FLYING LESSONS for March 10, 2016

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1 FLYING LESSONS for March 10, 2016 Suggested by this week s aircraft mishap reports FLYING LESSONS uses the past week s mishap reports to consider what might have contributed to accidents, so you can make better decisions if you face similar circumstances. In almost all cases design characteristics of a specific make and model airplane have little direct bearing on the possible causes of aircraft accidents, so apply these FLYING LESSONS to any airplane you fly. Verify all technical information before applying it to your aircraft or operation, with manufacturers data and recommendations taking precedence. You are pilot in command, and are ultimately responsible for the decisions you make. FLYING LESSONS is an independent product of MASTERY FLIGHT TRAINING, INC. This week s lessons: Pursue Mastery of Flight We have a lot of great reader mail, so this week we ll go straight to the Debrief. See Debrief: Readers write about recent FLYING LESSONS: Several readers commented on last week s LESSONS, derived from the NTSB s Probable Cause report on the 30 October 2014 crash of a King Air at Wichita, Kansas. Instructor/aircraft manager David Dewhirst writes: Great article on engine failures on takeoff. Recall for a moment the Beech 1900 accident at Charlotte about 20 years ago where the airplane was rigged incorrectly, not allowing full down elevator, and the airplane was loaded to the aft CG limit. When encountering an uncontrollable pitch-up, the pilot tried to continue the takeoff, crashed, and all aboard died. The continuation of the takeoff is what the airline taught after switching to a Part-121 certificate. What the pilot should have done was to immediately retard both power levers to idle and make the best of the inevitable splat. At least it would have been wings level and at a slow airspeed. That is an aborted takeoff after becoming airborne and with runway remaining. That is exactly what the King Air pilot should have done. It should not have been, right rudder, gear up, flaps up, and feather, all in an attempt to make the airplane fly. The pilot should have immediately pulled both power levers to idle and landed on the remaining 9,000 feet of runway. We added that idea to our training programs after the Beech 1900 accident. A takeoff can be aborted even after becoming airborne and that may be the best option. Make the airplane fly only when no runway or overrun is available. That was the LESSON that multiengine pilots are taught and evaluated on V MCA roll recognition and recovery for a reason, to abort the attempt to keep flying if control is lost immediately after 2016 Mastery Flight Training, Inc. All rights reserved. 1

2 takeoff that I wrote as a result of this crash when it occurred (FLYING LESSONS for November 6, 2014). The V MCA response is not just a checkride circus trick, as I explained in that LESSON, the maneuver is actually designed to teach us something that can save our lives. This reaction to a loss of directional control following engine failure is vital even if you no longer have usable runway ahead on which to abort the takeoff. If you did not PUSH DOWN to the point airspeed decays and you can no longer MAINTAIN HEADING even with full control deflection, your survival depends on chopping both throttles and pushing the nose down more even if that means a controlled off-airport landing. Just as if you lost power taking off in a single-engine airplane, land Wings level, Under control, at the Slowest Safe speed to survive. Thanks, Dave. See: f5184a148889&pgsize= Reader/pressurized twin pilot Tony Crescimanno notes: That [LESSON] was excellent, Tom. Coming through the military and airline it became habit to strive for perfection in all phases of my flying because just "good enough" just isn't good enough when it pertains to flying. Too many lives are at stake as well as the airplane and property. I fly my pressurized Baron with the same attitude. I don't always reach the level of perfection I want and I'm not always satisfied with my performance, but I always strive to do better. I've long been an advocate for [type-specific training] that's available. And I have flown [a type-specific] simulator and practiced many engine failures in different phases of flight. These programs provide excellent training and I believe made me a safer and proficient pilot. (left) Are you satisfied with being an OK pilot? Or can you do better? See But we can [also] train ourselves well by sitting in the cockpit of our airplane and mentally fly, throwing imaginary engine failures or gear malfunctions at ourselves just [or] run through the procedures and get out the checklists. It's my habit to always tell (brief) the person sitting next to me what we (I) will do if and engine fails on takeoff and what we (again I) will do if we need to go around on an approach. What's important to note here is that I am telling myself what I need to do before it happens. Excellent advice, Tony. Thank you. Reader Mike Lepore adds: Wow. Powerful thoughts. Thank you for the two initial thought and planning keys of PUSH FORWARD and MAINTAIN HEADING. Of course, we'll never know, but the fact that the gear was not retracted----- that being so very basic, leads me to think that there was some level of mental impairment. So awful, and so tragic. Thank you for an excellent analysis, and for helping to keep us safe as we pursue mastery. You re welcome, Mike, and thank you as