In this Issue. What's New?

September 1, 2015

Not on the mailing list?

Click here

to register.

In this Issue

What's New?

Accident Discussions:

Operational Tip

Accident #1

Quick Turns

Accident #2

Newsletter Archive

What's New?

National Safety Forum and Single Pilot Safety Stand Down

As a member of the NBAA safety committee, I would like to invite and encourage all of my readers to attend two events being held at the NBAA Convention in Las Vegas this November. The convention officially begins on Nov. 17, but the day before the opening session, Monday Nov. 16, will feature the Single Pilot Safety Stand Down “Pushing the Envelope on Loss of Control Prevention and Recovery.” The program will run from 9:30 AM – 3:00 PM and will be valuable for anyone who flies in a single-pilot capacity regardless of the kind of airplane flown. Then the National Safety Forum will be held on the final day of the convention, Thursday, November 19 from 9:30 AM – 3:30 PM The day will start off with panel / town hall format addressing the safety challenges we face in our day to day operations. Anchoring our panel, we are honored to have Chairman

Christopher Hart, NTSB; Peggy Gilligan, FAA Associate Administrator, Aviation Safety; Ed Bolen, Chairman NBAA; Jon Beaty, President, Flight Safety Foundation; and Kurt Edwards, President, IBAC. During the afternoon breakout sessions, I will be conducting the Fitness for Duty presentation.

Think you're not a business aviation pilot? If you ever fly any kind of airplane in support of a business you are business aviation pilot subject to the same pressures of the folks flying the heavier jets. This is not an advertisement, just a recommendation. I have personally found NBAA safety activities to be extremely valuable and the members to be true professionals. (Hint: The dress code for the entire convention is business suit and tie.) Please look me up if you attend the convention. The mobile ap will help locate other attendees so just plug in my name. Click here for convention info on the NBAA website.

Increase in Number of GA Fatal Accidents

The NTSB has released preliminary aviation accident statistics for 2014 showing an increase in fatal general aviation

accidents, which increased from 222 in 2013 to 253 in 2014. That represents a nearly 14% increase. That figure might actually be much worse if we could calculate a fatal accident rate rather than just a number. The problem of course is that we do not have an accurate way to measure the amount of GA flying that occurs. But here are some sobering statistics. According to the U.S. Energy Information Administration’s tally of avgas deliveries, thirty years ago more than one million gallons of avgas were delivered each day. By 2006, the number had dropped to 646,000 gallons per day. So in an effort to look at the hours flown for 2013 as compared to 2014, 2013 saw 522,600 gallons per day while 2014, avgas deliveries were down to 453,300 gallons per day. That might (emphasis on might) mean that GA flying was down by about 13% while fatal accidents were up 14%. (Click here to see the USEIA data.)

The total number of GA accidents decreased by only 3 for the same period (1,224 down to 1,221). So if we apply our fuel deliveries decrease to estimate hours flown, we are again not looking good. I also fear that many crashes that used to be classified as accidents are now being classified as incidents, thereby skewing the accident numbers. I say this because I have seen many crashes reported in local news media with pictures of airplanes with significant structural damage that have been classified as incidents.

In any case, we need to help promote safety to pilots who need to hear the message. Every pilot knows someone like that. Invite one or more of those pilots to join you in attending a safety seminar or webinar.

Webinar Held Aug. 25

Graphic 1 - Risk Assessment Matrix Click image for a larger view.

Sample FRAT excerpt for Business Aviation Click image for a larger view

the kind comments that I received after the event though time did not permit personal replies to all of them. The webinar, titled "Help! My Brain is Trying to Kill Me!" focused on the aeronautical decision making and particularly on cognitive biases. If you missed both of those webinar events but would still like to view the material and receive the Basic Knowledge-1 Wings credit, click here to take the associated online course.

OPERATIONAL TIP

I have had a considerable amount of email interest in the Flight Risk Assessment Tool or FRAT since I briefly mentioned the concept in a couple of recent webinars. So this month our discussion will focus on the concept, creation, and use of a FRAT in small and medium sized general aviation airplanes.

