Aopa Accident Case Study In Too Deep Sum

For pilots, a visit to an ATC facility often results in a mental sunrise on why things are done as they are and how to get the best service.

A local group of pilots visited an ATC facility and observed:

VFR flight following: At a moderately busy Class C facility, on a nice VFR Saturday morning, the amount of traffic was impressive—especially around the edges with clusters of aircraft who weren’t speaking to anyone.

At a satellite airport outside Class C airspace there were several VFR targets in the pattern or nearby. As an IFR Cessna 210 was picking up his clearance on the ground, the controller advised him of the nearby beehive. It got more exciting because although the winds were light, the 210 elected to depart against the prevailing flow—his prerogative. The controller advised of the nearest targets, altitudes, and that there was a Hawker jet setting up for an RNAV approach to the opposing runway. The 210 launched uneventfully and avoided everyone. We’ll catch up to him momentarily.

The Hawker was advised of “the hive” and the controller reminded him to cancel when appropriate. A thin layer of clouds precluded it right then and the controller asked for a pirep. Two minutes later the Hawker reported bases broken at 1,300 and canceled. The controller now had a better picture on what was going on and where a conflict might develop recognizing, of course, that everyone was adhering exactly to the prescribed cloud clearances. Right! Pireps are important—make ’em!

For pilots, the mantra is Aviate, Navigate, Communicate. For controllers it’s Safety, Efficiency, and Pilot Requests—in that order. Controllers may be working two or more frequencies, and we only hear one side of the conversation. Be patient since ATC’s highest priority is avoiding a paint swap before they can get to our request.

On an initial call for VFR flight following, just the call sign and possibly “flight following” is all that is needed. Don’t unload that you’re “a Buzzard 110 at 2,000 somewhere northeast of Mudville headed up to see Aunt Tilley who has a world class twine collection.” ATC will reply when they can with a squawk—and then it’s time to provide type, altitude, and destination.

The IFR Cessna 210 was headed northbound and assigned 7,000 but the Mode C readout showed 7,300 and climbing. The controller provided the altimeter setting and asked the pilot to check altitude. He reported level at seven and when the Mode C showed 7,700, ATC requested him to stop altitude squawk.

Meanwhile, an inbound RJ was descending out of 10,000, which the controller stopped at 9,000 just to be sure. The 210 was handed off to the adjacent sector and told to start squawk again, to ascertain the problem. The 210 showed level at 7,000, which points out that sometimes there are intermittent gremlins in the system. A good reason for the biennial altimeter/transponder check and the need to check anomalies in several locations/times. Perhaps in the distant future we’ll be using GPS-derived altitudes, at least in some airspace.

Approaching even moderate high density airspace, don’t wait until arriving near the boundary before calling. It’s a three-dimensional chess game of time, speed, and distance—the pieces are constantly moving. It’s even more complex when ATC has to anticipate what the non-participating players might be contemplating. ATC is managing considerable traffic 40 to 50 miles out from the Charlie or Bravo boundary of mandatory communication and typically up to 10,000 feet. So there is opportunity for unpleasant encounters even though communication is not required, as described in the accident below.

Arrival and departure gates are often a mystery to VFR pilots who sometimes believe staying clear of Charlie or Bravo airspace should eliminate any conflicts. Not so! The fast movers need to get into and out of the communication airspace (which AOPA works hard to keep as compact as reasonable). Choice of altitude becomes critical. A midair collision last year in the Charleston, South Carolina, area outside of Class C between an F-16 and a VFR Cessna 150 illustrates this point.

Minimum vectoring altitude, in this case, was 1,600 as the fighter was being guided to the final approach. The Cessna had just departed on a cross-country and was not in contact with ATC. While several traffic calls were made to the jet, the defensive approach would have been for the Cessna to level at or below 1,400 until establishing contact and to listen on the ATC frequency. It’s good to know those arrival and departure gate altitudes in areas where you fly a lot.

Some pilots are uncomfortable talking to ATC, being uncertain about what to say or that, somehow, there’s a violation lurking for the least little foul-up. As they say in Jersey, Fuhgettaboutit! ATC is there to help, and it’s seldom that controllers will be anything but helpful. Just tell them you’re a student pilot. I’ve used that to good effect in high-density IFR traffic in the Northeast, which always gets their immediate attention. (Just kidding!)