well. Reader John Dietz wraps up this part of the Debrief: I m an avid reader of your FLYING LESSONS and appreciate your careful and common sense teaching. This time I am moved to comment on your LESSON, in large part to express my gratitude for the compassion, resilience and resolve of the aviation training community in the wake of the King Air accident. I ve attended the FlightSafety program for [Beechcraft] Bonanza pilots annually in Wichita and I truly appreciate the dedication I experienced there. I have thought long and hard about the tragic King Air crash and what lessons it holds for people like me. This incident is all the more meaningful because it occurred across the street from your office and right there in Wichita, the epicenter of Aviation (with a capital A!). I m sure I m not alone in the saying that our hearts go out to you, the FlightSafety teams and all of the aviation community in Wichita. I admire your resolve and continued effective leadership. Thank you very much, John. I know a lot of FlightSafety people here in Wichita, including in the 2016 Mastery Flight Training, Inc. All rights reserved. 2

3 Cessna Learning Center that was hit and ultimately destroyed in this crash. The tragedy for those who were injured or killed, and family and friends of those people, is immense. The effect it had on their co-workers and friends was also enormous. The skill and discipline of the staff of that center that day was exceptional. Because of their efforts nearly 100 customers and employees were able to get out of the burning building unscathed, at least physically. They were true heroes that day. Frequent Debriefer Richard Druschel writes about the February 24 FLYING LESSONS prompted by the fatal crash of an airplane whose pilot appears to have departed with far less than the fuel needed for his flight: You have touched on another of my "hot buttons," which is always ensuring that there is an adequate amount of fuel in the airplane at all times. Airplanes can crash for a variety of causes, none of which are acceptable. Fuel exhaustion is the very least acceptable! Fuel is the one item that we have the greatest control over. In this particular case the pilot had to opportunity to top off the tanks prior to the long trip back to home base. But the fuel actually uplifted was grossly insufficient. He not only did not have any fuel reserves, he did not have enough to complete the trip itself. What was he thinking? Or was he? My personal minimum fuel reserve is at least one hour at touchdown. That leaves some room for the unexpected to happen. Often I will have more than the one hour remaining. I also keep a watch on fuel consumption by using the gages, fuel computer and the most important...the clock. If either begin to look out of line I start looking at alternatives. I frequently give my students the traditional "your engine just quit, or "you need to divert, where are you going?" scenario while flying. I do that at cruise very often. I want them to develop an ongoing situational awareness. This means always knowing where a suitable airport is relative to your airplane. In this case this pilot should have landed at one of the many airports that he flew over en route to the crash site. What was he thinking? Or was he? We do not know what was going on in the mind of this pilot. Did he wrongly assume that the winds would suddenly give him a nice tailwind going home? Did he simply make a fatal math error in calculating his time and fuel? Was he in a hurry to make another appointment or family commitment? Did he have the proper charts on board that would have aided him in finding a suitable alternate airport? If he had them was he following his flight progress? Did he actually know where he was relative to other airports? We don't know any of these things about his flight. But, as pilot in command, we must know each of these things about every flight we take. Fuel exhaustion is not an excuse for crashing an airplane. It is stupidity. See I appreciate your comments, Dick. Reader and retired airline pilot Larry Olson adds: Good reminder about fuel management. Seems like the total fuel related accidents are ~8% of the total accidents, and ~12% of those are fatal. About 80 and 10 in numbers. (If I m reading the Nall Report right). Also, the trend is improving over time. While not huge in numbers, it s enough to make one wonder. With all the fuel management stuff we have today, it s a wonder that anyone runs out of fuel. I d bet that the average general aviation airplane has at least two independent ways to monitor fuel, perhaps more. First, we can just look at how much is on board, dip stick, how much we added, etc. (Sure, in some planes it s hard to measure partial loads). Second, we can just look at the onboard fuel gauges. Third, we can just use fuel consumption rates from the POH and figure out how much time we have. And there¹s a lot of totalizers out there where we know precisely how much we¹re burning and how much is left and, coupled to a GPS, our range at that power setting and winds. So, why the heck are we running out of gas? And that s with a LOT of experienced pilots, too, with about 50% of the accidents are with a Commercial or ATP pilot on board! The accidents, especially the one you post, shows a rush, urgency to get there, perhaps lack of experience in the aircraft (but lots of overall experience), and just a blatant failure to plan. Perhaps the pilot in your example just flew too many planes, and didn t think, but winged it, when he planned his final flight. In light of that, I could make an argument to first, plan fuel correctly and know [how much fuel] you ll land with before you ever depart. If one is unfamiliar with the plane, add more for a comfortable reserve. Add some for unknown delays, ATC, wind bust, weather, etc. Also, monitor the progress with fuel check points en route: I ll need xxx gallons at xyz point, and if it doesn¹t work out, I ll go to. Pay attention in flight. There s nothing wrong with departing without enough for the trip at normal cruise power, but [you] should 2016 Mastery Flight Training, Inc. All rights reserved. 3