The Problem

We can have the best of intentions regarding safety but our humanness can easily get in the way of making good decisions about identifying and managing risk. Many human factors can influence our decision making. One way to help avoid having external factors influencing our decisions is to remove as much subjectivity from the decision making process as possible. That is an impossible task once a flight is scheduled and something perceived as being important depends upon making the flight.

The FRAT Concept

The middle name of the FRAT is "Risk Assessment" so let's start there. But for that, we must understand "hazard" and "risk." A hazard is a source of danger and risk is the future impact of a hazard that is not controlled or eliminated. A rattlesnake is a hazard. The risk is determined by how we deal with the hazard. If we go walking around in an area known to be inhabited by rattlesnakes while wearing sandals, our risk posed by the hazard is quite high. But if we visit a zoo with a rattlesnake contained behind glass, our risk posed by the hazard is quite low.

The idea of a risk matrix has been around for a long time. The matrix as shown in Graphic #1 plots the likelihood of an adverse event occurring versus the severity of the consequences if it occurs. This can be helpful in letting pilots determine whether or not a particular risk is acceptable or not. The concept is good, but the execution can be fatally flawed by our humanness. A pilot might determine that a particular risk is "high" for a flight to visit an in-law, but might determine that the same risk is "moderate" if attendance at an important business meeting is involved. So we want to remove as much of the subjectivity from decision making as possible. One way to work toward that goal is to make many decisions regarding hazards and risks when we are not pressured to conduct a particular flight. We can do this much more objectively when we are sitting down with a leisurely cup of coffee on a day in which no flying is planned.

So the FRAT, like the personal minimums checklist, is a personal

document, not a one-size-fits all. Two variables come into play. The first is the individual pilot's tolerance to risk. But it is important to remember that our decisions affect many people other than ourselves, whether they will

be onboard the airplane or not. The second variable relates to the pilot's proficiency in the particular operations involved. A pilot who is extremely skilled in handling the airplane in VFR conditions might not be as proficient in night or IFR flying. And, of course, the pilot's proficiency in the various tasks is fluid rather than fixed. An experienced instrument pilot will not be as proficient if no instrument flying has been done in six months, but a brief refresher with a CFI can bring the skills back to an acceptable level. Medical conditions, whether temporary or permanent, and the normal effects of aging must be considered. Therefore, the FRAT must be reviewed and revised frequently to reflect any changes in pilot proficiency or other conditions. I would suggest a complete review of the FRAT every six months with an additional review if any material changes occur in physical or mental condition.

A FRAT will contain numerous line items with each item assigned a risk value. The line items are designed so that each is answered objectively with a simple yes or no. If a yes is answered to a particular item, then the assigned risk value for that item is entered into the corresponding flight value column. When the FRAT survey has been completed, the flight values are added and compared to a maximum acceptable flight value that has been established for the FRAT. If the maximum value has been exceeded, the flight can only depart if the risk can be mitigated on one or more of the line items so that the flight value falls within the acceptable range. For example, if values for lack of recent night experience and a component of the flight being conducted at night have been entered, that risk can be mitigated by scheduling the flight so as to avoid night operations. Removing those flight values might lower the total flight value into the acceptable range.

General Aviation Frat Sample Excerpt Click image for a larger view.

News Photo Click image for a larger view

Of course, one important benefit of using a FRAT is the necessity to actually do flight planning. To accurately use the FRAT, we must know calculated takeoff distance, weight, etc.

I have provided a sample FRAT that can be easily customized for use. The sample document is intended as a model for use by VFR only pilots flying simple or complex single-engine airplanes. Let me stress that the document is a sample only and must be customized before it is usable. Please do not send me emails saying that something should be included and something else should have been excluded or that the assigned risk value for a

particular item should be changed. The document provided is intended to be only a framework on which to build a personalized, customized, usable FRAT.

Click here to download the FRAT in MS Word® format. Click here to download the FRAT is PDF format.

My best suggestion for customizing the FRAT is to do it as a cooperative effort with other pilots. That is not to say that each pilot in the working group will end up with the same FRAT. It can still be individualized but the interaction involved with bouncing thoughts off each other can be very valuable.

