ntsb Archives - Plane & Pilot Magazine https://www.planeandpilotmag.com/tag/ntsb/ The Excitement of Personal Aviation & Private Ownership Fri, 14 Jun 2024 14:08:05 +0000 en-US hourly 1 https://wordpress.org/?v=6.4.4 After the Accident: It’s Not Worth Showing Off https://www.planeandpilotmag.com/after-the-accident-its-not-worth-showing-off Fri, 14 Jun 2024 14:08:05 +0000 https://www.planeandpilotmag.com/?p=631624 With his parents watching, an F-14A fighter pilot took off from the Air National Guard airfield adjacent to Nashville International Airport (KNBA) in Tennessee. He immediately pitched up more than...

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With his parents watching, an F-14A fighter pilot took off from the Air National Guard airfield adjacent to Nashville International Airport (KNBA) in Tennessee. He immediately pitched up more than 50 degrees, climbing up into the clouds in a noisy blaze of afterburners. The pilot became disorientated, lost control, crashed, and died. A Navy inquiry determined the nonstandard, steep climb was intentional. It found the aviator’s judgment was “influenced by his parents’ presence at the field.” An admiral said the pilot was “showing off” to his parents.

This was back in 1996. A recently released National Transportation Safety Board (NTSB) report puts a modern twist on pilots showing off. It turns out we don’t need Mom, Dad, or a Tomcat jet fighter to bend our safety sense. We don’t even have to do anything that feels extreme.

It was May 17, 2021. The weather in Michigan was good. Summer felt close. A 23-year-old pilot departed the Clare Municipal Airport (48D) in a Cessna 182, flying low and slow for two hours. He had a passion for aviation, already logging more than 600 hours aloft. The week before he had obtained his commercial multiengine rating, taking another step closer to his goal of becoming an airline pilot. He landed at the Romeo State Airport (D98) in Ray Center, purchased fuel, and departed from there at noon. An hour later, cruising at 500 feet, suddenly, with no warning and no radio call, the Cessna crashed into a dirt field.

He was flying pipeline patrol. This is a big business. There are loads of commercial pilots in high-wing planes flying above oil and gas pipelines. They are looking for leaks (apparently you can see changes in the vegetation around the leak) and right-of-way encroachments (such as construction activity, trees, or repetitive riding of ATVs causing erosion). Sometimes they fly with an observer, sometimes solo. On this day, the accident pilot was alone in his employer’s 182.

The 1965 Cessna 182H with a 230 hp engine had been flying for the pipeline patrol company for years. NTSB postaccident examination of the wreckage “did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal operation of the airplane.” Likewise, autopsy results showed no medical issues for the deceased pilot. And the accident wasn’t tied to a metrological event. Ten miles away, the official observation was 74 degrees, scattered clouds at 5,500 feet, visibility 10 miles, wind 210 degrees at 5 knots. But the reason for the crash was obvious. It was even marked on the sectional chart.

Close to the field with the main wreckage was a 1,049-foot-high radio tower. The left wing and left cabin door were found by the tower’s base. The NTSB determined the probable cause for the accident to be “the pilot’s failure to maintain adequate visual lookout to ensure clearance from the radio tower and its guy wires.” Radar data shows the Cessna maintaining about 450 to 500 feet above ground level tracking the pipeline northwest. He had been maintaining the normal position, to the right of the pipeline. That’s standard operating procedure for airplanes and helicopters following roads or pipelines. Then he turned a little left, coming out of position and crossing over the pipeline. He wasn’t where he should have been. This was the side with the radio tower.

He saw it too late. The Cessna suddenly pitched up, climbing at 1,500 fpm. But it still collided with a tower support guy wire. The left wing separated from the fuselage at the wing root, falling almost straight down. The rest of the plane impacted in a field, a third of a mile from the tower.

That’s the “how” of the plane crash. But why did the pilot come off track? Why didn’t he see the tower earlier?

After the accident, the NTSB found that “it is likely the pilot was distracted while he used his mobile device in the minutes before the accident and did not maintain an adequate visual lookout.” Managing distractions is an airmanship task, requiring taking charge of our attention. And, down low, attention must be outside the cockpit. The mobile device the NTSB referenced was a smartphone, and this pilot wasn’t just texting or snapping photos, he had an audience. He was posting videos on Snapchat.