4 know what the best efficiency can do. And, have a few good backup airports. With our modern GPS and fuel flow meters, one can just adjust the power until the destination is made. But one needs to factor in winds, weather, and add the necessary amount to cover those things. Finally, I m on your page with landing with a hour of gas in the tank, and if the planning looks like even a pint low, consider your alternate. I could argue to declare minimum fuel if it looks like you ll be close to your minimum fuel on landing. There s a LOT more about fuel management that could be discussed, but [this is a] good LESSON for now. Indeed, pilots have many ways to monitor fuel, including: Visible fuel level check before flight Amount of fuel known to be in the tanks before preflight inspection Amount of fuel observed to be added to the tanks prior to engine start Fuel receipt from the Fixed Base Operator Cockpit fuel gauges Fuel totalizer, if pilot input is accurate Fuel flow and time computed before flight (and recorded for reference in flight) Fuel flow and time computed regularly during flight Calculated fuel remaining at en route waypoints and at destination (whether hand-calculated or done by GPS/fuel monitor integration) Use all of the available fuel status data on every flight. If any of the available data points disagree from the others, suspect a data input error, an actual fuel input error (not as much gas was loaded as you thought), a change in the conditions (for example, a stronger than forecast headwind), and/or an inflight fuel leak. The only way to resolve such a discrepancy is to land the airplane and add fuel until you can positively determine the amount of fuel actually on board and that it is sufficient to get you to your destination with adequate reserves. Thank you as well, Larry. Reader Dave Van Horn has an interesting point: I have found that even those CFIs that try to teach when to say no to ATC often fail to teach how. I think of it as a verbal contract; the controller s clearance is a proposal, your read back is your agreement. If you don t agree to it, don t read it back, or say Unable, but be prepared with a counter offer: N1234 would prefer... Thanks, Dave. And instructor/retired controller John Foster expands upon it: This sounds so much like the conversation we had [when we flew together] years ago. You need to be prepared to tell the controller what you need and what you intend to do. The primary responsibility of ATC is separation of known traffic. ATC is prepared to provide additional services based on the intentions of the PIC. They are not trained to make crucial decisions for the pilot. Aviate, Navigate, Communicate. Be alive at the hearing. It is a shame that the message needs to be repeated over and over, but please continue to spread the word. Indeed it is the same message again and again, John. Thank you. Frequent Debriefer David Heberling chimes in: It is sad to read about such an avoidable accident. It is so easy to use flight planning software to figure out your proposed fuel burn. Of course, such software requires realistic performance numbers for fuel flow on take off and climb out, plus fuel burn in cruise and decent. I also add a fudge factor to my fuel burn for cruise. I know I burn 13.5 gals/hr using lean of peak procedures. However, I use 15 gals/hr in my flight planning. In addition, I do check my progress to see how it stacks up to what I planned. I have flown my [aircraft] enough that I know my fuel tank gauges are consistent in how they indicate the level of fuel in each tank. The pointers tend to point at the same spot each time I switch tanks each half hour. They also fall at the same rate through out the flight. This is an obvious advantage of owning your own airplane. I too subscribe to maintaining one hour of fuel on landing. It actually amounts to 20 gallons total, which is somewhat more than one hour of flying. I know [many online pilots groups] mantra is aviation on the cheap. This is fine when it comes to maintenance under 2016 Mastery Flight Training, Inc. All rights reserved. 4

