September 1, 2011
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In this Issue
What's New?

August was an eventful month. As most of you know, my website crashed and burned. My knowledge of websites is minimal and my knowledge of servers is non-existent. I greatly appreciate the many offers of help that I received. In the end, a local, fellow pilot who owns a web services company came to the rescue. Once I contracted with him, life got much easier. His knowledge and extremely high level of support is what is making it possible for you to read this newsletter. If you are in need of any kind of web services, I would highly recommend that you contact Barry Orlando at Orlando Web Services. Check out his site by clicking here. My site isn't completely back yet. I decided it had been a long time since I had done a major re-work and it was overdue. I'm doing a bit every day and it is coming along. Check out the new look and see what is posted so far by clicking here.

My wife and I traveled to Lancaster, PA on the weekend of August 20-21 to meet up with my son and his family as well as his sister-in-law and her family. We enjoyed VIP airshow passes courtesy of the "Heavy Metal Jet Team." If you haven't seen this group perform, don't miss the next opportunity. On the day we saw them, they flew five L-39s and a MiG-17. Check out their website here.

And now I have some big news! (I know; that statement is better coming from me than from your teenage daughter.) I have decided to launch a major new initiative called "The Checklist Project." My study of general aviation accidents has made me realize that the lack of effective checklist use is the underlying cause of many accidents. Relatively few "Probable Cause" findings from the NTSB cite the lack of checklist usage. But fuel management accidents caused by failure to operate on the correct tank are really a result of not using a checklist. So is a takeoff accident that happened because the flaps weren't properly set or because control locks were not removed. And so is a carburetor ice accident that happened because of an undetected broken cable between the carb heat control and the door in the air box. The list goes on and on.

This comprehensive safety initiative will not only encourage pilots to use checklists, but will provide tools necessary to create or update checklists and will provide training in the efficient and effective use of checklists. The project will include online tools and templates, online courses, live webinars, live seminars at various locations around the U.S., and exhibits at aviation events and trade shows. The Checklist Project will be sponsored in part by Bright Spot, Inc. But that is an ambitious agenda and will require support in terms of additional sponsors and volunteers. Obviously, sponsors are needed to help fund this effort. But volunteers are needed for many areas including: technical expertise on aviation matters, graphics skills, video skills, publicity, sponsor recruitment and other areas that I don't even know about yet. So if you're ready and willing to help, click here to view or download an info sheet. The project is still evolving and more information, including an actual launch date will be available soon.

In addition to The Checklist Project, I am working on my speaking schedule for 2012. If you have an event coming up and would like to have me give a presentation, let's have a conversation. Click here to see a list of my prepared topics. If you need something different, we can still have a conversation and come up with something that works for everyone.

OPERATIONAL TIP

The first thirty-two years of aviation went by entirely without the concept of the checklist. It's not that checklists weren't needed. It's just that, like so many other good ideas in aviation, nobody had thought of it yet. Then, in late October of 1935 while performing a demonstration flight for the U.S. Army, Boeing's prototype B-17 crashed shortly after takeoff killing all onboard. The crash was caused because the crew had forgotten to remove a control lock. Many speculated that flying an airplane so large and so complex was beyond human capability. It was surmised that if these experienced Boeing test pilots couldn't remember everything that had to be done, the average pilot wouldn't have a chance. The Army cancelled their contract and it was nearly the end of the Boeing company. But somebody had an "ah-hah" moment. Why do pilots need to memorize all the procedures? Why can't the critical steps be written down and referred to as needed? The concept of the aviation checklist was born.

Now, almost seventy-six years later, most pilots regularly use a checklist in some form. A few pilots don't use a checklist and never will. They are doing their part to make sure I never run out of material for articles, webinars and seminars. But there is a great variation in the extent of checklist usage among pilots who do use checklists regularly. The low end of the scale includes pilots who may only use a"Before Takeoff" checklist. The high end finds pilots using upwards of a dozen different checklists for any flight. Yes, we're still talking about GA singles and light twins.