For those who don’t know, Snapchat is a social media messaging, photo, and video sharing platform popular with younger generations. Its defining feature is immediacy. Content is only available for a short time before becoming inaccessible, and after 24 hours it’s automatically erased. Several people were watching the pilot live on Snapchat. They were following his progress on the app’s map. Shortly before the accident, a video reportedly depicted the terrain ahead of the airplane’s position, including wind turbines and cornfields.

By the time the NTSB investigator in charge found out about the Snapchats, the platform had already deleted the footage. The agency was able to obtain screenshots of the Snapchat map, showing the pilot’s position as a jaunty, red biplane, and interviewed two people who had been watching online.

The last post was likely sent 35 seconds before the accident. He was 1.5 miles southeast of the tower, heading right toward it. If you’re playing with your phone, you’re not flying the plane. The NTSB concluded that “contributing to the accident was the pilot’s unnecessary use of his mobile device during the flight, which diminished his attention/monitoring of the airplane’s flight path.” He was too busy showing off.

Airline pilots impose a “sterile cockpit” below 10,000 feet, where phones are put away, and they don’t even talk about anything other than the flight. My glider club bans GoPros in the cockpit for the first month of the season. Professional YouTube pilots have assistants and set up multiple cameras that need no attention in flight.

Hollywood pilots extensively plan film shots and use professional aerial videographers.

After that F-14 crash, an NTSB investigator told me: “The most dangerous thing for an airplane is a camera.” Maybe pilots trying to be social media influencers should ponder this question—who is their camera really influencing? 

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Boeing Max and the Case of the Missing Bolts https://www.planeandpilotmag.com/boeing-max-and-the-case-of-the-missing-bolts Fri, 09 Feb 2024 16:43:45 +0000 https://www.planeandpilotmag.com/?p=629982 The National Transportation Safety Board released its preliminary report earlier this week on the midflight door plug separation on Alaska Airlines Flight 1282, and I am sure I’m not alone...

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The National Transportation Safety Board released its preliminary report earlier this week on the midflight door plug separation on Alaska Airlines Flight 1282, and I am sure I’m not alone in wondering if there are some proverbial screws loose between point A and point B in aircraft production. 

On January 5, a door plug separated from the frame of an Alaska Airlines Boeing 737 Max 9 as it climbed through 16,000 feet. The flight crew was able to report the emergency to ATC and land the aircraft—and only minor injuries were reported. 

Aviation has grown increasingly safe over the past few decades, with safety records ticking up steadily to the point that it’s statistically less dangerous to take a commercial flight across the planet than to get in your car and drive to the next city. General aviation isn’t quite at that level, although safety numbers on that front have been climbing as well—an aging GA fleet accessible to the majority of pilots notwithstanding. This incident would seem to be a warning call to remind us that aviation is safe because we work so hard to make it so. 

But apparently there were warnings before this for this particular aircraft. According to the NTSB’s preliminary report, the aircraft had experienced pressurization problems on December 30, just a few days before the door plug blew out. 

Without knowing all of the details, I can’t comment on this particular case. 

But the whole scenario has me thinking a lot in general about the human factors of aviation and the checks we use to protect ourselves and others in the air. We have developed these checks with the full understanding that human beings are fallible and subject to pressures that can lead, at times, to bad decision-making. 

In fact, the recognition of human factors in aviation dates to its early days when accidents were often attributed solely to technical failures. Over time, it became evident that human error caused a significant number of accidents. This realization led to the establishment of human-related factors as a distinct field within aviation, with a focus on studying and mitigating the impact of those issues. 

To help mitigate this fallibility, professionals in aviation go through rigorous training and testing. They must use checklists. And they are required to make decisions that occasionally put personal interest (or at scale, economic interest) behind scrapping a flight because the risk is just too high, whether because of a potential maintenance issue, weather, or a crewmember just can’t hack it that day. 

Economic considerations in aviation are not small. Sometimes the safety of a flight is weighed against the commercial ramifications of failing to complete it. And that is powerful medicine, especially when risk looks somewhat abstract from the ground. However, pressure to complete a flight or project on schedule or within a particular budget should never eclipse safety considerations. 

It’s always worthwhile to slow down, investigate, and triple-check that our T’s are crossed and I’s dotted. We can’t allow all of the safe flights we’ve had before lead to complacency. 

Aviation is made safe by people committing to following established procedures, double-checking everything, and putting the safety of a given flight above commercial concerns or other social or psychological pressures. It takes strength to do this, but it’s so vital. In commercial aviation or general aviation, we should trust—but always verify. 

