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First, please be sure to register for the upcoming webinar, "Checklists - Why? What? How?" I am presenting the same program three times on October 18. The sessions will be 3 PM, 8 PM, and 10 PM, all Eastern Daylight Time. Please convert to your own time zone if you are not in Eastern time. Click here to visit a page with more information on the webinar as well as the registration links. The webinar will introduce The Checklist Project that I wrote about last month. Click here for more information regarding The Checklist Project.
During the last week of September, I received an email from the folks running the FAA Wings program asking if it was OK to send out an email to all pilots registered on FAASafety.gov recommending that they take a look at the approach and landing material on my website. Of course I agreed. I had no idea what kind of response would follow. My website traffic was increased by about 30% for the last three days of the month. And, as of this writing, 1014 pilots over a three day period completed and received Wings credit for my online course "Psychology of Approach and Landing." All that additional traffic resulted in adding quite a few new subscribers to this newsletter, so if you are reading my rantings for the first time, welcome!
I'm presently working on my speaking schedule for 2012, so if you have an upcoming event and would like to have a lively presentation or an after dinner speaker who won't put the audience to sleep, let's have a conversation on how I might help. Contact me via email at gene@genebenson.com.
In other news, Cessna is facing a multi-million dollar fine proposed by the FAA for failing to follow quality control procedures at a manufacturing plant in
Chihuahua, Mexico. Among other problems, apparently a seven foot section of a Corvalis wing detached during a test flight being conducted by an FAA pilot. The portion of the wing skin unbonded from the forward spar. The airplane landed safely. The problem was traced to excessive humidity in the plant which prevented the bonded materials from curing properly. Cessna failed to follow its quality-control system when it manufactured the wings on the damaged airplane, as well as 82 additional parts, in the Chihuahua factory, the agency said. The manufacturer has since made improvements to the plant, FAA said. "Quality control is a critical part of the aircraft manufacturing process and has to detect problems before planes leave the factory," FAA Administrator Randy Babbitt said in a statement. "Manufacturers have to ensure that all the details are followed all of the time." Read my thoughts about this in the "Commentary" section of this newsletter.
Also, AOPA and EAA have teamed up to propose expanding the driver's license medical standard beyond LSA and into four seat aircraft up to 180 horsepower not flown for hire. Read more about this along with my thought in the "Commentary" section of this newsletter.
Finally, the FAASafety.gov website has received some much-needed upgrades. A number of bugs have been fixed and the site is easier to navigate. The FAA has been trying for more than a year now to figure how to do webinars and they aren't there yet. So, on September 12, I hosted a webinar in which Bryan Neville, the FAASTeam Outreach Manager, presented the website changes to FAASTeam Representatives across the country. The reps are generally a tough audience but they seemed to be generally pleased with the changes. If you haven't been to the website in a while, check it out at FAASafety.gov. |
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Last month I began a discussion of using checklists and I'm still on that rant so hang on. My inbox overflowed with comments which were overwhelmingly positive. Responses even included a few stories from pilots who had accidents or near misses which could have been avoided by better use of checklists. But a very few pilots expressed a distaste for checklists, stating that either they were so familiar with their airplane that they didn't need a checklist, or that their airplane was so simple that nothing could possibly be missed. It's a free country, as least for now, so if a pilot does not want to be burdened by using checklists, that is his or her right. But for the sake of family, friends, and especially passengers, I sincerely hope that those pilots will read on.
Let me counter both of those arguments with one personal story. I have been wearing pants with a zipper for more than sixty years. Let's say that I have worn those kind of pants for 99% of my days for sixty years. That is probably an underestimation since I'm just a couple of months short of my sixty-fifth birthday and I'm pretty sure I was potty trained well before my fifth birthday. So, not allowing for leap years during that time, that would yield 21,900 days. Now if I used the zipper an average of five times per day, that would show that I have logged 109,500 zipper uses. I think we can confidently say that a zipper is a simple device. Given my substantial experience with zippers on my pants and given that a zipper is a simple device, I should be quite expert in the proper operation of the zipper. But still, a couple of weeks ago my wife pointed out to me that I had neglected to close my zipper after using the restroom at Sam's Club. Of course, after visiting the restroom I had wandered the electronics section before meeting back with my wife. I'm sure somebody monitoring a security camera had a good chuckle. I'm just hoping I don't show up in one of those emails we all get.
So I would maintain that flying a simple airplane or being very familiar with an airplane does not exempt a pilot from the need to use checklists. If I can forget my zipper, a pilot can forget a fuel selector or trim. I would like to particularly address that comment to the experimental and amateur built communities. The number of accidents involving E-AB airplanes is disproportionately high to production airplanes given their much smaller representation in the general aviation fleet. Many amateur built airplanes are quite simple as compared to their production counterparts and certainly anyone who builds an airplane is very familiar with it. But simplicity and familiarity is not insurance against forgetting something. It is also true that many amateur built airplanes do not come with a checklist. That is a very poor excuse for not using one. A checklist should be tailored to the individual pilot anyway, so fire up the word processor and create. |
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. |
Accident Discussion - Simple Airplane NTSB Record: ERA09LA348 |
Does anybody really think you don't need to use a checklist in a simple airplane? Is any airplane more simple than an Aeronca 7AC? Here's an accident that probably would have been prevented had the pilot used a checklist.
