A Safety Journal for General Aviation
by Max Trescott, Master CFI & FAA Aviation Safety Counselor
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This is the first issue of Pilot Safety News. My primary objective is to provide aviation safety news to enhance the safety of General Aviation Pilots. Initially, the focus will be on Northern California. My philosophy is that flying is fun and pilots should enjoy themselves flying. Also, since about 85% of all accidents are a result of pilot error, they should be empowered by knowing that most accidents are avoidable if pilots take a thoughtful approach to the particular risks involved with each flight.
Please forward this newsletter to all of your flying friends. I hope that you find it informative. Let's see if together we can drive the accident rate down even further. Submissions and feedback are always welcome! You can click here to subscribe or email Feedback on Newsletter.
Max Trescott, Master CFI
SF Bay Area Fatal Accident Study
Night & VFR into IMC are greatest dangers
In the fall of 2004, I asked FAA Safety Program Manager Jack Hocker how the accident rate in the San Jose FSDO could be lowered. His response was that it couldn't get much lower here, since most of our pilots were crashing in other districts. That comment prompted me to research Bay Area fatal accidents to see if indeed local pilots are crashing elsewhere, and if so, to determine the primary accident causes.
By searching the NTSB database, I was able to pull reports on 99 fatal accident from 1990-2005 that occurred on flights to or from a Bay area airport. For the purposes of this study, Bay area airports included all airports as far north as Petaluma, as far east as Livermore, and as far south as Watsonville. This roughly corresponds with the Coastal Mountain Range that surrounds the S.F. Bay area.
The data verified that indeed most crashes occurred elsewhere. Of the 100 flights, more than half of the crashes were indeed outside of the Bay area. Detailed statistics were compiled for the 68 accidents in the years 1993-2000. Early years were not included since the NTSB data is not fully keyword indexed, and not all accidents to or from a Bay area airport could be identified. Later accidents were not used, since probably cause reports were not available for all accidents in later years.
Fully two-thirds of the crashes involved either Night or Weather or both! 30 of the 68 accidents (44.1%) occurred at night. This is double the rate for the rest of the country! The revised data for the Air Safety Foundation's 2003 Nall Report shows that 44 (or 21.6%) of the 204 fatal accidents identified for day versus night across the U.S. in 2002 occurred at night. In addition, night accidents are far more likely to be fatal. In the revised data for the 2003 Nall report, 14.9% of daytime accidents (160 of 1072) were fatal, while 29.5% of the night accidents (44 of 149) were fatal. So in the S.F. Bay area, fatal accidents are twice as likely to occur at night, and night accidents are twice as deadly as daytime accidents.
into IMC -- the Deadly Killer
The Air Safety Foundation has several sub-categories of Weather, or which VFR into IMC is the most significant. In the 2003 Nall Report, they identified 17 fatal accidents in the United States (5.4% of the total) that were caused by VFR into IMC. In the S.F. Bay Area from 1993 to 2000, there were 23 accidents in which VFR into IMC was a factor. This is fully 33% of the 68 fatal accidents that occurred! Hence the incidence of VFR into IMC is perhaps as much as 6 times higher in the Bay area than in other parts of the country. Interestingly, nearly half (11 of 23) of these VFR into IMC accidents occurred in the day. However, since most flying occurs in the day, one can conclude that there's a higher probability of getting into a VFR into IMC accident at night.
These accidents are also particularly deadly. Fully 90% of the VFR into IMC accidents (17 of 19) in the United States were fatal. That's why VFR into IMC accidents are called the Deadly Killer. The conclusion is unavoidable. If you inadvertently go into a cloud AND you have an accident, you're going to die.
How often do pilots inadvertently end up in a cloud? Far more often than you think. I've asked about 100 pilots at two safety seminars how many of them had inadvertently ended up in a cloud. At both seminars half of the pilots had accidentally gone into a cloud. When asked whether they had gone into the cloud at night, about 60% raised their hand to indicate that it was at night.
- Be wary of clouds, particularly at night
General Aviation pilots do most of their flying in the daytime. When I surveyed pilots at safety seminars, only a small percentage of pilots indicated that more than 5% of their total flying was at night. It's very hard to see terrain at night, so it's important that you use IFR-like procedures, and maintain a safe altitude over all terrain. If in doubt, stay at least 500 feet above the MEF figure (the large number in each quadrangle of your VFR Sectional Charts) to assure terrain clearance. Also, if there are common routes that you fly at night, fly them in the daytime to determine a personal minimum safe altitude for flying the route at night. For many S.F. Bay area pilots, this might be over some of the local passes such as the Hayward and Sunol passes in the East bay, and the Altamont pass just west of the Tracy & Stockton area. As the picture to the left shows, Sunol Pass can often be blocked by clouds.
