Safety Alert: Reduced Visual References Require Vigilance
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Safety Alert: Reduced Visual References Require Vigilance
- 1. Safety Alert: Reduced Visual References Require Vigilance 1
- 2. 1,500 aviation accidents per year 2
- 3. Top Occurrence Categories 3 Fatal accidents in GA personal flying sector, 2000-2011
- 4. Safety Alerts • General aviation on NTSB Most Wanted List • Need to reduce GA accident rate • Education, training, and risk management skills 4
- 5. Safety Alerts • Define a GA safety problem • Provide statistics on the problem • Provide examples of accidents • Provide ways to prevent accidents 5
- 6. Safety Alert Topics • Aerodynamic stalls at low altitude • Reduced-visual references • Aircraft mechanical problems • Pilots‟ risk management • Mechanics‟ risk management 6
- 7. Discussion of Accident Cases • Completed cases: common causes, factors, and scenarios • Used as educational tools • Not intended to admonish accident pilots • Intended to help other pilots learn 7
- 8. CFIT Accident: VFR into IMC 8 WPR11FA078 Perris, California
- 9. Accident Flight • Aero Commander 680FL • Mountainous terrain, daylight IMC • Pilot was fatally injured • Part 91, no flight plan • Returning airplane to base after previous weather diversion 9
- 10. Pilot • 33,000+ total flight hours • Airline transport pilot • Instrument current • Recent experience in accident airplane 10
- 11. Weather • No record of a weather briefing • Departure: VFR • En route: marginal VFR • Precipitation in area of accident 11
- 14. Accident Site 14
- 15. Missed Opportunities • Obtain a weather briefing • Adhere to cancellation alternatives • Resist external pressures to complete flight • Act before situation becomes dangerous 15
- 16. ASI Perspectives • Make the right decisions at the right time • If there‟s doubt, reevaluate • Never “go take a look” • You never have to be anywhere when flying an airplane 16
- 17. Spatial Disorientation: Dark Night VMC 17 ERA11FA412 Erwin, North Carolina
- 18. Accident Flight • Cessna 182S • Dark night VMC • Pilot and passenger were returning home • Radio contact lost about 25 minutes into flight 18
- 21. 21
- 22. 22 Runway 5
- 23. Accident Site 23
- 24. Accident Site 24
- 25. Pilot Experience • No flights logged within 8 months of accident flight • No recent flight review or instrument proficiency check • Only 0.2 hours of night experience in last year 25
- 26. Audio Panel 26
- 27. Missed Opportunities • Fully understand how to operate all onboard systems • Divert flight after encountering abnormalities • Terminate flight before nightfall • Find airport with continuous night lighting, without disorientation hazard 27
- 28. ASI Perspectives • Balance risk vs. practicality • Reduced visibility accidents are: • Often fatal • Easily preventable • No pilot is immune 28
- 30. Accident Flight • Experimental-AB Vans RV-10 • Seale, Alabama • Lebanon, Tennessee, to Eufaula, Alabama • Pilot and passenger/builder fatally injured 30
- 31. Accident Flight • Airplane equipped with “glass cockpit” flight instruments • Cross country flight to Sun „n Fun • Approach flown in daylight IMC • IFR flight plan 31
- 32. Pilot • 1,700 total flight hours • Instrument current, 358 flight hours in actual IMC • Majority of prior IFR experience in personal airplane, equipped with “conventional” instruments • No flight experience in the accident airplane or type 32
- 33. Pilot-Rated Passenger • Private pilot, no instrument rating • 68 flight hours in accident airplane • Co-builder of accident airplane 33
- 34. Weather • Departure and en route: VMC • Arrival area weather • 8 miles visibility • 1,000-foot ceiling • 4,500-foot cloud tops 34
- 35. 35
- 38. 38
- 39. Missed Opportunities • Declare an emergency • Utilize ATC - additional resources will become available if emergency declared • Climb into VMC • Glass cockpit training 39
- 40. ASI Perspectives • Pilot-rated passenger familiar with the airplane, but would not have been familiar with flying an instrument approach • Flight “legal,” but may not necessarily be advisable • Glass cockpit does not guarantee additional levels of safety • Read and learn from NTSB reports 40
- 41. Summary Safety Alert: “Reduced Visual References Require Vigilance” • Accident summaries • Links to educational resources • “What can pilots do?” 41
- 42. What can pilots do? • Preflight planning • Obtain weather briefing • Don‟t allow situation to become dangerous before acting • Ask for help from ATC 42
- 43. What can pilots do? • Prepare for the challenges of night flight • Be honest about skill limitations • Plan ahead with alternatives 43
- 44. What can pilots do? • Understand how to use all aircraft systems • Manage distractions • Instrument flying proficiency • IFR procedures 44
Notes de l'éditeur
- Good Morning.Thank you all for taking your time from the numerous Sun n Fun activities to attend my presentation today. I’d also like to thank the FAA for opportunity to speak at their Safety Seminar and Workshop program.On March 12, 2013, the NTSB conducted a Board Meeting on General Aviation Safety and issued 5 safety alerts. One of those alerts, Reduced Visual References Require Vigilance, I will be discussing with you today.This safety alertaddresses fatal accidents that occur in reduced visibility conditions. Historically, about two-thirds of all GA accidents that occur in such weather conditions are fatal. These accidents typically involve pilot spatial disorientation or controlled flight into terrain.[CLICK]
- As a background to the rational behind the GA Safety Alerts . . .Each year, NTSB regional investigators investigate about 1,500 accidents, averaging about 4 every day, in which about 475 people are killed.
