Author: Gene Benson

There are many ways to analyze accidents. One of those is to try to mentally put yourself in the place of the pilot at different stages of the flight, from flight planning through the end of the accident sequence. Part of that is to imagine the pilot’s state of mind as the situation deteriorates so that you can try to formulate actions that might have saved the day.

I can imagine that in many, if not most cases, at least for a fleeting moment, the pilot asks the rhetorical question, “What am I doing here?” Obviously, that is not a strategy to avoid the accident at that point, but it is helpful for us to study the accident and ask, “How did the pilot get into that situation.”

We know about the error chain and that usually a series of errors, rather than a single mistake, leads up to a crash. We also know that if the error chain had been broken somewhere along the way, the accident might have been avoided. So let’s look at some risk factors, commonly found as links in error chains, that we might be able to mitigate. Usually more than one of these risk factors work together or in sequence to answer our question, “How did the pilot get into that situation.” These are not presented in a particular order because they can all range from a minor, contributing factor to a major causal factor.

Proficiency  Pilots need to be proficient for any operations they might reasonably have to perform. The lower the pilot’s capability curve the lower the margin of safety. Of course capability must be measured against the task load for the particular operation. The pilot who always operates a Cessna 172 from a 6,000 foot paved runway with no obstacles at either end, has little need to practice short or soft field operations from a 1,500 foot turf runway with trees at each end. That might be true except when something does not go as planned. Unexpected adverse weather, or a mechanical problem might necessitate an unplanned landing at, guess what, the 1,500 foot turf runway with trees at each end.

But there are areas in which a pilot might not need to maintain proficiency providing there is no chance that the particular skill will be needed. An example might be the professional pilot who is multiengine rated but is retired and only flies single engine airplanes. There is no need to be proficient in multiengine, engine-out operations providing the pilot has the resolve to stay with just single engine airplanes. A common problem befalls the non-current, non-proficient instrument rated pilot. Needing to get home to go to work with IFR conditions and access to an IFR equipped airplane often provides too much temptation to think, “It will be OK just this once.”

Aircraft Maintenance The first link in the error chain often is put in place long before the flight occurs and sometimes that involves aircraft maintenance. An inflight mechanical problem, can range from catastrophic such as a control failure to a minor one such as the loss of an alternator during day VFR flight. But even a minor mechanical problem, increases the pilot’s task load and thereby decreases the safety margin. A well-maintained aircraft does not eliminate the possibility of a mechanical problem inflight, but it reduces the probability.

Fatigue Just about every high-stakes or mission-critical industry has come to recognize the risk posed by a fatigued operator. Of course that includes pilots. Fatigue is common in our society and of course varies in severity. The FAA has determined that being awake for 17 hours has the same effect on performance as having a blood alcohol level in the 0.05 to 0.10 range. The only way to reduce fatigue is to sleep. So the pilot who is otherwise very proficient and fit to fly, but who has been up most of the night, perhaps with an ill child, works a long day, then embarks on a long, cross country flight is adding a link to the error chain. That pilot will have decreased capability and therefore the a reduced margin of safety.

Impairment  Most pilots are well aware of risk of flying after consuming alcohol and refrain from doing so. Most pilots do not use illicit drugs and those who do mostly do not fly while they are under the influence. Unfortunately, we are seeing more cases of impairing, illicit drugs in toxicology reports of fatal accident pilots.  But many pilots are actively flying while being unknowingly impaired. That impairment comes from a variety of prescription and over-the-counter medications. Space here does not permit a detailed discussion, but a general rule that works most of the time is to read the label and ask a pharmacist. If the label says not to drive or operate machinery, that should be a big red flag. Interactions are also a factor, and that is where advice from a pharmacist comes into play. Any degree of impairment reduces capability and therefore the safety margin. Impaired flying presents a big link in the error chain.

External Factors In the human factors world we call this pressure. It is simply something that causes us to press the envelope and go into a situation which is ill-advised. External factors often add the deciding link to the error chain. Common sources of this pressure are a need to conduct a flight to get back to work the next day, provide a promised flight to another person, attend an important meeting, get a child back to college for exams, and many more. Our cognitive biases work on our unconscious mind to make us believe that the risks are lower than they really are.