5 supervision of an A&P, or outfitting your hangar with a cheaper way to turn on your aircraft heater. However, it has no place if it causes you to shortchange the amount of fuel you carry to conduct a flight. The law of physics is implacable to your concerns about the cost of fuel. It will still take X amount of fuel to fly Y amount of hours, no matter what the fuel costs. (right) Some countries require periodic re-calibration of an airplane s fuel quantity gauges. This photo from a friend s Beechcraft Baron in Australia shows the required placard, calibrated in liters for the Left Hand (L/H) and Right Hand (R/H) fuel gauges. Thank you as well, David. Gold Seal instructor Alan Davis writes: There's an old Quaker saying, "Altitude above thee, runway behind thee, and fuel left on the ground do the no good!" You may not have known that Quakers were that much into aviation - my Quaker Chief got quite a laugh on that one when he heard me use it the first time. The fact is that high [pilot] time does not equal either safety or good planning. In fact, it leads to complacency. One can always "figure" wrong. A student of my did that once, didn't refuel where I told him to do so because he "figured" he had enough to get home, and wound up about a mile short in a corn field. Fortunately, he made a good landing and walked away from it - literally, as he was not there when I arrived! There simply is no excuse for poor planning (or not planning) and that was the cause in your LESSON. The key: every flight has to be planned (in this case, since he was a professional pilot - professionally) even if the only passenger on board is the pilot. Failure to do so no only endangers the life of the pilot, in this case, but the lives and property of those on the ground (if he can't get clear). Sounds a lot like 91.13(a). [Add fuel,] then add some more for SAFETY. Thanks for helping to keep us SAFE - whether you want to call your lessons safety lessons or proficiency [airmanship Mastery] lessons, it s still all about being SAFE!! I always appreciate you insights, Alan. Reader Sandy St. John also writes: I always enjoy your FLWs and learn greatly from every issue. I am so grateful of you taking the time to put it together for us. However, I am constantly flabbergasted and almost angry about the ADM [aeronautical decision-making] in quite a few of the accident lesson scenarios that you publish (not angry at you, just at the pilots who crashed and perished). One particular standout is the 17,000-hour pilot you mentioned in your 2/24/16 issue of FLW. Seems to me, as a pilot's experience level and hours increase, so should his aeronautical decision-making. But in a lot of cases, I see that it is just the opposite. Just like a lift/drag diagram, sometimes as a pilot's experience level increases, his ADM decreases and his complacency increases. I'll never criticize a pilot for crashing, and even more so a deceased pilot who can't tell us what he was thinking or what happened in the last seconds of his life and flight. I will only try to learn from them so as to try to not make the same mistake. And I never say that I'll never experience an accident of some sort. I always say "There but for the grace of the Lord go I". But in reading about the 17,000-hour pilot who crashed for no other apparent reason than running out of gas, I just got mad. Because of a rookie mistake, he died, his family and friends will never see him again in this life, and an apparently perfectly good aircraft was destroyed. Because of one link of complacency in the accident chain, a lot of people were affected. There are probably a lot more details of the accident that I don't know and maybe my comments here are way off base. If so, I apologize. However, regardless of whether he encountered a 30-knot headwind in the final descent to the airport or whatever, he was stretching his fuel time. [On the other hand], maybe the company was pinching pennies and told the pilot to save on fuel if possible. Only the Lord knows - all I know is that another pilot died needlessly because he ran out of gas. I lost five friends in 2015 because of small plane crashes. Four of them can most likely be attributed to pilot complacency related issues. Personally, I think that complacency is an issue that needs to be heavily addressed during initial training and re-addressed during a [Flight Review] Mastery Flight Training, Inc. All rights reserved. 5

6 Just my thought about your LESSON. Keep up the good work! I think we all share your frustration, Sandy, and send our sympathies for your losses. Reader John Scherer comments: When I read the NTSB preliminary report [on the fuel exhaustion event] I had a sinking feeling that he had run the airplane out of gas. I was immediately taken back to 1990 or 1991 when I was Flying Safety Officer at the Quantico Marine Corps Flying Club. One of our members checked out a PA to fly to Orlando, Florida. He was a physician with an instrument rating and described as a meticulous pilot. He flew to somewhere in North Carolina (From Quantico Marine Corps Air Station) and stopped for gas. He filled up and launched for Orlando. One of his passengers was his dad, a retired Air Force flight engineer. After four hours and twenty eight minutes of flying, the engine quit on short final to Orlando Executive Airport. The airplane landed in the lake off the end of the runway. The flight engineer passenger got everyone out of the airplane before it became a U-boat. Fortunately, no one was injured. I was tasked with investigating the accident. I talked to the Centers along the way and got the transcripts of conversations with the accident pilot along with his groundspeed. I calculated that the endurance of the Cherokee he was flying was 4 hours 30 minutes. If my memory serves me correctly, he was on short final to Orlando Executive at 4 hours 28 minutes [after takeoff]. That pilot stated that he wasn t wearing a watch and kind of lost track of time during the flight. This was the first time that he had flown this airplane on a long cross-country. I determined that he did not know the fuel consumption rate of the airplane. But, he still attempted a trip at the outer-limits of endurance, with no thought of adequate reserves. Needless to say, he was asked to resign