- The most common accident occurrence categories are noted here. In-flight loss of control, although due to various underlying reasons, accounts for the overwhelming majority of GA accidents. This presentation will be considering flight in reduced visibility conditions. These accidents are commonly attributed to spatial disorientation, which results in a loss of control, and to controlled flight into terrain, which may have been preceded by an encounter with IMC.[CLICK]
- Becauseof the need for improvement in the decade-long plateau in the GA accident rate, the NTSB has placed GA safety on its Most Wanted List.Education, training and risk management skills can assist pilots, mechanics, and members of the aviation community in reducing this accident rate.
- Each safety alert defines a GA safety problem, identifiesstatistics related to the issue, and provides accident case studies. Finally, the alerts highlight practical remedies to mitigate the problem and enhance safety of flight.[CLICK]
- Overall, the Safety Alert topics include: aerodynamic stalls at low altitude in daylight visual weather conditions (which is a type of loss of control accident); reduced visual reference accidents (which we will be discussing in this presentation); accidents involving pilot inattention or inappropriate responses to aircraft mechanical problems;risk management strategies for pilots because effective risk management is essential for preventing all types of GA accidents; and, finally, risk management strategies for mechanics because aviation maintenance technicians play a critical role in GA safety.[CLICK]
- It should be noted that the accident case studies I will discuss today are for educational purposes. They are not intended to admonish the accident pilots. Rather, they are intended to help other pilots learn and apply the lessons learned to your flying and your decision-making process.
- The first accident case study involved VFR flight into IMC conditions, which resulted in controlled flight into terrain. It occurred near Perris, California, on December 20, 2010.[CLICK]
- In December 2010, shortly into a VFR cross-county flight, an Aero Commander 680FL airplane collided with mountainous terrain in daylight instrument meteorological conditions about 7 miles north of Perris, California. Theairline transport pilot was killed. No flight plan had been filed.The flight was the pilot’s second attempt at retuning the airplane to it’s home base after the first attempt required a diversion to Palm Springs the previous day.[CLICK]
- The pilot had accumulated more than 33,000 flight hours, held an airline transport pilot certificate with multiple type ratings, was instrument current, and had recent experience in the accident airplane.[CLICK]
- There was no record that the pilot obtained an official weather briefing prior to the flight, though he did tell a customer service agent at the fixed based operator to hold a rental car for him in case he needed to return to the airport because of weather. About the time of departure the Palm Springs airport was reporting VFRconditions.Weather stations along the pilot’s initial intended flight route were reporting marginal VFR conditions with ceilings that varied between 1,500 feet and 2,500 feet above ground level.NEXRAD weather radar images showed that an area of concentrated precipitation surrounded the area of the accident site at the time of the accident.[CLICK]
- GPS data recovered from a portable receiver on board the airplane provided information about the flight path. This map shows the accident airplane’s flight path in red. Surface roadways are shown in yellow.The airplane departed from Palm Springs,[CLICK] and headed west along a highway corridor through a mountain valley pass.[CLICK] For the majority of the flight, the airplane maintained altitudes that kept the airplane about 900 feet to 1,200 feet above the valley floor, but below the peaks that surrounded the highway corridor. About 3 minutes before the airplane collided with terrain, the flight track turned to the southwest,[CLICK]away from a concentrated area of precipitation but directly towards a small, isolated mountain with a 2,700-footpeak; it rose about 1,000 feet above the surrounding terrain.[CLICK](brief pause)[CLICK]
- This map shows airplane’s flight path during the final minutes of the accident flight, beginning in the upper right corner of the map. About 1 minute before the airplane impacted terrain, [CLICK]the pilot reported to an air traffic controller he was having difficulty maintaining VFR and he asked for an IFR clearance. The airplane was already in close proximity to terrain at this time and no further communication was received from the pilot. The airplane impacted terrain[CLICK]near the crest of the mountain peak.[CLICK]
- This photograph shows the airplane’s wreckage debris field near the summit of the mountain.The NTSB determined that the probable cause of this accident was the pilot’s decision to continue visual flight into instrument meteorological conditions, which resulted in an in-flight collision with mountainous terrain.[CLICK]
