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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 student pilot's fatal accident was caused by an engine power interruption due to water-contaminated fuel, originating from a damaged and leaking fuel tank, during an aborted go-around.
  • The pilot's injuries were likely unsurvivable because he was not wearing his seatbelt, a possible consequence of in-flight distractions and an interrupted pre-landing checklist.
  • This tragedy underscores the importance of strict standardization and accumulated experience in aviation to minimize risks and prevent a "chain of events" from leading to catastrophic outcomes.
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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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