Safe Landings - December 2011

Fly The Airplane

A review of recent ASRS reports indicates that failure to follow one of the most basic tenets of flight continues to be a concern when pilots are faced with distractions or abnormal situations. Since the consequences associated with not flying the airplane can be serious, this month’s

Safe Landings revisits the problem and re-emphasizes a lesson as old as powered flight: Fly the airplane; everything else is secondary.

Note that the phrase, “FLY THE AIRPLANE” appears in all-caps in each of the following reports. The emphasis is not an editorial addition, but rather reflects the importance each reporter placed on that admonition.

A Flying Lesson

Two Cessna 205 pilots flying in IMC and experiencing communication problems were fortunate that one of them recognized the importance of actually flying the aircraft.

• We were in a well-equipped C205 with a thorough annual completed a few weeks earlier…. The ceilings were lowering quickly as lines of widely spread thunderstorms moved through the area. We had satellite weather and weather radar on board so we had updated information even though I did a thorough weather brief. We figured we’d be in front of the line of weather as long as we were  airborne early. Our release time was 20 minutes later than hoped for. Satellite weather still showed, “Waiting for data.”

We launched and within a minute were in IMC. The left seat pilot wasn’t doing a very good job of keeping wings level. I pointed to the attitude indicator…and decided that I’d only interfere if bank angle exceeded 15 degrees or so.

I tried calling Center— nothing. We were at 3,500 feet (and cleared to 5,000). We should have had contact by now. I tried Approach — nothing; Towe r— nothing. [There was] lots of activity on the [weather radar]; we needed to deviate soon…. I saw that we were in a 30-degree bank and said, “Let’s turn on the autopilot while I figure out this communication problem.”

I fiddled with the radios, tried different frequencies— still nothing. I looked at the attitude indicator and saw a steep descending turn. I switched off the autopilot, grabbed the yoke and tried to figure out why the autopilot didn’t correct the bank angle. Then I heard a voice in my head, “FLY THE

AIRPLANE!” I leveled the wings and arrested the descent. …. Lessons learned? Make sure you can hear some transmissions before taking off into IMC. The autopilot cannot be relied on to reduce pilot load when there are system problems. A handheld GPS device with independent battery and approaches is a lifesaver. Practice for emergencies. They don’t happen when you are expecting them. And, most importantly, FLY THE AIRPLANE.

“It is possible to fly without motors, but not without knowledge and skill.”

Wilbur Wright

In the following two reports, the pilots of a Cessna 210 and an Experimental Homebuilt both had a loss of oil pressure and were facing imminent engine failure. They had to make some quick assessments to determine the best course of action, but in the process they wisely maintained flying the airplane as their first priority.

• We were flying [a Cessna 210] on an IFR departure…and were vectored to 080 degrees then southeast. As I rolled level [there was] a loud bang and heavy shudder of the engine. I turned the boost pump on and manipulated the throttle with no effect. RPM stayed about 1,000-1,200. Oil pressure was zero. We declared an emergency and turned direct to [the airport] and were cleared to land, but we were unable to make it to the airport. We considered the highway, but there was heavy traffic. We located an open field and committed with a good approach and landing. [There was] no damage.

The event confirmed the wisdom of FLYING THE AIRPLANE!

•  We flew our [Experimental Homebuilt] aircraft at about 2,500 feet and under the Class C airspace. About one hour into the trip, I heard a pop and there was smoke in the cabin. I had to assume that the smoke would only get thicker (though it did not). The EFIS (Electronic Flight Instrument System) was flashing Zero Oil Pressure. I immediately looked for a good spot to put the airplane down. I knew from the GPS that we were not close enough to an airport. So much raced through my mind that I am not sure how to explain it as anything but almost instantaneous. All of the hours training for this came back with multiple instructors’ voices in my head repeating the procedures. I do not think I can emphasize this enough. It really was rote. I did not have to think about it.