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After the Accident: Worst Glide https://www.planeandpilotmag.com/after-the-accident-worst-glide Wed, 15 Nov 2023 13:22:36 +0000 https://www.planeandpilotmag.com/?p=628508 A little after 9 a.m., 45 seconds after takeoff, one of the pilots of a Velocity V-Twin radioed the tower at Janesville, Wisconsin (KJVL): “We’d like to circle back and...

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A little after 9 a.m., 45 seconds after takeoff, one of the pilots of a Velocity V-Twin radioed the tower at Janesville, Wisconsin (KJVL): “We’d like to circle back and land Runway 32 and…work through some engine issues if we could.”

ATC acknowledged the request, asked the pilot to report turning final for Runway 32, and if they needed assistance. The reply—“No, sir. We should be fine. Give you a call turning final.” That was the last transmission. N13VT went down while turning onto final, killing both pilots.

Their journey began at 6:30 a.m. on February 16, 2021, leaving Appleton, Wisconsin (KATW). Their destination was Sebastian, Florida (KX26), for planned maintenance. The airplane had issues with its retractable landing gear and was being flown on a ferry permit, which required the aircraft operate with the gear extended at all times. Also, the permit required a copilot even though the four-seat light piston didn’t require one.

The Velocity V-Twin is a two-engine pusher canard. Built as a comfortable long-haul cruiser with an advertised range of 1,100 nm, the experimental category fiberglass kitplane is a stunner. Outside, it looks like sort of a smaller version of the Beechcraft Starship. With big gull-wing doors, inside it has sports car styling with side-sticks and flat-panel displays.

On the front of the fuselage sit canards, small controllable wings that handle pitch control. Used in many aircraft, from the Wright Flyer to the Eurofighter Typhoon, canards can offer excellent control authority. They were designed to stall before the main wing, so at high angles of attack the nose automatically bobs down, always keeping the main wing flying.

On the back of the airplane are the propellers. Pusher aircraft allow the wing to fly in clean, undisturbed air and offer pilots unobstructed views. We don’t see a lot of pusher aircraft because the propellers work in the more turbulent air behind the wing, and there are troubles with engine cooling. What is certainly an advantage with the V-Twin design is the closeness of the two engines to the aircraft centerline, reducing unwanted yaw in single-engine operations. The airplane was built in 2020, and other than the gear mechanism issue, had no known mechanical discrepancies.

The pilots landed at the KJVL—a tower-controlled field with three paved runways—for fuel. The pilots pulled into the Janesville Jet Center and asked to be fueled up with 100LL. The manager remembers nothing unusual—“chitchat mostly”—about their flight down to Florida. The National Transportation Safety Board (NTSB) found no issues with the 100LL.

The weather was good in Janesville. It was winter, and for sure it felt cold, just 7 degrees Fahrenheit. But that’s nothing these two pilots, both in their mid-20s, who grew up in Wisconsin, hadn’t experienced before. The unlimited visibility, complete lack of precipitation, 5,000 foot cloud ceiling, and a light 9-knot wind out of the north would have been welcome VFR conditions.
They taxied out and took off normally. So what was the engine problem? And why couldn’t they return to land on the remaining engine?

Post-accident examination of the airplane revealed a chafed wire on the left-engine oil pressure sender. The NTSB report states that based on “ATC communication, the engine teardown, recovered MFD data, and POH rate-of-climb data, it appears that the flight crew may have shut down the left engine seconds after their radio call as a precautionary measure.” The damaged wiring harness caused the cockpit display to show a red “X” where the left engine oil pressure value would normally be. The left throttle, propeller, and mixture controls were found in their aft (shutdown) positions.

So far, so good—a precautionary engine shutdown and immediate return to land. The airplane continued to climb but at a slower rate consistent with single-engine performance. They were now heading south on a modified left downwind for Runway 32. The flying pilot further pitched down to a level flight attitude. Their indicated airspeed increased to about 16 knots above the maximum for flight with the landing gear extended (VLE is 140 knots for this Velocity V-Twin).

One minute and 10 seconds later, part of the right main gear door came off the airframe and struck the right propeller. All three blades separated about 18 inches outboard from the propeller hub, creating a total loss of right engine power. Immediately, their altitude and airspeed started to decrease. The NTSB performance analysis dryly notes that from here: “with both engines inoperative, N13VT likely did not have the energy required to glide back to the airport.”

