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The Human Factor: It Takes Only a Second

Sometimes all it takes for a fatal aircraft accident is one critical mistake.

(March 2012) Slipping gradually toward an accident is very common, but it is not the only way accidents happen. At the opposite end of the spectrum lie accidents in which a pilot who has always flown in a safe and professional manner makes one critical mistake. One area in which this type of accident is prevalent is controlled flight into terrain (CFIT). This type of accident can be the result of a pilot gradually getting used to flying lower and lower just for the thrill of it. However, it can also result from one isolated failure to keep track of the terrain, usually during a night flight. This is especially common here in the Southwest, where the general elevation of the terrain can be much higher than anticipated and sharp peaks often poke up out of otherwise level terrain.

CFIT
There are quite a few examples of experienced pilots colliding with terrain. In November 2007, two Civil Air Patrol pilots with a total of 53,000 hours of flight time and just about every certificate and rating available flew a new Cessna 182T with a Garmin G1000 glass cockpit into an 8,000-foot mountain 1,000 feet below the summit on a clear night. They were likely distracted because one pilot was demonstrating how to work the G1000 to the other pilot and failed to adequately plan the flight, including checking for terrain.

In November 2011, an experienced pilot took off just after dark in a Rockwell 690A and flew into a mountain east of Mesa, Arizona, minutes later, killing the three adults and three children on board. The high-performance airplane was reported to be a recent purchase by the copilot, and the FAA had recently altered the Class B airspace east of Mesa, reducing the clearance above the mountains for pilots departing to the east without getting a clearance through Class B airspace from ATC.

Scud Running
Another common accident involves a very experienced professional pilot attempting to scud-run rather than filing an instrument flight plan.

An ATP-rated pilot with 33,000 hours and seven type ratings in transport category airplanes hit a hilltop at an elevation of 2,500 feet. The pilot had left the Commander 680 at Palm Springs the day before due to bad weather at his planned destination in Chino, California. The next day he returned to Palm Springs to fly the airplane the 63 nm back to Chino. The weather was VFR at Palm Springs, but his route through the Banning Pass was obscured by dark clouds. The pilot had almost made it through the pass flying at altitudes as low as 700 agl when he turned southwest to avoid an area of moderate to heavy rain. He had just requested an IFR clearance when he impacted a small peak that rises 1,000 feet above the valley floor.

In November 2009, an ATP-rated pilot with 14,000 hours who was also a designated pilot examiner flew into a mountain in upstate New York at 4,000 feet elevation, about 600 feet below the mountain peak. The pilot was returning home after administering a check ride. He was flying the Piper Cherokee 140 visually at night in a mountainous area in which there were patchy low clouds, haze and fog.

In February 2008, a 21,000-hour airline captain crashed in a 1948 Cessna 140 he had just purchased. The airplane was equipped with a venturi powered turn-and-bank indicator, and the pilot was using a handheld GPS for navigation. The pilot took off under a 1,500-foot ceiling with just over a mile visibility in light snow and continued into an area of 400-foot overcast skies and 1.5-mile visibility in mist with a one-degree temperature/dew point spread and an advisory for moderate icing below 8,000 feet. The GPS showed that the pilot turned and climbed abruptly just short of a wind turbine farm with blades that reached into the overcast. He then made several figure-eight turns in the clouds before crashing next to the wind turbines.

Deviating From Rules
It is just as sad when a newly minted private pilot makes what appears to be an isolated decision to break the rules. In June 2010, the 25-year-old pilot had 100 hours when he rented a Piper Arrow to give three friends a ride before a family picnic later that afternoon. His instructor said that the pilot had always respected the FARs and that he had never observed him operating in a reckless manner. He also said they had never done any low flying during dual instruction. The instructor had signed him off for solo with fewer hours than are usually required due to his “proven skill and ability to make safe decisions.” Several witnesses observed the airplane flying as low as 50 feet above a local river and stated that it barely cleared a ridge near their house. After a three-day search, the wreckage was found on a steep hillside in a canyon.

Distractions
Sometimes it is a momentary distraction that leads to a fatal mistake like in this January 2007 accident in which the copilot was talking with a bystander as he loaded the baggage into the CitationJet prior to departure and apparently neglected to lock the door, which opened just after the airplane lifted off. The NTSB determined that while some debris did enter the right engine, both engines were still operating, but the pilot failed to maintain adequate airspeed, leading to an inadvertent stall and spin.

These accidents illustrate some of the areas that can cause problems for an otherwise careful pilot:

Unfamiliar Airplane or Equipment
It is a basic tenet of error prevention that, if you are flying an airplane that is unfamiliar to you, you will be distracted. No matter how hard you work to prepare to fly that airplane, there is no way that you can match the easy familiarity that comes only after hundreds of hours in an airplane. Flight planning will take longer because you won’t have simple rules of thumb to fall back on for fuel flows and weight and balance computations. In flight, you have to stop and think where a switch is located or how a system works. All this results in a reduction in overall situational awareness. If the airplane has more performance than you are used to or more-sophisticated avionics, you may also be lulled into complacency by these new capabilities, even though you are not competent enough to really take advantage of them yet.

Less-Sophisticated Equipment
Different factors come into play when a pilot used to flying advanced technology and/or transport category aircraft flies an older, simpler airplane. A study by the Dutch National Aerospace Laboratory showed that people working with old technology systems were more likely to not adhere to procedures than when they were working with the latest equipment.

Repositioning Flights
Pilots sometimes skip flight planning and abbreviate checklists when they are “just doing a short hop.”

Local Flights
If you are used to flying long trips in difficult weather conditions, it can seem like it is silly to put much effort into planning a local flight on a clear day.

Only as Good as Your Last Flight
It’s been said that we are only as good, safe and professional as we are on our last flight. You can fly hundreds or even thousands of hours safely, but if you make a critical mistake or do something stupid on your next flight, that one moment in time can have a devastating outcome that completely negates years of flying safely. No matter how simple or sophisticated the equipment is — whether you are flying across town or across the country — it is critical to approach each flight with the same attitude of aggressive skepticism that actively seeks out the traps and pitfalls that can trip up a pilot who is not paying attention.

Obviously a trip across town on a clear day won’t require nearly as much thought and planning as a trip across the country in challenging weather conditions, but it is still good to go through a basic but complete analysis of aircraft performance, weather, airspace restrictions and terrain as required by FAR 91.103. Then carry that professional approach over into your preflight and on into each phase of the flight. That way you can enjoy the flight knowing that you have covered all the bases so that there shouldn’t be any surprises, and your professional attitude will help you fight off any temptation to cut corners or operate in an unprofessional or risky manner. It may take a few extra minutes to do things right, but it takes only a second to ruin a safe flying record.

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