from the Flying Club. I m still thankful to this day that no one was injured. Sometimes the lure of making an exotic destination non-stop can be overwhelming. This pilot was not highly experienced, but known to be meticulous. The 17,000 Hour ATP is more puzzling why not just fill up the tanks? Thanks, Tom, for making us think each week. Thank you as well, John. Test pilot and Designated Pilot Examiner Dale Bleakney wraps it up this week, writing from his experience: I really like your discussion about the Bonanza fuel exhaustion incident. As a survivor of a number of engine failures, I liked some of the points you made and would like to reinforce them: 1. Keep track of your nearest emergency landing spots and always have a plan B. a. I like this approach and have been conditioned thru experience to always do this. If I didn't have the experiences I have had with engine failures, I would undoubtedly be like all the other people reading your column and wouldn't think it would happen to me. I choose to be a "guarded pessimist" when it comes to the continuous operation of the engine and try to always have a plan if the engine quits. b. On takeoff, I do a very similar briefing in a single that I do in a twin. I discuss what I will do in the unlikely event of an engine failure at different points during the takeoff including altitudes and options. In a Bonanza, I would not try to turn around unless I was at least 1000 feet above the ground. There are pros and cons about the altitude you should have before you make the first turn after takeoff. Some people choose traffic pattern altitude, some choose a number like 500 feet. For me, it depends. If I put more options in play by turning at 500 feet (taxiways, ramps, downwind landings on runways, etc.), then I will do that instead of trying to climb over bad terrain until high enough for a turn around. c. I don't climb out at Vy unless I have obstacles I need to clear. I choose to accelerate in ground effect or shortly thereafter so that in the unlikely event of an engine failure, I am closer to my best glide speed. In Cessna airplanes (other than the TTx), the short field takeoff speed and best glide speeds are closer together so this is not as big of a concern as it is on higher performance airplanes like the Bonanza or TTx. 2. Sometimes downwind is your best option for safety. I took off runway 14 in Wichita in 2013 and lost 80% of my engine power as I was climbing [southward]. Conventional wisdom would have had me slow to best glide and land at the best suitable point, into the wind. Unfortunately all of those landing spots had trees at both ends. It would have taken a perfect approach and landing to make one of those work and it still would have been a toss of the dice as to whether the airplane or me was damaged as part of it. Instead, I made a very quick commitment to turn around and head back to KICT. I knew it was going to be tight but I also knew that I had open areas and roads that I could use if the 2016 Mastery Flight Training, Inc. All rights reserved. 6

7 airport was not an option. I was able to milk all of my available energy (altitude and airspeed) to allow me to make a down landing on runway 32 with a few feet of altitude to spare. The only reason this was true is because I had about a 15-knot tailwind. Some people may think I cut it too close but I would rather make it to the runway, than make it to a field. The other part is that I self-briefed my options before takeoff and declared an emergency as soon as I had a problem. ATC was able to help clear the way and assist. 3. Don't underestimate the panic on the other side of the radio transmitter. As a survivor of a number of "bow shots from God", the one thing that I have learned to appreciate is the fact that the person on the other end of the radio [Air Traffic Control] will go thru the same kind of psychological steps that those of use in the "emergency" will. They will be kind of useless for the first few seconds, or longer, as they comprehend and deal with the situation. Often they will ask for information that only clouds the ability of the pilot to deal with the situation: number of souls on board, amount of fuel, etc. This is useful information for the emergency response team or will help the people when they write their report but it doesn't really help the pilot deal with the situation at the moment. Pilots should be prepared to answer these questions without it inhibiting the proper flight of the airplane. Finally, I appreciate all that you do. Thanks for your very interesting and thought provoking articles. I appreciate your unique insights as well, Dale, and all the readers who added to the discussion. What do you think? Let us learn from you, at mastery.flight.training@cox.net It is unfortunate that [my donation] amount comes nowhere near the value I receive from FLYING LESSONS. Like last year, if I were able to I'd send much more. Kelly Beerman Please support FLYING LESSONS through the secure PayPal donations button at Thank you, generous supporters. Share the skies with master aviators. Forward FLYING LESSONS to a friend Pursue Mastery of Flight. Thomas P. Turner, M.S. Aviation Safety, Three-time Master CFI Flight Instructor Hall of Fame 2010 National FAA Safety Team Representative of the Year 2008 FAA Central Region CFI of the Year FLYING LESSONS is 2016 Mastery Flight Training, Inc. For more information see or contact mastery.flight.training@cox.net Mastery Flight Training, Inc. All rights reserved. 7