I believe in three checklist categories, "Normal Operations, "Abnormal operations", and Emergency Procedures. Each of these categories is divided into numerous individual checklists. For a single-engine airplane or light twin, I like fourteen checklists in the normal operations category. Some of these are rather lengthy such as the "Preflight Inspection" and "Before Takeoff" lists. Some, such as "Climb" or "In-Range" lists contain only three or four items. I also have a few "Memory Items" for things that might happen without the luxury of time to pull out a printed list. These would include things such as engine failure right after takeoff.

I have heard statements like, "Using all those checklists takes all the fun out of flying." Let's be serious. Read the two accident discussions below and think about how much fun those pilots had. And remember that these are not isolated cases. Similar scenarios play out several times every week. Many less serious accidents happen daily as a result of failure to do something. In most cases, using a checklist would have prevented the omission. We average more than one gear-up landing every day. Most cases do not involve mechanical failure of the landing gear. Pilots of fixed-gear airplanes aren't off the hook. The laundry list of accident causes includes failure to properly set flaps, failure to properly set trim, and others too numerous to mention.

So let's vow to do three things. First, let's get our checklists in order. Make sure that appropriate, up-to-date checklists are readily available to the pilot. Second, let's review the checklists and make sure the steps are clearly understood and can be followed. Finally, let's make sure we use all the checklists on every flight.

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: CEN10LA430

This accident is, or should be, a pilot's worst nightmare. The pilot made an error which resulted in the crash. He received only minor injuries but his wife died at the scene. Personally, I can't imagine the agony of having to live with that. This accident happened in July of 2010 in South Dakota.

CEN10LA430

The pilot's error was a simple, yet common one. He was flying a Piper Warrior which does not have a "BOTH" position on the fuel selector. Only one of the two fuel tanks can be used at a time. The pilot must remember to switch fuel tanks if all the fuel aboard the airplane is to be used. On this day, the pilot had flown on the right fuel tank and had nearly depleted its contents upon arriving at the destination airport. He almost got away with it, but he got slow on final approach and elected to execute a go-around. He flew the length of the runway, made the crosswind turn, and began a turn onto the downwind leg. As he executed the turn from crosswind to downwind, the engine lost power. He attempted to execute a forced landing, but the left wingtip made contact with the ground and the airplane impacted a tree after the airplane touched down. The right wing separated and the airplane continued on for another sixty feet.

The pilot told investigators that there was no mechanical failure of the airplane. He reported that he did not switch the fuel tanks prior to landing, and that the “engine quit due to fuel starvation.” The accident investigation revealed that there was no evidence of fuel in the right wing fuel tank, but that the left wing tank was full of fuel.

Like most accidents, this one was easily preventable. And like many accidents, the use of a checklist could have made the difference. The "Before Landing Checklist" should have, for this airplane, included "Fuel Selector - Fullest Tank." Had this pilot taken the quick and simple steps required to make sure there were adequate checklists in the airplane and then to actually use them, he would have been reminded to move the fuel selector to the left tank position. Had that happened, he would have been able to enjoy a pleasant weekend with his wife and then fly home with some nice memories. Instead, he has to live the rest of his life knowing that his actions directly resulted in his wife's premature death at age 54.

Click here to read the full accident report on the NTSB website.


Accident Discussion - Complex Airplane NTSB Record: CEN10FA364

This accident resulted in the deaths of the pilot and his passenger. It happened in Kansas in July of 2010 shortly after the pilot of the Beech F33A Bonanza reported that he had lost engine power while climbing from 7000 feet to 8000 feet. ATC provided vectors but the pilot reported that he was unable to reach an airport and was going to attempt a landing on a road. He apparently lost control of the airplane after a stall and entered a spin.