- In looking at this accident, there are a number of missed opportunities that could have changed the outcome of this flight.There was no record that the pilot obtained an official weather briefing. However, he appeared to have at least some awareness of the possibility of adverse weather along his flight route, as evidenced by his request that a rental car be held for him in case he needed to return because of weather. Although the pilot’s request to hold the rental car shows that he did plan ahead with a flight cancellation alternative, it is interesting to note that he decided to first attempt the flight, rather than cancel it, before using that alternative. There were external pressures on the pilot to complete the flight because the airplane needed to be returned to its home base. However, it is not known why he was motivated to complete the flight that day. Although the pilot asked to pick up an IFR clearance in flight, he had allowed the situation to become dangerous before he made that decision to act. By the time that he made his request, it was too late. He had already encountered the adverse weather, and the terrain collision was imminent.[CLICK]
- When we look at the lessons that can be taken from this accident, it really all comes down to decision making.More so, it is about making the right decisions at the right time.And if there is any doubt about the weather, specifically if you can accomplish a flight VFR, that should immediately trigger something in your mind to reevaluate the situation, your competencies, and the airplane’s capabilities . . . and either cancel the flight or make the flight under IFR.Taking off into marginal weather to “take a look” should never be an option. When things start to go wrong, as in this case, you’ve already passed the right time to make a good decision.It’s important to remember that you never HAVE to be anywhere when flying an airplane.[CLICK]
- The second accident case study involved spatial disorientation that occurred in dark night VMC. It occurred near Erwin, North Carolina, on July 20, 2011.[CLICK]
- In July 2011, a Cessna 182S impacted trees and terrain during a flight that was conducted in dark night VMC. The instrument-rated private pilot and the passenger were returning home from a vehicle auction and were both fatally injured. Shortly after departing on the accident flight the pilot requested VFR flight following services from air traffic control, and stated that his destination was Columbus, Georgia. About 25 minutes after departing, radio contact with the pilot was lost after air traffic control issued the pilot a frequency change.[CLICK]
- GPS data recovered from portable receiver provided information about the flight. This map shows the airplane’s flight path in red.The airplane departed from Meridian, Mississippi,[CLICK] and shortly thereafter radio contact was lost here.[CLICK]Upon reaching Columbus, Georgia,[CLICK]the airplane turned northeast toward Erwin, North Carolina. [CLICK]
- Sunset and the end of civil twilight occurred nearly 1 hour before the airplane reached Erwin, near this point.[CLICK]The moon did not rise until about 1 hour after the accident.A witness, who landed at Erwin about 1 hour after the accident, reported that the area to the southwest of the runway was a “black hole” due to the lack of ground lighting, and stated that flying in the area could be very disorienting.[CLICK]
- This map shows the airplane’s flight track as it approached Erwin. The airplane initially intercepted and tracked the final approach course to runway 5.[CLICK]The airplane then began maneuvering in the vicinity of the runway, turning southeast, -- [CLICK] -- back northwest, -- [CLICK] -- and again southeast, -- [CLICK] -- while climbing and descending to altitudes that varied between 1,300 and 2,500 feet.The airplane crossed -- [CLICK] -- the final approach course for a final time at an altitude of 2,000 feet.[PAUSE][CLICK]
- This graphic shows airplane’s flight path during the final seconds of the accident flight, beginning at top of the map.[CLICK]After crossing the final approach path to runway 5 for the final time, the airplane entered a descending right turn.[CLICK]The radar-observed descent rate during the turn exceeded 4,800 feet per minute, as the airplane descended from and altitude of 2,000 feet.The airplane subsequently impacted trees in a right bank, about 1/2-mile from the runway threshold.[CLICK]The main wreckage came to rest partially submerged in the Cape Fear River, about 700 feet beyond the initial impact point.[CLICK]
- This photograph shows the wreckage of the airplane as viewed from the south bank of the river.[CLICK]
- … and this photograph shows a portion of the wreckage after it was recovered to the shore of the river.[CLICK]
- A review of the 79-year old pilot’s flight logs showed that he had not logged any flights within the 8 months preceding the accident flight. The log showed that the pilot’s most recent flight review was completed nearly 5 years before the accident flight. While the pilot did hold an instrument rating, there were no records of the pilot having completed an instrument proficiency check.The log also showed that the pilot had only two tenths of an hour of flight experience at night within the preceding year.The NTSB determined that the probable cause of this accident was the pilot’s loss of control due to spatial disorientation while maneuvering in dark night conditions.[CLICK]
- The investigation also discovered that the airplane’s audio system was configured in a way that would not have allowed the pilot to contact air traffic control facilities or activate the pilot controlled lighting at the Erwin Airport, as can be seen in this photograph. (CLICK) If the pilot had inadvertently configured the system in this way, it might account for his loss of communications earlier in the flight and for his maneuvering in the vicinity of the airport as he attempted to activate the pilot controlled lighting there in vain.
