Thursday, September 21, 2017

LAMENTABLE TRAGEDIES


Pilot error is the single most important cause of fatalities in aviation. Especially when you allow the statisticians their free reign at numbers. The percentages that pile up suggest upwards of 80% of all fatal accidents are pilot related. One wonders then how these lamentable tragedies don’t ease up? If we as pilots know of all the various ways of crashing an airplane, why do we keep doing it? To get better at it? No, possibly not for that reason. There is something else here that escapes the eye. Let us dig deeper into this morass of prejudged eventualities.


Why does a VFR pilot fly into the clouds only to lose his way in the soft bitter blindness of grey? To be a little considerate of this poor bloke, let us look at how that is possible. Given the mind’s judicious use of fuzzy logic to plant an image where one does not exist, is one way. As the visibility lowers in haze, the mind continues to fool the decision maker into thinking that the buildings he was seeing are still there albeit a little hazy. He soldiers on, only to suddenly realize that the there is not there and panic sets in. I remember flying in a flight of two on a summers day with a VFR-only pilot and his companion. As the visibility lowered and my eyes diverted to the instruments, I realized that the other pilot did not have the same capability. I asked the Air Traffic Control to tell my “company aircraft” to reverse course back to our departure airfield. Upon landing, we checked the weather and further west of our 180-degree site had gone IFR.

Preflight is another big bugaboo. Multi-hundred-hour pilots will treat flight as if it is riding a bicycle. They will assuredly “kick the tire and light the fire” and off they go, as if they are exempt from the rigors of human fallacies. Most times it is okay, but then there is that one in thousand NTSB report that makes your heart sink. How could he? Why do we ignore a good and thorough preflight? Mostly because, a) we expect it to be okay, b) it is a time drain and delays our ultimate thrill to be up in the air, c) heuristics of laziness d) all others you can conjure up. But preflight is when you find all sorts of things that can go wrong: a) contaminated fuel, b) a broken spring on the landing gear, c) cowl plugs plugged in deep, d) a bird-nest e) open baggage compartment door, f) a fouled plug or a broken ceramic spark plug, g) low oil, h) a flat spot on the tire ready to go, i) a blocked pitot tube and myriad other potential maladies that can lead to those lamentable tragedies.


The pilot is the Commander of his aircraft. No one has the authority other than when he or she delegates to a flight instructor or another pilot in the right seat. One of the mainstays of safety is never ever to abrogate one’s authority to fly the aircraft. You are the boss. You make the decisions (you may elect to recognize other’s opinion especially if it is a contrary opinion for inclusion sake) but the ultimate responsibility still weighs heavily on the pilot. You decide if the rudder or your authority is breached in a crosswind landing. You decide on an alternate airport as the weather deteriorates. You decide on the weight and balance. You decide what is the safest and most favorable approach to a safe arrival at your destination. You are it. You are the Big Cheese! Take that responsibility seriously but with a dose of humility.

Above it all, as a pilot you must learn to respect two very important things: 1. The Aerodynamic limits of the airfoil and 2. Your own Experiential Limits. Never let the latter exceed the former and never let yourself be seduced into trying to find the edge of the aerodynamic envelope without first experiencing it with a more experienced and knowledgeable instructor.


In the end, then, all lamentable tragedies are a learning experience. They titillate the journalists into writing hyperboles but at the very core, these disasters are learning experiences. Unfortunately, others have shed blood and bent aluminum not to be rendered as a “stupid mistake” or an act of “incoherent idiocy” or be subject to the glowering mean judgmental eye, but they are to be used as a mechanism to learn from and avoid similar errors. Safety is like climbing on the shoulders of others and seeing what they have seen and learning to avoid where they might have erred.

To Err is Human

Did you make a mistake today? If you said no. I would beg to differ. We make tiny errors in our daily lives that go unnoticed because they are isolated mostly and of little consequence. The adage is “To err is human. To err is universal. To err is inevitable.” But here is the question, “Is To err a bad thing?”

To answer that question, we may have to ride the train backwards in time. During WWII planes were falling from the sky. More lives were lost from mistakes than from enemy aircraft shoot-downs.


We obviously learnt from those mistakes. The fatal aircraft accident rate in the United States gradually declined dramatically. From 1959 when the fatal accident rate was 1 in 100,000. A remarkable feat from just 7 years before. As 2016 became history the fatal commercial aircraft accident rate declined to an astonishingly low rate of 1 per 10 million flights. Imagine the log reduction in loss of life! A proof worth hanging your hat on. Education about Loss of Control, Fuel Management, Decision Making and Judgement were the mainstay to bring the number down. Yet if we were to look at airline safety data from 2009 (without jinxing anything) there has been a zero-accident rate in the seven-year period. That is incredible.


The General Aviation Accident Rate per year however is a different story. It is presented below and is based on the NTSB data available to date. The higher rate of fatal accidents in the general Aviation Community is partly because of lack of professionalism, single pilot operations and the “bold pilot” mode of thinking.

YEARS
GA Accident Rate/100,000
GA Fatal Accidents
GA Fatalities
FY10
1.1
272
471
FY11
1.12
278
469
FY12
1.09
267
442
FY13
1.11
259
449
FY14
1.09
252
435
FY15
0.99
238
384
FY16
0.91
219
413

So, let me get back to the issue of is “To Err” a bad thing?

The answer is a qualified NO. However, with a caveat, to repeat an error made by others, which has been used as learning event, is definitely a bad thing. It is important to know that the NTSB data was created out of bent metal and loss of life. Errors made by expanding the envelope of flight teach us what not to do. The FAA rules are created based on the NTSB information for pilot’s personal and his or her passenger’s safety and based mostly on the erroneous adventures of others.


The FAA has in place a NASA form just for this purpose. If you make a mistake or believe you might have, it is important to fill out the form and send it along for record keeping. The form is evaluated based on ATC tracking data and if no accidental errors were made, the pilot receives a response in kind. If however, there was an error committed, the pilot has protection by self-reporting of the error. A pilot is forgiven for any errors committed over a three-year period. A continuous flow of errors however point to the pilot’s competency and decision making that might require a rehabilitation and remediation strategy.

ASRS Form available below

Assuming you are in a hurry and wish to fly for a $100 hamburger with impatient passengers tapping their toes. Allowing them to influence your preflight decisions to not drain the fuel or check the oil content, hazards will loom in that flight. These risks may remain only as risks and not bite you or your passengers, but the “kick the tire and light the fire” does have adverse consequences if repeated. And one day, when all the gremlins go for their “Labor Day vacation” watchout!

Based on the FAA…


The Top 10 Leading Causes of Fatal General Aviation Accidents 2001-2013:

1. Loss of Control Inflight
2. Controlled Flight into Terrain
3. System Component Failure – Powerplant
4. Fuel Related – contamination, starvation or exhaustion
5. Unknown or Undetermined
6. System Component Failure – Non-Powerplant
7. Unintended Flight in IMC
8. Midair Collisions Low
9. Altitude Operations
10. Other


Aviation Safety is no accident!

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