Just after I finished writing this article and creating the sample FRAT, the FAA published an article on risk assessment which also contains a sample FRAT. Theirs is a bit fancier than mine and is also customizable. Mine addresses more areas than theirs, but I am guessing that they wanted to produce something that is quick and easy to use so as to not discourage pilots from using it. Please take the time to look at their thoughts and their FRAT so that you can develop your own customized tool to be safer. Click here to see the article on the FAA website.

Next, we will discuss two accidents that might have been prevented had the pilot done a better job of assessing risk.

Accident Discussions

Accidents discussed in this section are presented in the hope that pilots can learn from the mistakes of others and perhaps avoid repeating those mistakes. It is easy to read an accident report and dismiss the cause as carelessness or a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

Accident #1

The 47 year old pilot died in the crash of his Cessna 172 in January 2011. The crash occurred in Missouri during a protracted cross country flight.

The NTSB accident report includes the following information: "The accident occurred during the fourth leg of a visual flight rules cross-country flight. The pilot departed on the first leg of the trip shortly after sunrise, about 11 hours prior to the accident. The pilot made 3

intermediate stops during the day, where he purchased fuel. The accident flight was approximately 1 hour in duration and was conducted in night visual meteorological conditions. Radar track data depicted the airplane established on a west-southwest course and at a constant altitude. About 15 seconds prior to the accident, the airplane entered a descending left turn, and spiraled down, ultimately impacting an open field. A

postaccident examination of the airplane did not reveal any anomalies consistent with a preimpact failure or malfunction. Postmortem toxicology testing was consistent with the prior use of a prescription anti-anxiety medication and marijuana. Due to limited samples, a determination could not be made as to when the substances were last used. Accordingly, no

determination was made as to whether the pilot was impaired at the time of the accident. While the departure from controlled flight suggested spatial disorientation, and the extended duration of the trip likely contributed to pilot fatigue, the exact nature of the loss of control could not be determined."

The NTSB report also states, according to local law enforcement, 12 bags, each containing approximately 1 ounce of marijuana, were recovered from the airplane after the accident.

The NTSB probable cause finding states, "The pilot's loss of control for undetermined reasons. Contributing to the accident was the pilot's fatigue."

NTSB Photo Click image for a larger view

NTSB Photo Click image for a larger view So let's see how this flight would have scored had a FRAT been used. Though this leg of the flight was to be only about one hour, the entire flight would have triggered a score for long duration. This leg was at night, so a score for night flying would have been listed. There is no record of the pilot having made a night flight during the past 90 days so an additional item would have been scored there. No mention of an anti-anxiety prescription medication being reported to the FAA was made, so we must assume it was not. That would also trigger a score. By the time the accident happened, the pilot would have had less than 7 hours sleep in the past 18 hours so a score for that would have been recorded. Then, of course, there is the marijuana. Anyone who uses a recreational drug should include a line item in their personal FRAT to address recent use. If we were to use our sample FRAT for this flight, the score would have been 20, our maximum acceptable value before the marijuana was considered. Certainly a few points would have been allocated to that item so the pilot would have been outside acceptable limits.

Click here to read the accident report on the NTSB website.

Accident #2

A pilot died and his wife was seriously injured as a result of a crash involving a Piper Warrior. The crash occurred in Missouri in March of 2012. The pilot attempted a takeoff from a turf runway having 6 to 10 inch tall grass. The 2,600 foot runway was also described as being soft. There was also a quartering tailwind.

The NTSB report includes: "The airplane departed about 1,900 feet down the runway, veered to the left, stalled, and collided with trees before it came to rest in a field. Interpolation of available takeoff performance revealed that the airplane would have needed about 2,312 feet of ground-roll distance for a successful takeoff from a paved, level, dry runway, with zero flaps, under the existing wind conditions. No mechanical deficiencies were found with the airplane or engine that would have precluded normal operation at the time of the accident."

The 61 year old pilot had a total of 152 flight hours of which 45 hours were in the Piper Warrior. Clearly, takeoff performance calculations would have revealed that this takeoff was not possible. The takeoff performance charts provided by the aircraft manufacturer clearly state that distances must be increased for takeoff from a grass runway and any pilot should know that 6 to 10 inch tall grass puts the takeoff distance out of the park for an airplane in this class.