As the airplane drifted lower, recovered onboard avionics data showed a rising angle of attack, followed by increasingly frantic gyrations in pitch and roll. The tower controller saw the airplane descend beyond trees southeast of the airport, in a left bank that started to tighten. The controller saw the airplane’s nose “almost pointed down toward the ground.”

The last eyewitness, walking his dog southeast of the airport, described the flight path “as similar to something that would be seen from a crop duster popping up over a field” with an engine “chopping at the air and working hard.” A few seconds later, it disappeared behind trees and crashed. The airplane came to rest inverted in a 3-foot-deep tributary of the Rock River, about a mile south of KJVL. The aircraft was found upside-down, mostly underwater, with its main landing gear in the air. One had the gear door plate attached; the other didn’t. The cause of death was officially reported as drowning and hypothermia, with complicating blunt-force injuries to the head.

The NTSB found no evidence of preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the engines. It was after takeoff that the problems began.

To the pilots, this must have seemed like a nightmare worse than any simulator session. Soon after feathering the left prop and shutting down the left engine for an oil pressure problem, the right engine suddenly—violently—quit. Too far and too low to glide back to the airport, they would lose control and crash three minutes later.

Maybe a single-engine mindset would have saved them. In a single-engine airplane (or, of course, a glider) we must always be mentally ready to set down within gliding distance. Keep control and fly the airplane to the best landing spot. But multiengine pilots are usually more like systems managers, trained to operate on the remaining good engine to get to a suitable airport.

I thought it odd that only a 16-knot overspeed would break off bits of the landing gear, but the NTSB explained that mystery in its examination of the previous flight’s data. From Appleton to Janesville, the pilots flew the Velocity V-Twin well above the VLE speed of 140 knots for operation with the gear extended. In cruise, they maintained between 170 and 180 knots. Starting the descent, they reached 190, a full 50 knots above the listed maximum speed. The NTSB noted this may have weakened the gear door attachment points. Then, when single engine, the higher-than-normal sideslip angles may have helped force the door off the landing gear legs.
Two lessons are obvious from this crash, despite its crazy one-in-a-million double-engine failure: Don’t exceed aircraft limitations, and be prepared to land off-airport.

There’s a third lesson. Do we have to shut down an engine when the gauges show a big red “X”? An engine fire always requires a full shutdown. But if a powerplant seems to be running OK, might we be better off in some conditions letting it produce thrust for as long as possible?

For light aircraft, there have long been debates about whether two engines are really safer than one, the efficiency of pusher props, and the effectiveness of canards. This just-released NTSB report reinforces the reality that while a canard might stop you from stalling, it won’t keep you from crashing—and two engines won’t prevent you from losing all power. 

Editor’s Note: This story originally appeared in the July 2023 issue of Plane & Pilot magazine. 

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Southern California Helicopter Collision Results in 3 Fatalities https://www.planeandpilotmag.com/southern-california-helicopter-collision-results-in-3-fatalities Wed, 09 Aug 2023 16:39:22 +0000 https://www.planeandpilotmag.com/?p=627960 The National Transportation Safety Board is investigating the midair collision of two firefighter helicopters in California that killed three people on Sunday. According to multiple media sources, the two helicopters,...

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The National Transportation Safety Board is investigating the midair collision of two firefighter helicopters in California that killed three people on Sunday.

According to multiple media sources, the two helicopters, a Bell and a Sikorsky S-64 Skycrane, were part of a six ship response to a fire in Cabazon, a small community in Riverside County approximately 90 miles east of Los Angeles. The initial fire call was for a structure fire, but it quickly spread to the dry grass and scrub brush nearby.

The three souls lost were aboard the Bell helicopter, which was used in an observation and coordination role when it collided with the Sikorsky S-64 Skycrane. The latter are often used to drop water or fire retardant.

The Bell crashed on a hillside, touching off another blaze that grew to 4 acres before it was extinguished. The names of the three people killed had not been released by publication time. They were, however, identified as the contract pilot, a California Department of Forestry and Fire Protection (CAL FIRE) chief, and a CAL FIRE captain. 

The Sikorsky made a hard landing, but no injuries were reported.The NTSB and FAA are investigating the accident.

This is an evolving story that FLYING will continue to follow.

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After the Accident: Nightmarish Scenario https://www.planeandpilotmag.com/after-the-accident-nightmarish-scenario Fri, 04 Aug 2023 11:07:57 +0000 https://www.planeandpilotmag.com/?p=627945 A little after 9 o’clock in the morning, seconds after takeoff, one of the pilots of a Velocity V-Twin radioed the Janesville, Wisconsin (KJVL), tower: “We’d like to circle back...