Try to plan your flight to arrive back in the Bay area before darkness, particularly in the winter months when days are short. If you're unable to get through any of the passes, make a 180 degree turn early, and land at Livermore, Stockton or other airports where it is still clear. Rent a car, call a friend to get you, or stay overnight in a motel. Alternatively, you may be able to get above the marine layer, cross the bay area, and then descend in open areas near your destinations, if the local ATIS or FSS suggest that there are still cloud openings near your destination airport. In any case, choose an alternative that guarantees that you won't end up on a mountain ridge where you'll become another statistic!
A good source of information on Night Flying is the Air Safety Foundation's website. Click on "Safety HotSpot," go to the bottom and select "Safety Hotspot Archive." The hotspot on "Night" features an excellent VFR Night Checkup that you can print out in kneeboard format and carry with you when flying.
2003 Cirrus Crash Final Report Issued
Pilot distracted during IFR approach
The NTSB recently issued a probable cause report on the Cirrus SR20 that crashed while IFR on the GPS approach into Reid-Hillview airport in January, 2003. If you fly IFR in the S.F. Bay area, you know how busy you can be responding to multiple vectors to avoid traffic, and many frequency changes as you fly across the region. Read the full narrative of this report (which incorrectly states the crash was in 2002), and you'll see that this pilot had his hands more than full with ATC instructions that were non-standard and confusion and distraction over an incorrect frequency issued to him by the controller shortly before the crash.
The probable cause was listed as: "The pilot's failure to maintain the course for the published approach procedure due to his diverted attention. The distraction responsible for the pilot's diverted attention was the erroneous frequency assignment provided by ATC and the resultant task overload induced by this problem and the confusion surrounding the ATC clearances to get established on the final approach course, which likely involved repeated reprogramming of the navigation system. Factors in the accident include the failure of ATC to provide the pilot with a timely and effective safety alert concerning the deviation from the proper course, which was influenced in part by the features of the radar display at both facilities which made the deviation more difficult to detect, and the nature of radar as a secondary tool for a VFR tower controller. An additional factor was the nonstandard method of providing approach clearance, which likely may have exacerbated pilot task overload."
Portion of the GP31R approach to RHV. The approach starts from the south, and concludes near the airport at waypoint RW31R.
The pilot was north of RHV, and issued a clearance direct to OZNUM. After reaching OZNUM, the pilot was told to proceed direct to ECYON, which was a non-standard way to be guided to an approach. Typically, the approach would start at an IAF (initial approach fix) such as GILRO or ZUXOX or the pilot would be given vectors to intercept the final approach course 3-4 miles outside of the FAF (final approach fix) which is at OZNUM. Vectoring the pilot to ECYON was nearly equivalent to vectoring the pilot onto the final approach segment, though the NTSB report noted that the intercept angle was about 40 degrees, which is greater than the 30 degrees a controller is to use for an intercept vector. Nonetheless, the pilot successfully got onto the approach and all was well again until he reached OZNUM for the second time, now headed for RHV.
As the airplane passed just northwest of OZNUM, ATC instructed
the pilot to contact the tower on frequency "118.6." This frequency is
actually assigned to PAO tower. The pilot queried the controller if that was
actually correct. The controller insisted, "Yes sir, it is." The pilot
complied and contacted PAO tower. The pilot and the PAO controller
discussed that he was on the wrong frequency and the pilot said he would switch
to the RHV frequency of 119.8. Almost 1 minute elapsed between the pilot's
acknowledgement of the erroneous frequency, and his initial contact to the
correct tower. During this period the airplane's heading diverged approximately
90 degrees from the published final approach course toward rising terrain and
the accident site. Radar showed the aircraft visibly displaced from the
final approach course at 1652:33, approximately over JOPAN waypoint. At 1652:50,
the pilot reported to RHV tower "descending from JOPAN two thousand feet
five point four miles from missed approach point." The Minimum
Safe Altitude Warning alarms went off in the TRACON and in the tower, and the
tower controller provided a low altitude safety alert based on the alarm by
saying "check your altitude immediately." The radar track of the
airplane was lost in the area of high-tension power lines, located 6.7 miles
south east of RHV at an altitude of 1,600 feet mean sea level (msl). The last
radar data with an altitude return was at 16:53:40, and showed the airplane at a
mode C reported altitude of 1,700 feet.
It's always hard to second guess what happened. Most accidents occur to competent pilots who had a lapse of judgment at a critical point. The key for us as pilots is to have a set of standards by which we fly, and to avoid violating these standards. Always question or decline a vector if it doesn't make sense. In this case the non-standard vector onto the approach wasn't directly responsible, though it added to the pilots workload. One of your personal rules should be to Always Fly an Approach as Published!