The AOPA Air Safety Institute’s recently updated Say It Right: Mastering Radio Communications is an excellent free online course to help you feel better about it. You’ll be talking like a pro in no time.

Post your thoughts about using Flight Following in the comments section:

a) I always use Flight Following – when available

b) I stay away from the busy airspace

c) My eyesight is excellent and I have lightning fast reflexes to see and avoid any traffic

d) Other comment

More of a factor than you might think…

Some years ago I got interested in the role of pilot incapacitation in serious general aviation accidents. What started me looking at this was a statement in the Air Safety Foundation’s Nall Report that in a recent year there were no cases of pilot incapacitation leading to accidents.

I faxed ASF seventeen NTSB reports from that year citing pilot incapacitation as a cause or factor in serious accidents. Some other folks found even more.

There are some who think sugar-coating helps on things like this. I don’t and later, and still some years ago, did a lot more research on the subject. What I found was revealing and it is worth a review.

The NTSB found pilot impairment or incapacitation to be a factor in about ten-percent of the fatal general aviation accidents. (I used fatal accidents only because that is the usual result of established impairment or incapacitation.)

That is not a big number but when you examine the records there is another ten-percent where no smoking gun is found. Good weather, no mechanical problems, no reported other problems, nothing revealed in an autopsy, yet the flight terminates with a catastrophic crash.

Look first at the established cases. This is where the heart attacks would be found. There are few. While the well-intentioned aviation medical community would like for us to believe that they are safety sentinels, they are not. The exam is brief, not complete at all, and from six months to three years goes by without further contact.

Between physicals, pilots self-certify that there is nothing going on that would affect their ability to fly. If the questions on the physical application are answered honestly and all the answers are correct, then, in effect, pilots self-certify almost 100-percent of the time.

Legal and illegal drugs and alcohol also fall into the established causes, with legal drugs an ever-increasing factor.

The alcohol part is pretty simple. Just follow the FAA bottle-to-throttle rules and understand the effects of a hangover. The latter is an individual thing and only the pilot can tell if a night of hooting with the owls will affect the ability to fly like an eagle the next day.

As one who has enjoyed beer and expensive bourbon for almost 65 years, since age 14, I could tell when it was okay to go flying after a night on the town. Like anything else, a cold for example, this might depend a little on the complexity of the flight at hand. It also depends a lot on whether thinking about the ailment is distracting.

Many safe hours have been flown by pilots who were technically hung over (if there is such a thing) and there is seldom a problem unless the pilot doesn’t know what he is doing. If the pilot is really hung over and not still abuzz, then nothing would show on an autopsy and the hangover could indeed be a factor that would show up only in the pilot’s inability to manage the flight.

On legal drugs, the rule says no flying if impaired by the drug. The FAA does have a list of permissible drugs but I don’t think I would fly if using some of those, based on my reaction to drugs in general.

There is no question that some of the strong stuff has no place in a pilot flying. In the accident reports you can find cases where someone who should know better, like a doctor, was self-medicating and flying.

I’m too old to have been around when recreational drugs became popular and always wondered about the difference between being “stoned” and “loaded.” I found out last summer.

I had a hernia repaired and, when I walked out of the surgical center, the nurse told me to take the oxy-something if pain started to appear. Taking it after the pain got bad wouldn’t do nearly as much good.

A while after I got home, I thought pain might be starting so I took half the maximum dose, relaxed in my chair, and found out what it is like to be stoned. Zonked is more like it and I can sure see why you can’t mix that stuff with flying.

If a pilot would think logically about drugs and alcohol and flying, he would be extra careful. Just consider that few pilots are caught doing this. The bad stuff is usually detected during an autopsy. In other words, pilots catch themselves. No second chances.

Things get more complicated with the ten percent where there is no reason found for the accident. Here we can only speculate.

My favorite guess here is fatigue. This is a hard thing to measure, or detect, yet all pilots suffer some degree of it some of the time or even much of the time.

I did some research flying with a sleep-deprived pilot a good while back. The first day he just made small mistakes but as the flying continued and the level of fatigue built, the mistakes became more serious. Finally, on an approach to a minimum-length runway, the airplane started to get way ahead of him. I let it progress for as long as I could but finally had to take control of the airplane and fly it out of the developing bad situation.

This pilot had clearly become too tired to do anything very demanding with the airplane.

I know of cases where pilots went to sleep with control either lost, or an errant autopilot or altitude misjudgment resulted into flight into terrain.