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A little after 9 o’clock in the morning, seconds after takeoff, one of the pilots of a Velocity V-Twin radioed the Janesville, Wisconsin (KJVL), tower: “We’d like to circle back and land runway 32 and…work through some engine issues if we could.”

ATC acknowledged the request, asked the pilot to report turning final for Runway 32, and asked if they needed any assistance. The reply—“No, sir. We should be fine. Give you a call turning final.”—was the last transmission. N13VT went down while turning onto final for Runway 32, killing both pilots.

Their journey began at 6:30 a.m. on February 16, 2021, leaving Appleton, Wisconsin (KATW). Their destination was Sebastian, Florida (KX26), for planned maintenance. The airplane had issues with its retractable landing gear, and was being flown on a FAA ferry permit. The permit required the aircraft operate with the landing gear extended at all times. In addition, the permit required a copilot for the flight even though the four-seat light piston normally didn’t require more than one pilot.

The Velocity V-Twin is a two-engine pusher canard. Built as a comfortable long-haul cruiser with an advertised range of 1,100 nautical miles, the experimental category fiberglass kitplane is a stunner. Outside, it looks like something from a James Bond movie—sort of a smaller version of the Beechcraft Starship. Entering through big gull-wing doors, inside it has European sports car styling with side-sticks and flat-panel displays.

To some the airplane looks backwards. On the front of the fuselage sit canards, small controllable wings that handle pitch control. Used in many remarkable aircraft, from the Wright Flyer to the Eurofighter Typhoon, canards can offer excellent control authority. In this case, they were designed to stall before the main wing, so at high angles of attack the nose automatically bobs down, always keeping the main wing flying. 

On the back of the airplane are the propellers. Pusher aircraft allow the wing to fly in clean, undisturbed air and offer pilots wonderful unobstructed views. We don’t see a lot of pusher aircraft because there remain issues with the propellers working in the more turbulent air behind the wing, as well as troubles with engine cooling. What is certainly an advantage with the V-Twin design is the closeness of the two engines to the aircraft centerline, reducing unwanted yaw in single-engine operations. The accident airplane was built in 2020, and other than the landing gear retraction mechanism issue, had no known mechanical discrepancies.

The pilots landed at the Southern Wisconsin Regional Airport (KJVL)—a tower-controlled field with three paved runways—for fuel. The pilots pulled into the Janesville Jet Center and asked to be fueled up with 100LL. The manager remembers nothing unusual—“chitchat mostly”—about their flight down to Florida. The National Transportation Safety Board (NTSB) found no issues with the 100LL pumped aboard. 

The weather was good in Janesville. It was winter, and for sure it felt cold, just 7 degrees Fahrenheit. But that’s nothing these two pilots, both in their mid-20s, who grew up in Wisconsin, hadn’t experienced before. The unlimited visibility, complete lack of precipitation, 5,000 foot cloud ceiling, and a light 9-knot wind out of the north would have been welcome VFR conditions. 

They taxied out and took off normally. So what was the engine problem? And why couldn’t they return to land on the remaining engine?

At about 1,000 feet above the field, one of the pilots radioed the tower about an issue and requested the return to land. Post-accident examination of the airplane revealed a chaffed wire on the left-engine oil pressure sender. The NTSB report states that based on “ATC communication, the engine teardown, recovered MFD data, and POH rate-of-climb data, it appears that the flight crew may have shut down the left engine seconds after their radio call as a precautionary measure.” The damaged wiring harness caused the cockpit display to show a red “X” where the left engine oil pressure value would normally be. The left throttle, propeller, and mixture controls were found in their aft (shutdown) positions.

So far, so good—a precautionary engine shutdown and immediate return to land. The plane continued to climb but at a slower rate constant with single-engine performance. They were now heading approximately south on a modified left downwind for Runway 32. The flying pilot further pitched down to a level flight attitude. Their indicated airspeed increased to about 16 knots above the maximum for flight with the landing gear extended (VLE is 140 knots for this Velocity V-Twin).

One minute and 10 seconds later, part of the right main gear door came off the airframe and struck the right propeller—an immediate traumatic event. All three blades separated about 18 inches outboard from the propeller hub, creating a total loss of right engine power. Immediately, their altitude and airspeed started to decrease—slowly, steadily, and irrevocably. The NTSB performance analysis dryly notes that from here: “with both engines inoperative, N13VT likely did not have the energy required to glide back to the airport.”