Besides being vectored into a non-standard start to the approach, the SR-20 pilot was given the wrong frequency to call Reid-Hillview tower. Apparently he was aware that he was given the wrong frequency since he questioned it, but ATC convinced him that it was indeed the correct frequency and he lost more time and more button pushes calling the wrong tower, got distracted, and began an inadvertent right turn and descended into terrain. Are inadvertent turns to the right common? You bet! Often I see pilots reach to tune the radios in the center console while, unknowingly, their left hand moves the plane into a right turn. One possible solution is to just let go of the stick or yoke briefly while tuning the radio. If you're well trimmed, the plane will often fly better by itself for a few seconds then it will if you leave your left hand on the yoke while tuning radios.
If there's a lesson to be learned from this accident, it's to always fly approaches as published, Not Allow Yourself to Be Distracted and to Fly the Airplane First. This applies equally well to VFR pilots, and is one of the reasons that the Private Pilot PTS requires Designated Pilot Examiners to attempt to distract pilot candidates during their checkride to assure that they stay focused on flying the airplane.
Recent Fatal crashes
It had been more than a year since there was a fatal crash on a flight to or from a Bay Area airport. Tragically, that streak has ended, and we've had two crashes in February, 2005.
Photo from Petaluma
On February 9, 2005, a Grumman Tiger crashed shortly after takeoff from
Petaluma Airport killing the pilot. The plane, according to witnesses, was
flying at about 100 feet when the engine started making sputtering sounds. One
witness stated that "The plane was traveling at a very slow speed when it
suddenly just dropped to the right side, hit the ground and spun around,"
onto a golf course near the airport. At this writing, no NTSB report has been posted.
On Sunday, February 6, 2005, the pilot of a Cirrus SR-22 crashed
in the Sugar Bowl Ski Resort. About 15 minutes after departing Reno, NV
enroute to Oakland, CA, reported at about 16,000 feet that his wings were icing
up and he was going down. Apparently the parachute was deployed but did not save
the plane. One source indicated that the plane was equipped with the TKS
anti-icing option, but this hasn't been confirmed. At this writing, no NTSB
report has been posted.
Update: A pilot who has training in accident analysis was at the ski area when the crash occurred and visited the crash site. He told me that the airplane appeared to have broken up in flight, and that wreckage pattern suggested that it was spinning as the plane broke up.
Safety Seminar Website
Many pilots licensed for more than 5 years remember the monthly FAA mailings that used to announce upcoming safety seminars throughout the area for the next month. Unfortunately, the mailings fell victim to budget cuts, and for the last few years there wasn't an effective way to notify pilots of seminars and attendance dropped.
Last year, however, a new website debuted at www.faasafety.gov, which gives timely notice of local safety seminars. About 30% of local pilots are now registered, and as a result they receive email notifications each time a seminar is posted on the website. Pilots set their preferences with the distance they're willing to travel to a seminar, and then receive email notification for each seminars within that distance from their home. Not surprisingly, seminar attendance has risen dramatically.
However, there's still a large, untapped portion of the pilot community that's interested in seminars, but haven't registered. How do we know? In January, a small budget came available for postcard notifications, and all pilots on the FAA database receive notification of some seminars. The results? Seminar attendance was double what it was for early seminars that received only email notification.
So here's your call to action. Make sure ALL of your pilot friends are registered on www.faasafety.gov. Or, bring them with you to the next safety seminar that you attend!
Who would have thought that protocol on the taxiways of our local airports could be so different. The result is that pilots visiting adjacent airports may get reprimanded for doing exactly what they do correctly at their home airport! Here are a couple of differences to remember as you travel the area. If you know of other differences at S.F. Bay area airports, please email me.
After your runup, when ready to depart, hold your position, and notify the tower you're ready to take-off. Then, when instructed by the tower, move up to the hold line. After landing, it's not unusual to taxi onto the parallel taxiway before calling ground. If you don't, there's no room for another aircraft to exit the runway behind you.
After your runup, when ready to depart, first move up to the hold line and then notify the tower you're ready to take-off.
After landing, you'll be instructed to contact ground. You'll cross the first parallel taxiway (Yankee), and then you must stop and not turn onto the parallel taxiway Zulu until instructed to by ground. How's a pilot to know the local differences between these two airports? Probably not by the signage, which is weak on these points. This newsletter is the first place I've ever seen it documented. It's no wonder transient pilots get confused at these two airports.
San Jose International
After your runup, when ready to depart, you must first contact ground before moving out of the run-up area. There's an active taxiway between the run-up area and the Runway 29 hold short line. Fortunately, signage regarding this is excellent.
March 17, 2005 6:30PM Elks Lodge, Santa Clara, CA 99's Pasta Night Fundraiser. www.santaclaravalley99s.org
April 18, 2005 7:00PM Sheraton Gateway, Burlingame, CA Air Safety Foundation Seminar on Weather
April 23, 2005 All Day 99's Flying Companion Seminar Call 510-673-4505
Pilot Safety News
© 2005 by Max Trescott
Master CFI & FAA Aviation Safety Counselor
Please contact me with your feedback or if I can be of service to you.
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