Understanding why accidents happen aboard perfectly functioning aircraft is probably the most challenging task our industry has been undertaking over a very long period of time.
Eons back, it was a very well known fact that the mechanical reliability of « flying machines » was always in question. Why? Well simply because the strenuous constraints put upon airframes by reciprocating engines, especially the radial types, were the main culprit. We had no other choice, that was simply the way to go.
Airframes are irremediably allergic to vibrations, flutter and all sorts of shaking motion. Not the ones produced sometimes by the pilot.
With the advent of turboprop engines and finally jet engines, aircraft have become gradually more dependable. Completely absurd failures nowadays, the ones « old buggers » had to deal with scrambling all over the sky with aircraft parts flying in more or less close formation, are simply not possible anymore. Multiple failures are a rarity. Add to this dependability improved metallurgy, learned engineering and immensely improved maintenance techniques. The air transport system has evolved to produce sturdy flying platforms.
An engine failure per say, constitutes an « abnormal » condition on a multi engine jet. For the sake of the argument it could categorized in anything but a catastrophic emergency inducing loss of control (LOC). Serious airframe failures causing LOC have gradually disappeared from our airspace. The last significant event is cited in 2001 as an A300 that went down in New-York following the encounter of wake turbulence. Full rudder reversal imposed so much stress that the complete fin assembly separated. . Such an occurrence where the crew has no chance of recovery simply does not exist but on scarce statistical events. With professional hindsight, we have learned about the issue and trained accordingly.
To maintain control: it is essential
One can think that the 1989 very hard landing of a DC-10 in Sioux City, Iowa was an accident caused by one of those failures. On the contrary, it was nothing else the superior airmanship of the crew involved to maintain control of the aircraft. This is what it’s all about: we pilots have to maintain control.
A similar rarity was in 2005 an A310 rudder separation which ended with a diversion and a safe landing. Long story short, early composite use interface with traditional metal was at stake. Again, control mastery resulted in a joyous outcome.
Yet, the American NTSB cites loss of control (LOC) accidents of sound aircraft as the most fatal cause of accident. There exists no distinction: big or small. The difference between large carriers and general aviation is the shear enormous amount of safe flying done as opposed to the much smaller general aviation group. The LOC events are all the same while airframes are almost always sound.
It is recognized that within those LOC event the most problematic are the ones where the aircraft is in the maneuvering phase of flight:
- Take-off and landing
- Being close to ground level
Within the parameters it is also found that accidents are caused by:
- Engine failure(s)
- Aerobatics, improvised or planned
- Aerobatic is defined by a bank angle greater than 60˚ and pitch angle greater than + or – 30˚
- Low time pilots
- #1 reason: stalls and spins
Human factors work
The common link is once again human factors.
The transport industry has been working hard on those human factors over the decades. The DC-10 event is precisely a well documented and successful « advanced » human factors event aka as cockpit resource management (CRM).
But what are we to say about general aviation CRM to counter the aforementioned items? As opposed to the transport industry, GA is not so well « disciplined » or supervised by centralized authority. Our poor legislator is precisely this: poor. It cannot participate at all in GA let alone cope with all events, never mind educate. The key words emanating from the legislator high offices here is « risk management ».
This leaves GA flight safety out to dry.
It would appear obvious or at least hoped that we as pilots aspire to be perfect. Some actually attest to the acquisition yet the statistics haunt us otherwise.
Prior to actual LOC many elements will have insidiously slipped in the ideal flying routine/procedure (emphasis on the word procedure). We have proven to world many years ago that we were empowered to fly when we passed the licensing flight test. In light of those LOC events cited by the NTSB: what has been done to maintain if not improve that skill?
How can one deal in the 21st century with LOC events?
Firstly, one can maintain or improve those flying skills by practising. Flying is a perishable good. Sadly, cost becomes a factor. In order to become pilots, we have to demonstrate many qualities. Self evaluation is not one of them. This is where the proverbial yet underused annual training with an instructor comes in.
The objective eye of a professional can bring a wealth of information on our actual flying standard. New perspectives can be reviewed on upset training, stabilized approaches (VMC or IMC), safety risk management in flight (pilots should also be organized risk managers) or CRM work involving your passengers finding traffic for example.