As the airplane drifted lower, recovered onboard avionics data showed a rising angle of attack, followed by increasingly frantic gyrations in pitch and roll. Through the tower window, the controller saw the airplane descend beyond trees southeast of the airport. It was in a left bank that started to tighten. As this happened, the controller observed the airplane’s nose “almost pointed down toward the ground.”

Walking his dog southeast of the airport, the last eyewitness to see N13VT aloft described the flight path “as similar to something that would be seen from a crop duster popping up over a field” with an engine “chopping at the air and working hard.” A few seconds later, it disappeared behind trees and crashed. The airplane came to rest inverted in a 3-foot-deep tributary of the Rock River, about a mile south of KJVL. There was substantial damage to both wings,  canards, and the fuselage. The aircraft was discovered upside down, mostly underwater, with its two main landing gear legs sticking up in the air. One had the gear door plate attached; the other didn’t. The pilots were found dead in the wreckage.

Their cause of death was officially reported as drowning and hypothermia, with complicating blunt-force injuries to the head. 

The NTSB found no evidence of preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the engines. It was right after takeoff that the problems began.

To the pilots, this must have seemed like a nightmare worse than any simulator session. Soon after feathering the left prop and shutting down the left engine for an oil pressure problem, the right engine suddenly—violently—quit. Too far and too low to glide back to the airport, they would lose control and crash three minutes later.

Maybe a single-engine mindset would have saved them. In a single-engine airplane (or, of course, a glider) we must always be mentally ready to set down within gliding distance. Keep control and fly the airplane to the best landing spot on the best terrain presented. But multiengine pilots are usually more like systems managers, trained to operate on the remaining good engine to get to a suitable airport.

I thought it odd that only a 16-knot overspeed would break off bits of the landing gear, but the NTSB explained that mystery in its examination of the previous flight’s data. From Appleton to Janesville, the pilots flew the Velocity V-Twin well above the VLE speed of 140 knots for operation with the gear extended. In cruise, they maintained between 170 and 180 knots. Starting the descent, they reached 190, a full 50 knots above the listed maximum speed. The NTSB noted this may have weakened the gear door attachment points. And then, when single engine, the higher-than-normal sideslip angles may have helped force the door off the landing gear legs.

Two lessons are obvious from this crash, despite its crazy one-in-a-million double-engine failure: Don’t exceed aircraft limitations, and be prepared to land off-airport. 

Plus, there’s a third lesson.

Do we have to shut down an engine when the gauges show a big red “X”? An engine fire always requires a full shutdown. But if a powerplant seems to be running OK, might we be better off in some conditions letting it produce thrust for as long as possible? I fly a two-engine airliner across the North Atlantic every week, and when we’re two and a half hours away from the nearest suitable airport, it will take more than a missing oil pressure indication to shut down an engine.

For light aircraft, there have long been debates about whether two engines are really safer than one, the efficiency of pusher props, and the effectiveness of canards. This just-released NTSB report doesn’t resolve any of those disputes. But it does reinforce the reality that while a canard might stop you from stalling, it won’t keep you from crashing—and two engines won’t prevent you from losing all power.

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New Rules Coming for Alaska Air Tours? https://www.planeandpilotmag.com/new-rules-coming-for-alaska-air-tours Wed, 26 Apr 2023 00:43:13 +0000 https://www.planeandpilotmag.com/?p=627524 The National Transportation Safety Board (NTSB) published a letter urging the FAA to develop and implement new airspace regulations for Ketchikan, Alaska, a popular air tour area. The proposed framework...

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The National Transportation Safety Board (NTSB) published a letter urging the FAA to develop and implement new airspace regulations for Ketchikan, Alaska, a popular air tour area. The proposed framework of regulations would be, according to the NTSB release, “…specific to Ketchikan to require more conservative flight visibility minimums and enhanced weather training for air tour pilots flying there.”

Since 2007, the area has seen a string of fatal air tour accidents, a period the board investigated in forming its recommendations. During that time, there were seven air tour crashes in which 31 people were killed and 13 seriously injured. The rules are needed, the NTSB wrote, to implement procedures that will be more effective in improving safety, something the NTSB said was much needed. “There have been too many air tour tragedies in Ketchikan, a place with unique—but well under-stood—safety hazards that endanger the lives of pilots and passengers alike,” said NTSB Chair Jennifer Homendy.