- In looking at this accident, there are a number of opportunities where the pilot could have changed the outcome of the flight.First, it is possible that the pilot may not have fully understood how to operate all of the onboard systems, including the audio panel. While this may seem innocuous on the surface, as this accident has evidenced, when compounded with other decisions, resulted in this tragic outcomeAfter encountering communication abnormalities, the pilot could have diverted the flight to a nearby airport, or could have landed at one of the many airports he overflew enroute to Erwin.The pilot also could have terminated the flight prior to nightfall in order to troubleshoot the problem on the ground, possibly with the help of a mechanic.Upon reaching the destination airport and not being able to activate the airport’s pilot controlled runway lights, the pilot could have diverted to another airport where continuous night lighting was provided, and where such a disorienting non-ground lit area was not present.
- As a pilot and flight instructor, I can appreciate the challenges pilots face in managing the risks associated with each flight, and balancing those risks with the practical considerations of trying to make it to a business meeting, return home to family, or when flying just for the fun of it. As an Air Safety Investigator, I have the unique opportunity to see first hand what happens when pilots are unsuccessful in managing those risks. When an accident occurs in reduced visibility conditions, the results are often fatal, which when juxtaposed against how easily preventable these accidents are, makes them particularly tragic. Additionally, no pilot is immune to the dangers of flying in reduced visibility conditions. These accidents have taken the lives of countless student, instrument-rated, and even airline transport pilots, their friends and family.I truly believe that by following the suggestions provided the Safety Alerts we are discussing today, every pilot can take one step toward making their flights safer, and reduce the likelihood that they or their families will ever have to meet me in a professional capacity.
- The third accident case study involved spatial disorientation in day IMC. It occurred near Seale, Alabama, on April 7, 2008.[CLICK]
- The accident involved an experimental amateur-built Vans RV-10 airplane that impacted trees and terrain during an instrument approach into Columbus Metropolitan Airport in Georgia. The airplane departed Lebanon, Tennessee, about two hours prior, with an intended destination of Eufaula, Alabama. The private pilot and pilot-rated passenger/builder sustained fatal injuries.[CLICK]
- This was one of the first RV10 kitairplanes tobe completedand it was equipped with “Glass Cockpit” primary and backup flight instruments.The flight was intended to be a cross country trip to the Sun ‘n Fun fly-in in Florida with Eufaula as a first stop.The approach portion was flown in daylight IMC - an IFR flight plan had been filed.[CLICK]
- The pilot had accrued a total of about 1,700 flight hours.He was instrument current and about one-quarter of his flight time was in actual IMC. However, the majority of his prior IFR experience was in his personal airplane - aCessna Cardinal, which was equipped with “conventional” instruments.I’d like to point out that in my experience with spatial disorientation accidents, this is an unusually high number of actual IMC hours for a GA pilot.Additionally, he did not appear to have prior flight experience in the accident airplane or type.[CLICK]
- The passenger was a private pilot with no instrument rating. He had accumulated 68 hours of flight time in the airplane, was the co-builder, and appeared well versed in its operation.[CLICK]
- For the first two hours of flight, VMC conditions prevailed.The arrival area weather was VMC, with 1,000 foot ceilings and 4,500 foot could tops.[CLICK]
- Here we can see the GPS flight track in red, indicating a total flight distance of about 300 miles.The data indicated that the autopilot was most likely engaged during this flight segment.The approach required a descent into IMC about 25 minutes prior to the accident, as indicated by the orange bracket.[CLICK]
- In this image we can see the flight track for the final 20 minutes of flight, covering about a 30 mile radius.The green dotted line indicates the radial for the Eufaula VOR RWY 18 instrument approach, and as can be seen by the track data, the pilot was clearly experiencing difficulty maintaining a stabilized approach.He ultimately requested vectors to Auburn, the direction of which is indicated by the yellow arrow - However, while enroute, he requested a diversion to an airport with an ILS approach. He was subsequently cleared for the Columbus ILS 6, the localizer of which is indicated in blue.As can be seen, he again appeared to experience difficulty intercepting the localizer, with the ultimate location of the wreckage indicated by the white circle.[CLICK]