I read recently of an incident where a private Piper Meridian departed in a rush after many distractions on the preflight with the elevator trim set in the full nose up position. The aircraft was fresh out of maintenance. The checklist item was missed, there was even questioning post event as to why would the trim be set to that extreme. Who cares? The unfortunate point was the item was missed on the otherwise « rigorous pre-take-off scan ». No checklist was used. It appeared that the many years of experience made it possible to bypass the time tested checklist. On take-off, the PT-6 provided the unmistakable power and the Meridian headed vertically with no possible pitch control from the yoke. The unfortunate pilot had the eventual reflex to cut the power, the nose came down for a hard landing on the grass grass beside the runway. Every one reading this will say: « This would never happen to me ! » Not so fast, please.
How can we avoid LOC can start with avoiding undesirable aircraft states: UAS.
UAS can be defined crew-induced aircraft position (within airspace) or speed deviations, misapplication of flight controls or incorrect systems configuration, associated with a reduction in margins of safety. This can be unintentional or intentional. We will not even deal with the intentional part.
So how does one deal with this prior UAS prior to LOC? It takes discipline in the short term and certainly some expenditure in the medium to long term. « Certified aviation » was never meant to be inexpensive, more on this later.
If we look at the previous 4 items list from the NTSB, we can question ourselves on how do we stay away from an accident causing LOC? Remember those are major items, the list is not restricted to the items in question.
In strict human factors approach the initial thought from the instructor’s seat is: « Fly the aircraft ! » One can be surprised how this common sense issue gets tossed out to the recycling bin.
- During an engine failure (single or multi) the initial items on the procedure (any aircraft make) is to precisely fly AND trim the aircraft. Within the next few seconds one will be so busy with other items that the aircraft, if improperly trimmed for the desired flight path, will head out for the rhubarb, hence the UAS.
- Aerobatics. How many times can we admire a nice sleek machine on take-off with a 5 feet level-off (or lower) to Vne and then flick-in the « Top Gun Afterburners, We’re Going Ballistic Goose » and followed by the hard break right? Ahhh, improvised aerobatics. Low flying not connected to landing falls (deplorable pun alas intended) in the same category: UAS.
- This one, the low time pilot is a different call. There is so much out there that can bite you’re six. In order to stay out of UAS, planning and preparation is the first order of the day PLUS categorically sticking to the plan. Experience takes time to acquire. Use it wisely.
- Stalls and spins. An aircraft will never get there by itself. It is always pilot induced, there is no black magic involved here, just science. This item is certainly the most tragic LOC type of event considering the amount of initial training devoted to the cause and the immeasurable amount of writings such as this one published. Prior getting there, major UAS has developed without any check.
Cost of improving safety
Practice is a must. One cannot simply call oneself safe by flying 10 hours a year. Sorry it does not work that way. That is where the cost of safety comes in.
Who is prepared to pay for an absolute minimum of one hour instruction time a year? The law in Canada does not even require this for GA pilots. A simple questionnaire is to be filled once a year and to be « safely » kept in archives to prove the completion. Really?
The proven best investment for GA to reduce accidents caused by LOC, is proficiency training. How about 30 minutes of upset training caused by paying too much attention to technology on short final? How about super slow flight to positively identify the consequent UAS?
A supplemental note on human factors: drugs. A lot of flue medicine is prohibited for pilots when flying. It begs to be asked: why fly when one has a cold or the flue? Flying while being tired is another item high on the human factor degradation list. Being able to stay awake does not mean one is not tired. I will state this again, only to support his memory, I lost a flying friend due to exhaustion. Judgement impairment by drugs or otherwise is the perfect incubator to UAS.
Technology does come in the picture. Yes, technology is expensive. I suppose different people put different value on life. Much like spending for a life raft, when required. There are the cheap, pardon affordable, models and then there are the proven designs. Who cares really, if you have no intention of using the life raft, right?
I am a big fan of technology. Not having to carry paper maps on board is great. I can concentrate on looking outside. One up for iPads! Same with ADS-B: anyone having flown with one even the ADS-B « in » model will attest that the units pick-up traffic way before your eyes do behind a scratchy and bug filled windshield. With AHRS bonus? Bring it on! Then add the voice activated traffic alert. I never leave the hangar without one. Not being able to pick up traffic when advised by ATC is an UAS. How about those angle of attack systems developed for GA? They should become mandatory if you ask me.
Working on improving GA accident rate is an ongoing issue for all of us. It takes deliberate discipline, time and financial effort.