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How to read an accident report and learn from it...


HRM

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In the March 1 issue of Gene Benson's Vectors for Safety, Gene laments that he is:

 

...very tired of reruns. No, I am not talking about TV shows. I spend plenty of time reading accident reports and I have not seen any really new programming in a very long time. In one accident report after another, pilots follow the same old tired scripts with only slight variations in the details. I could understand this if the pilots involved were new and inexperienced, not having the benefit of what is well-known about accident prevention. But that is usually not the case. We very frequently see highly experienced, knowledgeable, respected pilots showing up in the wrong column of statistics.

 

The easy explanation is to blame overconfidence and complacency or an attitude of invulnerability. But doing some hard examination of a significant number of accidents, including accidents in which I have had personal friends killed, I am convinced that there is more going on. I think a deeper look into our humanness might reveal some explanations.

 

He goes on to explain that pilots should think about the psychology behind accidents and he gives an example of what is known as choice blindness, which I will bet any pilot with a couple of hundred hours has probably experienced--I know I have. Most of the time we get away with it and Gene notes how a tail wind can be a validator. Enough of a tail wind and we get a pass for a bad descision.

 

The hard part is overcoming our own humanity, working past the psychology that is trying to undermine us. Frankly, the best solution is to train and train hard. Frankly, just never quit training. When you are in the left seat with a CFII on your right, you immediately enter into the trainee consciousness. The downside of it is that you might get the feeling that if anything goes wrong you are covered. After all, you have god as your co-pilot, right? We could discuss the merits and demerits of that sort of thinking, but I'd rather concentrate on the upside. The upside is that you are on your best behavior. You damn well better go item-by-item through that checklist. Why aren't you dead on that altitude? You know the FAA allows 200 feet, but you also know your CFII only allows 50. Yeah, things are different when he's there. So, why not fly like he is always there? 

 

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Why should I just pay attention with a CFII on board? I admit that this attitude was with me the first 2 years after I earned my wings.
Then I bought my M20F and since then things finally changed... - now I try to give my FIs and CFIIs a good time when they fly with me to check me out...
Ever thought of challenging your CFII? Well, that is what I love to do... - steep angle (5°+) approach to a 2000ft runway, no flaps landing on a 1500ft runway, power of stalls, really steep turns... - telling them about the specialities of our birds like hydraulic flaps, leaning procedures during climb, etc...

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Why should I just pay attention with a CFII on board? I admit that this attitude was with me the first 2 years after I earned my wings.

Then I bought my M20F and since then things finally changed... - now I try to give my FIs and CFIIs a good time when they fly with me to check me out...

Ever thought of challenging your CFII? Well, that is what I love to do... - steep angle (5°+) approach to a 2000ft runway, no flaps landing on a 1500ft runway, power of stalls, really steep turns... - telling them about the specialities of our birds like hydraulic flaps, leaning procedures during climb, etc...

 

Yes...Yes....Yes....exactly what I was talking about--there was a bit of tongue in cheek in my post.

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How often does your time with your CFI focus on decision making?  Even then it is easy to give the right answer when you are removed from the actual scenario.

 

One big problem with human decision making is that we are often rewarded by success even when we make the wrong decisions.  We then falsely associate our success with our superior skills and assume that we will be successful in similar situations in the future.  In other words, we succeed in spite of our decisions/actions rather than because of them.

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The issues you are bringing up is exactly the reason for the move to scenario-based training within the past decade and the current steps being taken to change the PTS to bring more focus to human factor issues.

 

Historically, we've been quite deficient in our training, even at the simplest level? How many of you (except fairly recently) have had to divert and set up a landing at an unplanned airport on your dual student pilot cross country? Or have heard volumes about the "go/no-go" decision but next to nothing about the "continue/divert" decision?

 

 

 

Why should I just pay attention with a CFII on board? 

 

Actually, I've been exactly the opposite. I tend to be sloppier knowing there is someone in the right seat watching over me than when I am the one truly responsible for my own fate (not to mention my passenger's).

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I was diverted and landed on my PPL dual XC in March'07. That's before the scenario-based training became a hot topic, but still fairly recent in the grand scheme of things.

But I like Gene Benson's website and newsletters, too.

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Not all CFI's are created equal. I have flown with guys who only have experience in 172's and I find that they frequently get behind the Mooney very quickly. Likewise, I brief my passengers on things that they can help me with, even if they have no experience (looking for traffic, ask and verify that I put my landing gear down, explain approach speeds, bank angle, et cetera). 

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Not all CFI's are created equal. I have flown with guys who only have experience in 172's and I find that they frequently get behind the Mooney very quickly. Likewise, I brief my passengers on things that they can help me with, even if they have no experience (looking for traffic, ask and verify that I put my landing gear down, explain approach speeds, bank angle, et cetera). 

 

I am going to say that the worst CFI/I's after you have your ticket and/or ratings are "teachers". After you join the club, the CFI/I must become a coach. The coach watches your form, offers correction, keeps you centered and on track. This is very different from teaching. Some CFI/I's can transition, others cannot. I am not saying that a coach can't teach you something, but it is a different way of doing things.

 

I have been in my Mooney with CFI/I's of both kinds that you describe, know Mooney's and don't know Mooney's. The non-Mooney "teachers" quickly get behind since they have nothing to teach, the Mooney "teachers" try to undo whatever someone else has taught you. The non-Mooney coaches are in awe of the plane, sense this and then coach you to better performance because it is just an airplane after all. The best of all is the Mooney coach—they take you to the next level.

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I do a lot of process work to pay for my flying.  I think the FAA ADM process is flawed because they are looking at it from an accident investigation after the fact has occurred.  They teach the accident chain all the way through to auguring in. Perceive Perform Process will keep you going until you are a NTSB report.   There should be a Stop in the process.  And there should be a process to learn how to stop.   I have probably read more than a 1000 NTSB reports during training.  Most all of them could have been prevented if the pilot had stopped.  That may include putting it on the ground and evaluating why you are in the air. From day one in our training we learn that time is money and the Hobbs tells us that.    I think there were more than a few times where I told the CFII that we are just going to sit here for a few minutes. A form of get there itus is taught to us in training.

For me some of the signs to stop are:

The weather "should" start looking more like I planned for it to be

Any time you say "We should be able to make _______"

If _____  and ______ happen then we will make it

Also being able to dynamically set minimums and then adhere to them.   We need 2000 feet for that area.    Weather stations are reporting 1600. We need to set it down and reevaluate all the options prior to continuing.  

 

There are 1000s of decisions you are making while flying a plane being able to stop the overload is also important.   Some of this is taught as we learn the skill of flying and comes out as that "pilot stuff"  When a gust blows you off center line and now you are looking at grass 10 feet above the ground, you just need pilot stuff to cram and level and fly the plane.

 

   The one accident report that I read about a Mooney CFIT in Colorado keeps an image in my mind.  I went to google earth and found you could still see the outline of the plane just below the ridge top.  I am sure the guy was thinking "I should have just enough to clear it"

The other two are the family that was killed around Bryan Texas as they were trying to cross a front line and the charter pilot with the Cessna 400 that tried to fly through the front and spun it in around East Texas.   What was crazy about that is he could have flown around the tail of the front and probably only added 45 minutes to his flight.

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