“Unless the FAA acts swiftly, experience tells us to expect even more heartbreak and preventable loss of life.”The NTSB panned the current safety plan, saying, “…the FAA’s response to many of its recommendations involved voluntary operator actions that are no longer in effect or that had proven ineffective at mitigating the ‘overlapping hazards’ presented by a rapidly changing weather environment and mountainous terrain. Both are often factors in fatal air tour crashes in Ketchikan.”

In its report, the NTSB discussed the most recent fatal air taxi (Part 135) accident, which occurred in August of 2021. On August 5, 2021, a de Havilland DHC-2 airplane, N1249K, which was operated as a Part 135 air tour, impacted heavily wooded, mountainous terrain near Ketchikan. The pilot and five passengers were fatally injured, and the airplane was destroyed.

A review of weather camera imagery, forecasts, weather observations, and passenger photographs revealed that while the pilot was conducting the flight under visual flight rules (VFR), the airplane entered a narrow valley and encountered deteriorating weather. As the cloud cover increased and visibility was reduced due to precipitation and mist, passenger photographs show that the pilot flew at lower altitudes, consistent with a passenger report from the pilot’s previous flight where he attempted to remain below the cloud ceiling and avoid entering instrument meteorological conditions (IMC). On the accident flight, the airplane impacted mountainous terrain in IMC.

The NTSB determined the probable cause of this accident to be, in part, “…the pilot’s decision to continue visual flight rules (VFR) flight into instrument meteorological conditions (IMC), which resulted in controlled flight into terrain.”

There was a wealth of evidence the accident investigators had to work with, largely because the electronic devices of several of the passengers aboard the accident flight were recovered, and many contained photography and videos of the accident sequence. In the report, the NTSB wrote, “Based on passenger photographs and videos, the accident pilot likely flew close to the right side of the valley where the accident occurred. Ketchikan air tour pilots typically fly along the side of valleys to avoid collisions with other aircraft or to provide more room to reverse course if they observe deteriorating weather ahead, such as low clouds or poor visibility (see the accident valley in Figure 2).”

There’s a big caveat here, though. The Board wrote, “Many valleys in the area are too narrow for an airplane to make a full 180-degree turn to avoid entering to escape an inadvertent entry into IMC. In post-accident interviews, two pilots familiar with the valley where the accident occurred stated that they thought it was likely too narrow to safely execute a 180° turn in an airplane.”At issue is the nature of the current voluntary operating procedures, which the NTSB called ineffective and suggested were often not adopted or used by air tour operators. Instead, the NTSB is calling on the FAA to put into place operating rules that would be mandated, comparing the intended rules to those established by the FAA decades ago for air tours operating in locations in Hawaii and over the Grand Canyon.

Those Special Flight Rules Areas (SFRAs) have very specific operating limitations to prevent the kinds of incidents that occur in those locations. The ones promulgated for Ketchikan would consider the flight hazards associated with the terrain and weather in the area and would include more conservative weather minimums. While the FAA has the authority to write and implement such rules, it is under no legal obligation to do so, at least not based on the NTSB’s recommendations, though the concern about safety in the area is surely shared by those at the FAA.

Editor’s Note: This article was originally published in the March 2023 Issue of Plane & Pilot. Subscribe today so you don’t miss an issue!

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Nall Report a Blueprint for Flight Instruction https://www.planeandpilotmag.com/nall-report-a-blueprint-for-flight-instruction Tue, 25 Apr 2023 19:59:48 +0000 https://www.planeandpilotmag.com/?p=627514 The flight instructor is the first gatekeeper when it comes to aviation safety. It is incumbent on the CFI to teach and model good habits for mitigating risk—and you can’t...

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The flight instructor is the first gatekeeper when it comes to aviation safety. It is incumbent on the CFI to teach and model good habits for mitigating risk—and you can’t do that without understanding where the risk is coming from, and when and where during the flight training process we are at a higher risk for an accident.

One way to do this is for the CFI to review the Nall Report, the Aircraft Owners and Pilots Association’s (AOPA) Air Safety Institute’s annual report that looks into accident causal factors—and to develop training scenarios to give learners the tools to address these risks.