An airfield was out; the fields looked small and hilly; there was a road that was about to turn to a straight section directly in front of us. I pulled off the power and lined up on the road…. I started trying to tune the radio to 121.5, but then I heard, “FLY THE AIRPLANE” in my mind as I gave up on the radio. I did not exactly establish best glide as I needed to lose too much altitude. I was in a slight dive…. As we got closer to the road, I saw how close the trees were to my wingtips and how many power lines there seemed to be.

We were flying right behind a truck and coming to a set of power lines…. I had put it in my head that I needed to fly as if I would lose the engine at any second, but I thought, “Well, I’ll go over that line and under the next!” I added power and I felt as though I were threading a needle. My foot slipped on the rudder pedal and I glanced down to see a river of shiny black oil on the floor. No time to think about that; FLY THE AIRPLANE! We sailed over the truck and…touched down and started the rollout.

There is an old aviation adage that sums up the lessons in all of this month’s reports and it is just as valid today as when it was first expressed: Aviate; navigate; communicate. In other words, fly the airplane first.

Safe Landings - November 2011

Upside Down and Backwards

One of several versions of the origin of “Murphy’s Law” contends that the Law’s namesake was Captain Ed Murphy, an engineer at Edwards Air Force Base in 1949. Frustration with a transducer which was malfunctioning due to an error in wiring caused him to remark that—if there was any way that something could be done wrong, it would be.

Recent ASRS reports indicate that Captain Murphy’s Law was in full effect when several aircraft components managed to get installed upside down or backwards.

Pernicious Panel Placement

An aircraft Mode Selector Panel that “looks the same” whether right side up or upside down, and that can be readily installed either way, is a good example of a problematic design. Confronted with an inverted panel, this Cessna 560 Captain found out what happens when the wrong button is in the right place.

• During the takeoff roll, the First Officer called for rotation and I pulled back on the yoke and focused my attention on the V-bars. Instead of finding the bars above the horizon as expected, they were on it. I reached up and pushed the upper left Selector Panel button again, but the bars did not spring into place as anticipated. I glanced back at the panel and, for the first time, realized that it had been installed upside down. Looking across, I found the First Officer’s side was upside down as well. We returned to the airport and reported the discrepancy to our company.

Upon reflection, I realized that I’ve become so accustomed to the panel that I may no longer read the writing on the buttons; I just press the place where that button should be. Instead of pressing HDG, I pushed VS on the inverted panel. The faulty installation escaped the attention of two Avionics Technicians, one Quality Control Inspector and, of course, both pilots. The panel looks exactly the same whether right-side up or upside down except for the labels. I find it surprising that it was designed in such a way that it could be installed incorrectly.

Although the aircraft had just come out of maintenance, there seemed no logical reason for giving extra attention to the Mode Selector Panel since none of the maintenance directly involved avionics repair or installation. We later learned that the panels had been removed during the replacement of the nose fans.

If anyone had asked me if I observe the Mode Selector prior to pushing a button, I would have assured them that I do. Since this incident, I’ve come to notice how often I (and I suspect most people) rely on “standard position placement.” The lesson is obvious; be more observant. I also question the wisdom of manufacturing a part that is capable of being installed incorrectly.

The Downside of Upside Down

Without detailed instructions and clear notation, nearly symmetrical parts can be installed incorrectly. Faced with the replacement of such a part, this CRJ 700 Maintenance Technician wound up with a case of component “misorientation.”

• The aircraft returned to the field due to the landing gear not retracting. Previously, the nose landing gear torque links had been replaced to fix a nose wheel shimmy problem. While installing the torque links, the lower assembly was installed upside down. The lower torque link assembly looks similar upside down to the way it does right-side up. The Maintenance Manual does not specify anything about the orientation, nor is there any indication on the part itself. I feel that if there had been a specific note that the part is able to be installed upside down, I would have paid closer attention to the orientation. The operational check of the installation did pass, but it does not require a gear swing. A note should be added in the installation task noting that the part is able to be installed incorrectly and that it looks close to the correct installation.

Bonanza Blunder

In order to mount a Beech 33’s ailerons on the wrong wings, a resourceful paint shop crew had to mount the ailerons upside down and use incorrect hardware. The achievement may have been dubious, but the confirmation of Murphy’s Law was unambiguous.

