise survivable accident deadly.
  • The incident highlights the "chain of events" concept, where mechanical issues (fuel contamination) combined with human factors (inadequate response to pre-flight findings, unsecured seatbelt) to create a catastrophic outcome.
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Anyone familiar with accident investigation likely has heard the phrase “chain of events.” It refers to any number of factors contributing to the accident or its severity. Of course, the vast majority of accidents result from one or more mistakes made by a human, generally referred to as pilot error. Mechanical causes pose much less risk but, once they occur, can contribute to the pilot making a mistake in responding to the failure or mishandling the aircraft. An example of the latter might be the pilot who is so happy they made it to a suitable runway after an engine failure that they forget to extend the landing gear.

One of the best defenses against pilot error is standardization, followed closely by its first cousin, experience. Correctly performing tasks the same way every time is an example of standardization, while knowing when to go back and start over if a checklist is interrupted is a mark of experience. Standardization can be taught, beginning with primary training, but experience can be a hard-earned badge, often gained by—you guessed it—standardizing tasks and procedures, even in the midst of major distractions.

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