All of us have flown along fighting the urge to nod off. For some reason, the tendency to do that tends to fade with age.

Nobody condones turning the autopilot on and taking a nap but that is and has been done. On all those long record breaking flights, naps were inevitable. For the rest of us a nap might also be inevitable but it is best taken after a landing and a time out. A quick snooze, even one taken in a chair, can charge one’s battery quickly.

A huge percentage of accidents are attributed to pilot error but not enough thought is given to why pilots make so many fatal errors.

I think a fairly high percentage of these involve impairment or incapacitation of the pilot’s ability to cope, or, to think. A pilot whose brain freezes is just as incapacitated as one who is numb from alcohol or drugs, or who becomes physically ill.

We make much of pilots or crews who do well under fire. Captain Sullenberger was idolized for his cool in landing that Airbus in the Hudson River after both engines quit. An even more challenging event involved a superjumbo Airbus A380 operated by Qantas, the Australian airline.

This behemoth had one of its four jet engines suffer an uncontained failure, meaning that pieces of the engine impacted other parts of the airplane disabling systems and other things and leaving the crew with a thoroughly crippled airplane that they landed safely.

Captain Sullenberger had his copilot and the A380 crew had two check airmen on the flight with them.

Even airline crews can lose the ability to think. The Air France A330 that crashed in the Atlantic did so after the crew stalled it at 38,000 feet and never recognized that it was stalled during the long drop to the surface of the ocean. For more on this, look at Air France 447 on Wikipedia.

When general aviation pilots have a brain freeze they are most often alone. We have to catch it all by ourself.

There are many cases on record where you can see that the pilot lost it. Some of these are related to mechanical problems, some to confusion and some to weather issues.

I lost a good friend to an apparent mechanical problem. He was a well-trained and experienced pilot making a long night flight in a Cessna 340. He was at Flight Level 210, in and out of the cloud tops, when a controller informed him of an altitude deviation.  He replied that he had a gyro failure. Control of the airplane was lost and the airplane entered a spiral dive and reached the ground in less than a minute.

The NTSB did not find a reason for the loss of control other than spatial disorientation on the part of the pilot.

Whatever happened, it was enough to confuse this pilot enough that he lost control. All of his friends speculated on possible causes but there was never a consensus.

There is plenty of confusion potential in autopilots and avionics systems. That is why it is so important to understand the systems and make peace with them in good conditions before using them in poor weather.

I have read numerous accident reports where it was obvious that the pilot got so far behind things that he lost the ability to think and to plan. At times pilots will confess to a controller that they are confused but more often than not the clue comes from the flight path and altitude of the airplane. Being temporarily misplaced is a different matter than being hopelessly lost. The former has more potential for solution than the latter.

In bad weather, I think that more airplanes are lost because while the pilot retained the ability to think, he lost the ability to reason, with the airplane transitioning from the air to the ground in an unsuitable location.  Going below published minimums without good visual contact and scud running come to mind along with continued flight into icing conditions.

An area where thinking, and thinking about the right thing, is critical is flight in bad turbulence, whether in or away from a thunderstorm.

When a pilot flies into a thunderstorm the question that comes to my mind is, “What was he thinking?”

Pilots don’t intentionally penetrate thunderstorm cells in light airplanes so one who winds up in that bad place was apparently thinking he could miss the storm.

In the storm, there are two huge distractions. The turbulence is almost unbelievable and the noise from the rain is substantial.

The pilot has to concentrate on keeping the wings level with the power set to yield maneuvering speed at a level flight pitch attitude. The altitude cannot remain constant. The airplane has to be allowed to ride with the currents.

You also have to ignore the noise from the rain and resist the temptation to look at the windshield which seems the source of the noise as well as the most visible sign that you are playing submarine with your airplane. The flight instruments require 100-percent attention.

I know from experience that this is difficult to do and I suspect that some airplanes are lost to storms because the pilot panicked, turned into a passenger, and the airplane flew itself outside the flight envelope and the airframe failed because of excessive speed.

It is often pointed out that most accidents are caused by pilot error. That is more or less correct but not in the sense that a pilot made a mistake in handling the airplane. More often than not it is because the pilot failed to manage the airplane properly. Probably half the serious accidents are related to incapacitation or impairment of the pilot’s ability to think.

Is there any way we can teach pilots to avoid this?

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