AOPA released its 32nd report in October. The report looks at the number of events, the phases of flight where accidents happen, and contributing or causal factors. According to this latest release, most accidents happen during the approach to landing—in particular, when the pilot overshoots the turn to final, overcorrects with bank angle, and inadvertently allows the aircraft to get slow, resulting in an unrecoverable stall/spin. If you check the National Transportation Safety Board (NTSB) database, you will find hundreds of these accidents, which are usually fatal.

A scenario to address the risk involves taking the airplane to a safe altitude—like 5,000 feet—and practicing the base turn to final as if the airplane is in the pattern. This is a basic descending turn. Experiment with a combination of bank angles during a descent, working on coordination. Practice approaches with flaps and without. Use a cardinal heading as “final” and practice making 90-degree turns to that heading. Work on making the turn about timing—do a base-to-final turn at standard rate and roll out right on “center line.”

Make it a rule that if the aircraft is not stabilized on heading, speed, glide slope, and centerline—you will go around.

Uncommanded Loss of Engine Power After Takeoff

How many CFIs teach the “loss of thrust on take-off” briefing from day one? I do, as a part of the pre-takeoff checklist. There are too many fatalities caused by a loss of engine power shortly after takeoff—resulting in a stall/spin situation—to skip this critical briefing. It goes as follows, for flight in a Cessna 172:

Loss of thrust on takeoff briefing:

  • During the takeoff roll, if there is any issue with power production or controllability, the aircraft will be brought to a stop.
  • If there is an uncommanded loss of engine power during the takeoff and there is runway ahead of you, land straight ahead.

Loss of thrust after takeoff no runway remaining, below 700 feet:

  • If there is an uncommanded loss of engine power during the takeoff and the aircraft is out of usable runway, and at less than 700 feet agl, pitch for best glide and aim straight ahead for an open area, or, if needed, veer no more than 30 degrees off the extended centerline.

Loss of thrust after takeoff no runway remaining, 1,000 feet:

  • If there is an uncommanded loss of engine power during the takeoff and the aircraft is at an altitude of at least 1,000 feet agl, pitch for best glide and turn back to the runway at no more than 30 degrees of bank to reach either the runway or some other uninhabited landing field that’s free from obstacles.

Accidents During Landing

Most accidents overall occur during landing, a common cause being the unstabilized approach. Too fast and the airplane floats in ground effect, eating up all the available runway. Touching down too fast can also lead to a bounce and the dreaded “porpoise,” which can lead to a bent firewall and prop strike. Go around at the first indication you have that you won’t touch down and come to a stop within the first third of the runway.

Plenty of accidents happen when the pilot gets behind the airplane and takes incorrect action, such as trying to stretch a glide by pulling the nose up, or dumping the flaps in on final when the aircraft is going too fast and/or improperly configured—read that as the gear is still up. Dumping the gear and flaps at the same time can result in a loss of control with occasionally fatal results. If you are not configured by the time you’re on a long final, go around.

Fuel Mismanagement

Poor fuel management continues to be a causal factor in a great many situations resulting in accidents and incidents best described as “unscheduled off-airport landings.” This often breaks down to inadequate planning, poor decision-making, and a lack of knowledge about the aircraft’s fuel system. Just about every flight school has a story about a learner who either didn’t understand how the fuel system worked or failed to execute the emergency checklist by switching fuel tanks, resulting in an unscheduled off-airport landing that could have been avoided.

You can obtain the fuel endurance of the aircraft readily from the pilot operating handbook, yet sadly, many learners do not learn how to apply this information until they enter the cross-country phase of training. Anytime you land, check the fuel before taking off again. Every time.

Understand that some aircraft—because of age or engine modifications—may burn more fuel at a particular power setting. The art of leaning the mixture for best economy and endurance should be taught early in training.

VFR Into IMC

Flying VFR into instrument meteorological conditions (IMC)—followed by poor IFR technique—were cited as causal factors in a sizable portion of accidents. The FARs require private pilot candidates to log three hours of flight controlling the aircraft by instruments, and there are requirements for IFR currency—but not proficiency. That responsibility rests with the pilots. If you have an instrument rating, make a plan to fly under the hood at least once a month. Fly in VFR or MVFR with an appropriately rated pilot for practice.

If you are a learner pilot, ask your CFI to teach you how to fly an actual instrument approach as an emergency procedure. It is a practical application of the three hours of instrument training you are required to have during your initial course. Remember the most important skills you can have to avoid VFR into IMC are checking the forecast before flight and the 180-degree turn.

Editor’s Note: This article originally appeared on flyingmedia.com

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