CEN10FA364

We could chalk this one up to lack of proficiency in forced landings. But this one probably could have been corrected before the forced landing was necessary. The accident investigation revealed that the engine quit because the engine driven fuel pump had seized. Since this is a low-wing airplane, the fuel will not gravity feed so fuel must be pumped to the engine. The emergency procedures checklist for a loss of engine power included the activation of the auxiliary fuel pump. The aux pump switch was in the off position at the accident site. An examination of the auxiliary fuel pump revealed no anomalies. Certainly an engine failure above 7000 feet allowed ample time to run the checklist. In fact, the engine monitoring system recorded the fuel flow dropping to zero twenty-six minutes into the flight but the unit continued to record data for an additional six minutes. A simple flip of the auxiliary fuel pump switch would probably have brought the engine back to life.

Crash Location

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The failure of the engine driven fuel pump causing a loss of engine power and the pilot's failure to maintain aircraft control resulting in an inadvertent stall. Contributing to the accident was the pilot's failure to follow the emergency procedures checklist and utilize the electric fuel boost pump which would have restored engine power.

Click here to read the full accident report on the NTSB website.

COMMENTARY

Last month I wrote about "being better" as pilots. I received a number of positive comments and some suggestions on how we can be better. Most suggestions were excellent tips on ways to improve our skills and knowledge. Here is a brief sampling of what some readers shared. "Commit to learning one new thing every week. Pick a day of the week and make a calendar entry on that day each week of the new knowledge. Then, go back monthly and review what you have learned." Another pilot suggested, "Map out a plan for proficiency flying a year in advance. Include what you need to be legal plus what you need to be proficient in your kind of airplane and operations. For example, include night takeoffs and landings every three months. Include instrument approaches every month even though the actual requirement is less strict." And another suggestion was to form a "proficiency club" with local pilots. Each member of the club would take a turn at leading a monthly discussion in which the members would talk about their recent flights, what went well, what could have gone better, and how they could do better in the future.

In aviation as in life in general, being better includes being more honest. Pilots are generally an honest group, right? I think that's true except when we are talking about our hair raising exploits in which we fought extreme storms and horrific winds but managed to land safely in spite of it all. Bending the truth a little in that area isn't generally harmful. But some pilots are a bit less than honest when filling out the FAA Form 8500-8. That is the form we all complete each time we renew our FAA Aviation Medical Certificate. Many accident reports include information that the pilot had some condition that was not reported on the most recent application. It often can't be determined whether or not the condition contributed to the accident, but the question is raised.

No pilot wants the hassle of being denied a medical certificate or having to jump through some additional hoops to be certified. But we aren't always the best judge of what is safe medically. We simply don't have the medical background (except for you MD's among us) to make that determination. So we owe it to our families and to our passengers to "come clean" and let the professionals decide if we are safe to fly. And if we are not safe medically, then what we need to do to correct the situation and to be safe.

Now there may be another incentive to be honest about our medical conditions. A wrongful death suit has been filed in Florida following a crash in which the pilot and two passengers died. The estate of one of the passengers is suing the estate of the pilot, charging that he failed to report a diabetic condition on his most recent application for a medical certificate. The autopsy revealed a high level of blood sugar in the pilot. A high glucose level had been detected during the pilot's medical exam and the medical certificate was not issued. The FAA had requested that the pilot provide additional documentation on his condition but the request went unanswered. The pilot's medical certificate had expired at the time of the accident. If this suit is successful, it might pave the way for others to bring suit if an accident pilot has not been honest about a medical condition or is flying with an expired medical certificate. If the pilot sruvives and a suit such as this is filed, the result could be financially devastating. Even the cost of defending such a suit would be astronomical. This kind of suit would not be covered by any kind of aircraft liability insurance and most pilots would not have any coverage for this.

Let's keep trying to be better and let's make sure we are honest with ourselves and our Designated Medical Examiner about our condition.

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

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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.
Copyright© 2011 Gene Benson
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