■ After the rudder was balanced and reinstalled, I preflighted the aircraft and flew it back from the paint shop to [our base]. The only problem with the flight was that the aircraft wanted to make a shallow left bank when the controls were released.

I looked at this aircraft two days in a row and preflighted it twice. Our Chief of Maintenance walked around it and another Instructor Pilot from the flight school also looked it over and none of us realized that the ailerons were installed incorrectly. A Maintenance Technician noticed that the location of the static wicks was wrong. The wicks were attached to the top surface of both ailerons and should have been mounted on the lower surface. This made it obvious that the ailerons were installed wrong; the left aileron was installed upside down on the right wing and the right aileron was installed on the left wing. Incorrect hardware was also used for the installation. I did not believe you could install the ailerons incorrectly and still be able to control the aircraft properly.

Safe Landings - October 2011

See and Avoid

The number of midair collisions in the United States has averaged 30 per year since 1978.¹ These accidents primarily involve General Aviation aircraft, but Air Carrier, Corporate and other operators are by no means immune from potentially serious airborne conflicts.

In the preceding 12-month period, more than 4,000 in-flight traffic conflicts were reported to NASA ASRS. Of these, 235 met the ASRS criteria (within 500 feet) for a Near Midair Collision (NMAC). Nearly half of these NMACs involved Air Carrier, Corporate and Air Taxi operations.

Technological advances such as the Traffic Collision Avoidance System (TCAS) and Conflict Alert (CA) have enhanced the ability of pilots and controllers respectively to resolve airborne conflicts before they become critical, but the following ASRS reports show that the “see and avoid” principle remains a crucial aspect of collision avoidance in visual conditions.

Watch Out for the “Other Guy”

You may be following all the rules, but there is no guarantee that everyone else is. This SF340 flight crew had an all-too-close encounter when a crop duster approached out of the sun, at the wrong altitude and apparently not watching out for traffic.

• While level at 8,000 feet, we experienced a near collision with a turboprop crop duster. The other aircraft was coming from our 11 o’clock position and traveling northwest to southeast. It passed 300-500 feet in front of our aircraft and less than 100 feet above our altitude. The duster was so close that we could feel its wake turbulence as it went by. Our TCAS was operating and showed no other aircraft. Center and Approach Control gave no traffic warnings. No evasive action was taken as the encounter was over before we could take any.

We were doing everything correctly at the time of the incident. All of our checklists were complete and there was very little distraction inside our cockpit. We had followed all ATC instructions and our aircraft was in the correct location for our flight plan and ATC guidance. It is possible that the crop duster was blocked by my sun visor and possibly the window pillar, as this creates a blind spot in the direction of the other aircraft. That aircraft was also coming at us from the sun and at the wrong altitude for the direction of flight. Although we had all of our exterior lights on and were following instructions and standard operating procedures, it’s always necessary to watch out for “the other guy.” Even if TCAS is installed and you’re under ATC direction, “see and avoid” is still every pilot’s responsibility.

Who’s on Base

Tower assumed that the reporter’s aircraft would “beat” another aircraft to the runway. The reporter assumed that the other aircraft would make a 45-degree entry to the left downwind. The result was not a “towering” success.

• It was VFR— clear with unlimited ceiling. I was instructing in the right seat. We contacted Tower just south of [the] Class D [airspace]. We received instructions to make left traffic and were cleared to land. We executed a 45-degree entry to a left downwind. Abeam the Tower, I requested a short approach to give the student a simulated engine-out arrival.

The Tower Controller had cleared another aircraft to “enter left traffic.” He told me later that he thought we would beat the aircraft to the runway. Just past abeam the runway end, the other aircraft established not on a downwind, but perpendicular to the runway on a left base and streaked in front of us (… way inside the normal power-on base leg area). I took the controls and executed an evasive turn to the right….

The other aircraft clearly didn’t follow instructions to enter the pattern for left traffic and instead headed directly to a left base entry. We received no traffic advisories on the conflict and came very close to colliding with the other aircraft. We saw and avoided, fortunately. [I] really wouldn’t like to come that close to a midair again.