- This flight track of the last 3 minutes paints a fairly graphic picture of the airplanes final moments. The final turn was consistent with a “hook” maneuver, often observed during the last stage of a spatial disorientation accident.On multiple occasions throughout the last 14 minutes of flight the airplane deviated approximately 400 feet above, and 1,200 feet below its assigned altitude. The controller twice relayed low altitude alert warnings, and on five occasions alerted the pilot that he was not maintaining the assigned heading.[CLICK]
- The NTSB determined the probable cause as, “The pilot’s loss of airplane control due to spatial disorientation.” - One of the contributing factors washis lack of flight experience in the accident airplane.[CLICK]
- Missed OpportunitiesThe pilot did not declare an emergency at any point during the flight. Air traffic control personnel did provide the required assistance, however the pilots declaration of an emergency would have provided them further cues as to his plightand prompted additional resources to become available.The pilot did not initiate a climb into VMC - even though the cloud tops were relatively low.As mentioned, the pilot had no documented glass cockpit or type experience.Conversely, although the pilot-rated passenger had extensive knowledge of the airplane, he would not have been familiar with flying an instrument approach.[CLICK]
- The cross pollination of pilot and passenger experiencemeant that while the flight was perfectly legal, embarking on it was not necessarily advisable.In the last 4 years I have investigated nine fatal accidents where spatial disorientation was causal - four of these involved airplanes equipped with glass cockpits.When transitioning into a glass cockpit, training is crucial. Don’t think that if you can use an iPad, you can easily operate a Glass Panel. In fact, a recent NTSB study concluded that training in conventional cockpits does not prepare pilots for safe operation of the many complex and varied glass cockpit systems available.In conclusion, it’s easy with hindsight to pass judgment on the mistakes of other pilots; however, although they probably wouldn’t like to admit it, many of my fellow investigators have themselves at one time or another come close to being a statistic in the NTSB database. I would urge at minimum that pilots simply make a habit of reading, and learning from the mistakes of others.This concludes the staff presentations for this topic.[CLICK]
- NTSB accident reports, such as those presented here, provide pilots with a selection of “lessons learned” from which to hone their decision-making skills. Consider reviewing accident reports on a regular basis.In addition, the safety alert provides links to educational resources.It also provides some risk mitigation strategies . . .[CLICK]
- Preflight planning is crucial for any flight; however, it is critical for flights in marginal weather conditions. Obtain an official preflight weather briefing, and use all appropriate sources of weather information to make timely in-flight decisions. In-flight resources include ATC and Flight Watch.Don’t allow a situation to become dangerous before deciding to act. Be honest with air traffic controllers about your situation, and ask for help if you need it. The routine use of flight following will allow for immediate assistance from ATC.[CLICK]
- Remember that, when flying at night, even visual weather conditions can be challenging. When planning a night VFR flight, use topographic references to familiarize yourself with surrounding terrain. Consider following instrument procedures if you are instrument rated, or avoiding areas with limited ground lighting if you are not. During approach and landing at night, always use and follow any available glideslope guidance.Be honest with yourself about your skill limitations. When in doubt, consider bringing an additional, appropriately rated and current, pilot, or a flight instructor with you. Or consider postponing the flight. Plan ahead with cancellation or diversion alternatives. Brief passengers about the alternatives before the flight.[CLICK]
- Seek training to ensure that you are proficient and fully understand the features and limitations of the equipment in your aircraft, particularly the avionics, autopilot systems, and weather information equipment. Manage distractions: Many accidents result when a pilot is distracted momentarily from the primary task of flying. Request the assistance of a non-flying pilot or a passenger when prudent in order to maintain full attention to aircraft control.Obtain instrument flight training and consider getting an instrument rating. Maintain instrument currency and proficiency.Become familiar with minimum safealtitudes during preflight planning and utilize IFR procedures where practical.