Of course there are more of these factors and more possible scenarios for each. Below are links to a couple of accidents in the Accident Analysis section. Read through them and see if you can apply some of the factors above to determine how the error chain developed. Try to answer the question, “How did the pilot get into that situation.”

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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.

Please “follow” our SAFE blog to receive notification of new articles and also write us a comment if you see a problem (or want to contribute an article). We always need more input on aviation excellence or flight safety. There are many highly qualified SAFE members out there! If you are not yet a member, please Join SAFE and support our mission of generating aviation excellence in teaching and flying. Our amazing member benefits alone make this commitment worthwhile and fun.

Several years ago I was invited by the FAA to give a presentation at a required training event for designated pilot examiners (DPEs). My talk was titled, “Do No Harm!” That title was taken from the oath administered to new physicians in which they are admonished to always leave their patients in better condition after their treatment than before. My presentation featured several reconstructions of accidents where the actions of CFIs and DPEs had been a contributing cause. Yes, there have been accidents, even fatal ones, on checkrides.

My presentation was just a little more than one hour, a small part of an all day event. As the day unfolded, the term “gatekeeper” was used numerous times by the several presenters. The group was told that the CFI must be the “gatekeeper” to make sure that all pilots are competent in their skill, knowledge, and decision-making.

By mid afternoon, my stomach was getting an uneasy feeling. I reviewed what I had eaten for lunch and decided that since I had passed up the chilidog for the turkey sandwich on wheat bread, food wasn’t at fault. That gnawing in my gut must be from what I was hearing. If the CFI is the gatekeeper, why had my research found so many instructional accidents in the past five years? Who is keeping the gate on the gatekeepers? The FAA? Hardly. They don’t have the staff necessary to perform even the most basic level of oversight.

Then I had my epiphany. Most accidents, whether or not involving instruction, are not caused by a lack of skill or knowledge. They are also not caused by a lack of decision-making skills. Pilots making poor decisions cause accidents. How’s that again? There is a difference between having the ability to make good decisions regarding any aspect of a flight and actually making a good decision. A flight instructor can test the ability of a student to make good decisions but cannot effectively determine whether the student will actually make good decisions once certified.

Here is an example. An instructor may begin a cross-country flight into an area of deteriorating weather to determine if the student can evaluate the weather and make an appropriate decision on whether to continue, divert to an alternate airport, or return to the departure airport. From my experience as a flight instructor I can state that 99% of the time the student will make an appropriate decision. But that is an artificial environment in which the student advances only by making the safest possible decision. The real environment encountered once the pilot is certified has many outside determiners. The pilot’s decision may be influenced by the need to get to the destination on time, the costs associated with diverting to an alternate location, ego, machismo, or others factors.

So my point is simply this. Neither the flight instructor nor the designated examiner can really be the gatekeeper. We must all be our own gatekeepers. We have the tools to make the right decisions. We must make those appropriate decisions every time we fly.

I will relate a brief personal story. In the late 1970s I was a faculty member at an aviation college in Florida and I supplemented my income by flying part-time for a charter company. I was required to take a Part 135 checkride with an FAA inspector. As luck would have it, I drew the inspector with the hard-posterior reputation. I was nervous about the ride and I tried really hard to do everything by the book. The inspector really put me through the wringer and I was drenched when the ride was done, even though it was a cool day by Florida standards. During the debrief, the inspector not only told me that I had passed, but told me that it was one of the best rides he had given. Before my head could swell too much he said that he wanted to give me some advice. He told me that he was well aware of his reputation as being tough to please. He said that he was also aware that I probably wasn’t as diligent when not on a checkride. Then came the advice. He said, “If you want to have a successful career in aviation and live to get old, make believe that I am in your jumpseat on every flight and make all your decisions accordingly.” Those words stuck with me through more than 15,000 accident-free flight hours.

So in summary, I learned early in my career to be my own gatekeeper and I would encourage all pilots to do the same.

Please “follow” our SAFE blog to receive notification of new articles and also write us a comment if you see a problem (or want to contribute an article). We always need more input on aviation excellence or flight safety. There are many highly qualified SAFE members out there! If you are not yet a member, please Join SAFE and support our mission of generating aviation excellence in teaching and flying. Our amazing member benefits alone make this commitment worthwhile and fun.

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