 Easing Out of Formation

On short final, a Cessna 172 got so close to a B757 on final for a parallel runway that separating safely became a concern for the First Officer who submitted this report.

• Checking in with the Tower, we were advised of traffic, a Mooney, which we both saw. The visual approach was normal until short final. I commented to the Captain that if I had to go-around, I was concerned about avoiding the Mooney.

Below 400 feet, I heard the TCAS “traffic” call. I looked up from my primary scan on the runway and said that I had the Mooney in sight. I was unaware that the TCAS alert was not for the Mooney!

After the 300-foot callout, I noticed something to my left. I looked and saw a Cessna through the Captain’s window. It was very close and I feared a collision. The Cessna was in a shallow left turn, descending. It was less than 100 feet away and we had wing tip overlap. I thought quickly about my options and to go-around meant that our wing would hit him. If I turned right in avoidance, my left wing would have come up to impact the Cessna. I believed the only option was to continue straight and duck under him. I could not use much pitch input for fear of impact with the ground.

The Cessna had overshot the left runway final and had come into our space. We were at reference speed plus five knots so we passed him very quickly.

The Tower did not issue a traffic callout to us about the Cessna…. Tower stated that the person responsible for traffic separation was briefing someone else during the incident and that they failed to notify us of the traffic. He stated that the Cessna had been informed of our position and had a visual on us.

I believe that if I had not had many hours of formation time, we probably would have hit that Cessna.

¹ FAA statistic cited at SeeAndAvoid.org, a website created by the Air National Guard Aviation Safety Division with the ultimate goal of eliminating midair collisions and reducing close calls.

Safe Landings - September 2011

PAVE-ing the Way to Good Decisions

Chapter 17 of the Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25) offers pilots a number of resources for assessing the risks of flight and deciding on the best courses of action to mitigate risk. One of these is the PAVE checklist, which can help pilots during preflight planning to become aware of flight risks in four categories:

• Pilot-in-command (PIC) - The pilot must ask, “Am I ready for this trip?”

in terms of experience, recency, currency, physical, and emotional

condition.

• Aircraft - What limitations will the aircraft impose upon the trip in terms of performance, equipment, payload, ceiling, and fuel capacity?

• enVironment - How will weather, terrain, airports, airspace, and nighttime conditions affect safety of flight?

• External pressures - Why is the flight being made, how critical is it to

maintain the schedule, and is the trip worth the risks?

In this issue we will illustrate the PAVE concept using ASRS incidents involving General Aviation operations.

 “Indecision Becomes Decision With Time”

A low-time Cessna 172 pilot with instrument training let recent successes and get-home-itis seriously cloud decision making.

PAVE Factors: Pilot-in-Command, Aircraft, enVironment, External Pressures

• As a recently minted private pilot, just a week away from my instrument checkride, I was feeling dangerously indifferent about a current IFR AIRMET for my route of flight. The last two weeks, I had been able to easily out-climb previous IFR AIRMETS and stay on top…

I encountered IMC while trying to out-climb a layer of smoke coming from vegetation fires. I could not see the ground…and the forward visibility was not determinable. I was at my maximum altitude of 12,500, had climbed to 13,500 to see if I could top the smoke and it was clear I could not. I was on Flight Following when I turned around. Center contacted me asking why I wasn’t headed toward my destination. I told the controller I could no longer maintain VFR and was going to land at a nearby airport. I cancelled Flight Following but remained on frequency for good measure.

Upon my descent through 6,000, the smoke cleared significantly to around 15 sm visibility. I decided to continue my journey low since the visibility was much better. Upon continuing at a low altitude for 50 nm, the surface visibility dropped to 2 sm and I knew that I could go no farther at that altitude. I looked up and saw blue sky and bright sun. This indicated that the smoke layer I was currently in couldn’t be very high, so I initiated a climb to attempt to get on top. Upon reaching 7,500 MSL, I was surely back in IMC and the sun above me was now a deep red. I was now in some sort of smoke plume from one of these fires and was not going to out-climb it in a C172. It was at this point that I feared I was interfering with IFR traffic…

I immediately descended to 1,200 feet AGL, where, ironically, the visibility had improved to MVFR… I elected to push forward versus do the smart thing and land immediately. As I approached an airport indicating VFR conditions, the smoke and wind shifted making that airport MVFR too. I continued on and 10 nm past that airport I broke into the clear.

