Much attention is given to the prominent accidental causal factors such as thunderstorms, structural icing, midair collision, pilot impairment, and the like. But often a seemingly minor item can begin an error chain that ends poorly.
We have all heard the axiom regarding new pilots. It states that a pilot begins with a full bucket of luck and an empty bucket of experience. The challenge is to sufficiently fill the bucket of experience before the bucket of luck is emptied. I have written before about how that most certainly applied to me when I was a new flight instructor many, many years ago. One of those transactions of trading luck for experience taught me a lesson regarding one of those “little things.”
It was a clear, dark, cold winter night and I was taking a primary student out for his third and final night lesson before sending him for his private pilot checkride. We ordered fuel for the Cessna 172 and waited inside for the line person to complete the fueling process. I then sent my student out to perform the preflight inspection while I enjoyed the CFI’s prerogative of waiting in the comfy and warm FBO. The student signaled that he was ready so I went out, strapped myself in, and we were off for our flight. The student performed all of his procedures very well and we lifted off into the moonless, but star-filled night sky. I had instructed the student to perform a short field takeoff which he did quite well. Passing about 70 feet AGL he lowered the nose slightly to accelerate from Vx to Vy. A few seconds later we were beyond the airport boundary, over sparsely populated agricultural land, and to quote one of my favorite expressions, it was darker than the inside of a cow. We were climbing nicely in the frigid, dense air when suddenly the cabin was filled with loud, unfamiliar noise. It sounded like we were taking .50 caliber gunfire. My brain quickly dismissed that as an unlikely scenario as I scanned for possibilities. To the student’s credit, he continued to fly the airplane and simply asked, “What’s that?” I scanned the flight and engine instruments and all indications were normal and the airplane was apparently flying without difficulty. The racket continued however so I told the student to fly a normal pattern and return for a landing. As we entered the downwind leg I realized that the noise was coming from above us and the only items up there were an antenna and two fuel caps. We landed normally and soon confirmed that a fuel cap had come loose and was flapping against the fuselage directly above our head, safely tethered by its retaining chain.
Other than a few dings in the paint, the airplane was undamaged. Very little, if any fuel had siphoned out of the open fuel filler hole. No harm – no foul. I replaced the offending fuel cap and checked the security of the other cap and we departed again. The lesson was completed without further incident.
My bucket of experience got a bit more full having learned the valuable lesson that critical preflight inspection items must not be entrusted to anyone else. Two individuals who I believed to be competent, the line person and my student, had both handled the fuel cap. whether one or both was at fault in not properly securing the fuel cap is immaterial. It was my responsibility to make sure the airplane was prepared for flight.
It wasn’t until several years later that I realized the potential hazard presented by that loose fuel cap. At first, I did not consider the incident to have presented much danger. Even if fuel had been siphoning out of the tank, there was little fire risk since it would have streamed harmlessly past the tail. Even if the entire tank had been emptied, we still would have had a full tank remaining for our local flight, providing I selected the unaffected fuel tank to prevent cross-feed. So fuel exhaustion was not likely. The hazard presented was the increased risk of loss-of-control due to the distraction. Recall that it was a dark, moonless night. What I did not mention was that nobody onboard held an instrument rating. Back in the early 1970s, holding an instrument rating was not a requirement for a commercial pilot certificate or a flight instructor certificate. I had followed the normal progression for the time in obtaining my commercial pilot certificate and then my flight instructor certificate first, then using my instructing revenue for my instrument rating and my CFII. So there I was providing flight instruction to a primary student on a dark moonless night with no horizon and no instrument rating and now facing a formidable distraction. I suspect my luck bucket suffered some serious depletion that night.
So how can we mitigate the effects of such a diverse group of accident causal factors that have little in common? There is no single, simple answer to that but there are some things we can do to be more proactive. First and foremost, we must know the aircraft systems and maintain a high level of proficiency in the aircraft. The best way to do that is to be actively engaged in a formal recurrent training program. We don’t necessarily have to enroll with one of the “big box” training providers. Any competent CFI who is familiar with our specific aircraft should be able to create a program. And let’s not forget that the FAA Wings program will create a custom program for us automatically.
Also, we often know what we need to do but we fall short in the execution. We need to strengthen our resolve to have and use a checklist for each phase of flight, including the preflight inspection. We must resolve to keep our aircraft maintained to a very high standard, including compliance with service bulletins. We must also resolve to establish and enforce sterile cockpit procedures during critical phases of flight, including taxi.
Of course there are many other little things that can and do begin or continue an error chain. A cabin door popping open, an ill-timed question or statement by a passenger, an indication of a landing gear problem, an alternator going offline, unfamiliarity with technology, and many more “little things” can cause a distraction. A simple item missed on a preflight inspection or on a checklist can cause big problems in flight. And then there is the mistaken belief that just a little frost on the airplane is OK.
So, in summary we need to pay attention to the “big ticket” accident causal factors that get most of the attention. But we also need to be on top of our game, apply discipline and follow established procedures to help prevent the little things from becoming huge monsters.
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