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The certificated sport pilot lost control and collided with a ditch at Fairmont Municipal Airport, Fairmont, West Virginia. The pilot sustained serious injuries and the airplane was substantially damaged by impact forces. According to the NTSB report, the pilot stated that during the takeoff roll, the airplane "instantly" rolled on a 45-degree angle to the left and crashed into a ravine on the side of the runway. Examination of the airframe, flight control system, and engine components revealed no evidence of preimpact mechanical malfunction. During further examination, it was noted that the elevator trim was in the full nose-up position. When asked about this finding, the pilot stated that he had forgotten the trim in this position before and almost lost control during takeoff, but was able to continue flying the airplane. The airplane's "BEFORE TAKEOFF" checklist instructs the pilot to set pitch trim.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's failure to maintain control of the airplane during takeoff. Contributing to the accident was the pilot's inadequate use of the checklist.
So why didn't the pilot use the checklist? After all, he admitted that he had forgotten the trim before and narrowly avoided an accident. Either he was not adequately instructed in the importance of checklist use during his training, or he was surrounded by a culture that doesn't believe in checklists. Perhaps it was a bit of both. There is no indication in the NTSB report as to how long he had held a pilot certificate, but since he was a Sport Pilot, his certification was fairly recent. It would be interesting to know whether or not he was required to use a checklist by his instructor. I'm guessing that he was not. How sad that someone would be seriously injured by something as simple as forgetting to set the trim. Does anyone wonder why I'm advocating the use of checklists so strongly?
Click here to read the full accident report on the NTSB website.
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Accident Discussion - Complex Airplane NTSB Record: CHI08CA283 |
This accident resulted in only two minor injuries but could have been catastrophic had the pilot not been successful in maneuvering to land on an intersection where traffic was stopped. It involved a Mooney M20C and occurred in Illinois in September of 2008.
According to the NTSB report, the pilot reported that he performed a "runup" and switched the fuel tank selector to the fullest tank prior to takeoff on a cross-country flight. During takeoff the pilot retracted the landing gear, climbed to about 300 feet above ground level, and then encountered a loss of engine power. He stated that he banked left to avoid housing and landed the airplane at an intersection with stopped traffic. An airframe and powerplant mechanic that assisted the first responders stated that he found the fuel selector switch in the four o'clock position between the three o'clock right hand tank position and the six o'clock off position. An on-scene examination of the airplane revealed no other preimpact anomalies.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The non-mechanical loss of engine power due to the pilot's incorrect positioning of the fuel tank selector prior to takeoff and the subsequent fuel starvation during takeoff.
At first glance, this might not seem like an accident resulting from inadequate checklist use. The pilot did a run-up and then switched tanks just prior to departure. That's a huge no-no. Why? It's because if the fuel selector isn't positioned properly or if fuel isn't flowing properly for whatever reason, there is probably just enough fuel in the lines to allow the airplane to get airborne. That's exactly what happened here. The pilot probably did not follow a "Before Takeoff" checklist. He probably remembered to switch tanks just before he was ready to roll and went ahead and did it. Surely any good checklist would call for "Fuel - Fullest Tank" before calling for the engine run-up. This would allow fuel in the lines to be consumed during the run-up and any problem with fuel flow to be revealed before that takeoff run is begun. But, if the pilot was following a checklist, then that is a very poor checklist and it needs to be revised.
Click here to read the full accident report on the NTSB website. |
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FAA Administrator Randy Babbitt said, regarding Cessna's problem in their factory in Mexico, "Manufacturers have to ensure that all the details are followed all of the time." No kidding. For the price of a new Corvalis I would certainly hope that "all the details are followed all of the time." In fact, for the price of a new LSA I would have the same expectation. I do consulting work in error reduction for various industries. If anybody at Cessna reads this and wants some help, give me a call. I don't expect to hear from them. And by the way, was I the last person to learn that Cessna had a plant in Mexico? I hope they do better with their plant in China that is making the Skycatcher. At least Piper is still doing all of their aircraft manufacturing at their campus in Vero Beach, Florida. In fact, Piper is holding a job fair in Wichita, Kansas on October 7 in an attempt to hire qualified people to work in their manufacturing facility in Vero Beach. I suppose they are hoping to recruit some good people who have lost their jobs because of manufacturing being moved off-shore by other aircraft companies. American jobs - Hmmm. Maule and Aviat airplanes are also built in the U.S. If I was going airplane shopping...
Last month in this section I discussed the rising trend of pilots flying without a valid aviation medical certificate. Since that writing, AOPA and EAA have teamed up to propose expanding the driver's license medical standard beyond LSA and into four seat aircraft up to 180 horsepower not flown for hire. I don't know if I support that or not. My concern is for the unsuspecting passengers who assume that the FAA is making sure that all flying is safe. The reservation I have is that, like with the LSA rule, pilots are flying with known medical issues. Though it's not supposed to happen, pilots who know they won't pass an FAA medical exam simply don't take one and move into LSA. But, I also know of cases in which pilots just keep on flying their airplanes, sometimes very sophisticated ones, without a medical certificate when they know they won't pass the exam or even after they have had a medical certificate denied. AOPA says there have not been any documented cases of accidents involving medical incapacitation in LSAs since the inception of the rule. I suppose "documented" is the key word. I'm not so sure that there have not been undocumented cases. There are a number of accidents that can't be easily explained in LSAs as well as in larger, faster airplanes. Statements such as "loss of control for undetermined reasons" in the NTSB probable cause finding raise doubts. But, for the majority of pilots who have no health issues, not having to deal with the hassle and expense of the medical exam would be a positive change.
I'm sure we will hear much more about this proposal and have an opportunity to comment if a Notice of Proposed Rule Making is issued. Meanwhile, let's all err on the side of caution and make sure we are truly fit to fly. |
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