It was a very somber, pensive, and quiet ride to my fuel stop. I was horrified at how I responded to that situation…I shouldn’t have launched that afternoon but my previous successful experiences and my desire to get home were severely clouding my judgment.

The experience taught me great respect for AIRMETS and the value of sound aeronautical decision making. It was a watershed moment in my flying career….

“I Was Combining a Lot of New Things”

The pilot of a high-performance Cirrus SR22 undertook a 20-minute flight in Class B airspace with a first-time passenger on board. The flight was between two unfamiliar airports. And at destination, the pilot faced a “real” go-around situation for the first time.

PAVE Factors: Aircraft, enVironment, External Pressures

• The arrival airport does not have an ASOS, however the METAR for a nearby airport showed light winds. The arrival airport has two crossing runways: 13/31 is 4,165 feet long and 6/24 is 2,998 feet long. As we approached from the north, I selected Runway 6 for an easy entry on left downwind. On downwind, I set the first flap position. I realized I was high and fast after turning final. I pulled power to idle, but my speed was too high to put in full flaps. I considered a slip, but Cirrus does not recommend this maneuver. E-TAWS [Embedded Terrain Awareness Warning System] called out a sink rate warning. I had heard this before and landed without incident so I continued. I touched down about 1/3 down the runway. The plane bounced once medium-hard and lightly a second time. When I realized I would not have sufficient runway to stop, I initiated a successful go-around.

On the second attempt I was still too high, but did not attempt a landing. A friendly voice on the CTAF suggested Runway 13. At that point I noticed the windsock was indicating brisk winds (estimated 8 knots) roughly aligned with Runway 13. I switched to Runway 13 and made a nice landing.

Errors on this flight:

• Without local wind data, I should have overflown the field to observe the sock…

• With calm winds, there was no reason not to select the longer runway. While I have landed on 3,000-foot runways, most of the fields I fly out of are 4,000 and 5,000 feet. I had only landed on a runway shorter than 4,000 feet once before. While this 3,000 foot runway is within POH [Pilot Operating Handbook] range, it required nothing less than a well-stabilized approach.

 • I ignored the sink rate warning…This was the 3rd warning I ignored.

•This was the first time I ever had to do a go-around “for real.” I had a passenger that was flying with me for the first time. I’ve read how one can feel pressured by such a situation, but did not think it would happen to me. In this case, my desire to complete the flight did sub-consciously influence my decision making….

• I should have realized I was combining a lot of new things into one day.

Safe Landings - August 2011

What would you have done?

In this installment of Safe Landings, both of the reports involve incidents that occurred before, during, or immediately after takeoff. In “the first half of the story,” you will find report excerpts describing the situation up to the decision point. There are no “options” presented as in some of our recent “interactive” issues. It is up to the reader to determine all the possible courses of action and make a decision (preferably within the time frame suggested by the report). 

The selected ASRS reports may not give all the information you want and you may not be experienced in the type of aircraft involved, but each incident should give you a chance to exercise your aviation decision-making skills. In “the rest of the story,” you will find the actions actually taken by reporters to resolve each situation. Publication of a report does not constitute ASRS endorsement of the reporter’s action and the decisions presented may not necessarily represent the best course of action. Our intent is to stimulate thought, discussion and training related to the type of incidents that were reported.

The First Half of the Story

Situation #1: Flat Out Right…or Wrong (Experimental Aircraft Pilot’s Report)

■ [After landing], I realized that I had a flat left main tire. However, due to the strong winds, I was able to apply right aileron, lift the left main and taxi to the FBO on the right main and tail wheel. I…applied “Fix-a-Flat” to the tire [but it] failed to stop the leak. Because the aircraft uses “unusual” wheels, obtaining a replacement tire from the FBO was not an option. Ordering a replacement would have taken a week or so. My options were to fly the airplane home or leave the airplane at the FBO and get a replacement tire. 