The toxicology report on the pilot was positive for Acetaminophen in the urine and Diphenhydramine in the urine and blood.

The NTSB probable cause finding states: "The pilot’s failure to maintain airplane control during takeoff, which resulted in an aerodynamic stall and subsequent collision with trees. Contributing to the accident was the pilot’s inadequate preflight performance planning before departing on the soft, grass field with a quartering tailwind."

So applying the facts of this accident to our sample FRAT would have provided a definite no-go without even doing the math. The use of Diphenhydramine is disqualifying as is a takeoff requiring more than 70% of the runway length. If we were to also do the math, we would be adding flight values for less than 100 hours in aircraft type, any symptoms including allergies (hence the two medications), taking any OTC medication, turf runway, and a tailwind.

Click here to read the full accident report on the NTSB website.

Quick Turns

New FAA Enforcement Policy

safety management system (SMS) principles to improve the sharing of safety data between the FAA and the aviation

community. The policy explained, "To foster this open and transparent exchange of data, the FAA believes that its compliance philosophy, supported by an established safety culture, is instrumental in ensuring both compliance with regulations and the identification of hazards and management of risk.

"When deviations from regulatory standards occur, the FAA's goal is to use the most effective means to return an individual or entity that holds an FAA certificate, approval, authorization, permit or license to full compliance and to prevent recurrence. "The FAA recognizes that some deviations arise from factors such as flawed procedures, simple mistakes, lack of

understanding or diminished skills. The agency believes that deviations of this nature can most effectively be corrected through root cause analysis and training, education or other appropriate improvements to procedures or training programs for regulated entities, which are documented and verified to ensure effectiveness. However, reluctance or failure to adopt these methods to remediate deviations or instances of repeated deviations might result in enforcement."

The simple fact is that this is not a new policy. It is a newly-announced policy. For several years the FAA has taken little preemptive enforcement regarding general aviation. The only enforcement has been for the most egregious violations. Of course without preemptive enforcement, those violations are primarily revealed only after an accident. If a pilot survives an accident, suspension or revocation of his or her pilot certificate is of little comfort to the families of passengers killed or seriously injured in the crash.

This kinder, gentler approach has been used with the airlines for the past few years. It has been largely successful. However, I fear that many folks in the GA community do not share the commitment to safety or the safety culture found in the airlines. Many GA pilots and technicians operate in isolation and do not participate in the information sharing and training programs that are found at the airlines. To put it bluntly, I fear that many pilots and technicians, knowing that enforcement of the regulations is unlikely, will take advantage of the situation to save time and money. I know that I have used this analogy before, but I think that highway deaths would rise if the police agencies announced that "instances of repeated deviations might result in enforcement."

Nobody wants to see FAA inspectors roaming the ramps of GA airports looking for violations to write up. But I think those of us who realize the importance of following the regulations and established procedures in the interest of safety will be put more at risk by the few who will do whatever they think they can get away with. Just wait till the news media runs the special reports on the accidents in which the pilots were in gross violation of regulations and not reigned in by the regulators.

Not on the mailing list?

Click here

to register.

Please help support my safety

initiative by donating. These

advertising-free publications

including this newsletter, my website,

and my free online courses are

entirely personally funded.

(Donations are NOT tax deductible.)

Disclaimer: Material contained in this newsletter and in this section is for informational purposes only. It should not be construed as directive, doctrinal, or instructive. Individuals should consult with their flight school management, certificated flight instructors, aircraft manufacturer recommendations and directives, Flight Standards District Office (FSDO) and/or appropriate FAA publications including the Aeronautical Information Manual (AIM), the Federal Aviation Regulations (FARs), and applicable FAA Advisory Circulars (ACs) for specific guidance relative to any information or before employing any recommendations contained in this newsletter. Further, nothing on this web site or in this section is intended to contradict or be in disagreement with any official FAA rule or regulation, nor should such material be interpreted or construed as such. This web site is intended exclusively to promote general aviation safety and to increase awareness of current events in aviation.

Copyright© 2015 Gene Benson

All rights reserved