I began seriously considering flying the airplane home. My thought process was as follows: This is a tail wheel aircraft well known for its ability to takeoff and land at very slow airspeeds in very short distances. With a touch of flap and lightly loaded, it can lift off at approximately 20 knots. I had 20 knots of wind directly on my nose. I would be airborne with a ground speed of less than 5 knots. Takeoff would not be a problem, even with the flat. My home airport was reporting winds of over 25 knots down the runway so landing would also be a slow ground-speed event…. Having already landed with the flat, I knew that landing and ground handling was not an issue. I elected to fly the airplane home. 

I…was cleared to taxi…. Ground asked me if I was aware that I had a flat left main tire…. I said…I was OK with departing if he was OK with letting me go. Upon contacting Tower, I was told, “Enter the runway at your own risk.” I asked if I was cleared for takeoff. Tower said, “No takeoff clearance will be granted. Enter the runway at your own risk.” I said, “I don’t want to enter the runway if someone else is on final. Am I cleared?” Tower said, “No traffic is observed in the area. Enter the runway at your own risk.”

Situation #2: Low and Slow (Light Sport Aircraft Pilot’s Report)

■ I was to ferry a light sport airplane to its new owner. Since the departure conditions were gusty and the crosswind component was near the maximum demonstrated for the airplane, I considered my choices carefully—whether to leave at all, which runway to use, etc. 

Among the considerations was the takeoff flap [setting]. The manufacturer recommends either no flap, or 15 degrees. For a while, I was “on the fence.” No flap would minimize my initial drift while I was low, but 15 degrees (first “notch”) would have me climbing faster…. At one point I decided that my previous decision to use no flap was not the best choice. I moved the flap selection lever to select 15 degrees…more than the 15 I had already put in, and forgotten…. I failed to verify the setting by looking. Had I done so, I would have seen that the selection lever was pointing at 30 degrees. 

At takeoff, the airplane was climbing very poorly. I found myself drifting off center-line, low and slow over flat airport property in a matter of seconds.

The Rest of the Story - 
The Reporters’ Actions

Situation #1: Flat Out Right…or Wrong

■ I asked the controller straight out, “Are you going to issue me a takeoff clearance?” He replied, “No.” I was not about to cross the hold-short line without a clearance. “Enter the runway at your own risk” was not a clearance in my mind. So I decided that this flight was now over. 

In the end, I am glad that the Tower Controller did not clear me onto the runway and I am also glad that I elected not to cross the hold-short line without a clearance. Ultimately, not taking off and putting the airplane back in the hangar was the right decision. There is just no sense in increasing risk and, while I was sure that both the airplane and I could handle the situation, there is no question that the risk of taking off and landing with a flat tire is higher than without a flat tire.

Situation #2: Low and Slow

■ I realized the error immediately and elected to land on the flat ground, into the wind, rather than attempt to remove any flaps while I was low and relatively slow. The landing itself was normal and no damage resulted. I advised Tower that all was well and I prepared for another departure attempt. 

A friend, who was seeing me off, sent me a text message pointing out that I didn’t have to leave. I had a chance to reconsider. Incredibly, the thought of postponing hadn’t even crossed my mind. That message loosened up whatever mental cog was stuck. A decision to leave the next day seemed obvious, especially when I thought about how this would read in an NTSB report (Pilot attempted to take off; landed off runway after aborting; crashed on second attempt!) That no damage or injury was sustained is largely a matter of luck. 

Nobody would be the least inconvenienced or concerned if this flight took place a day later. What was I thinking? Factors: false urgency; “get-there-itis;” failure to fully appreciate just how vulnerable low-power, low-wing-loading aircraft are to strong crosswinds; failure to look and confirm settings; getting mentally stuck in a groove (i.e. not considering postponing the departure, even with “in my face” evidence of the unsuitability of the prevailing conditions).