What went wrong? Be a Boy Scout

Assuming you did something wrong and working to find it is a profoundly different posture from expecting you did everything right and working to confirm it. Any aircraft problem we encounter is far more likely to be caused by oversight, an errant switch, or misapplied procedure than by a system or component failure. Thus, reacting to an aircraft anomaly with the “what am I screwing up?” response encourages you to slow down and go back through your procedure methodically, looking to find the mistake.

This posture may have prevented the tragic crash of a Beechcraft Debonair in the Tennessee mountains on a cold, clear January afternoon. At about 7,000 feet msl, on the second leg of a cross-country flight, the Beechcraft’s engine sputtered, then stopped. The pilot confirmed no abnormal engine indications that would suggest overheating or mechanical failure, then attempted an engine restart with no success. According to the NTSB report, he broadcast a “Mayday” call on 121.5 MHz but heard no response. He pitched to best glide speed and turned in the direction of the nearest airport. Realizing he wouldn’t make it, he attempted a landing on a logging road in mountainous terrain with disastrous results. Some 20 hours later, rescue personnel located the airplane and found the pilot with serious injuries and the passenger dead.

NTSB investigators found the fuel selector switch in the Debonair on the dry auxiliary tanks, and the fuel indicator switch on the main tanks, which they determined held fuel at the time of the crash. During the investigation, the NTSB cranked the engine, which fired off immediately when supplied with fuel. The 377-hour pilot had 14 total hours in the Debonair. According to the NTSB, he mismanaged available fuel, resulting in loss of engine power because of fuel starvation. He then misapplied the air-start procedures, precluding an air restart.

A 377-hour pilot has plenty of experience to build strong fundamentals. With 14 hours in a new airplane, he was likely still getting comfortable with the Debonair, working toward feeling a true mastery and comfort in the left seat. He was probably still searching a bit longer to find a switch or taking a few extra glances to find the intended instrument. A cross-country flight is an ideal way to log valuable time getting comfortable in the airplane—working through scan patterns and learning the typical instrument readings, slightly nuanced in each airplane.

Fourteen hours is not enough time to feel confident in unusual circumstances. An anomaly can elevate anxiety and then exacerbate any gaps in familiarity, which drives down confidence and negatively affects performance. This seemed to be the case in the Debonair accident. When the engine sputtered, had the pilot asked himself, “what am I screwing up?” he may have methodically checked his switches and noticed an improper fuel selector switch, turned it to the proper position, and the engine would have sputtered back to life after loss of a few hundred feet. Instead, he was likely duped by his fuel indicator reading fuel levels in the main tanks, not the aux tanks he’d selected to operate the engine. As the airplane glided down over remote, mountainous territory, anxiety likely started to build. Seconds probably felt like minutes and delays in finding instruments, or pages in checklists, began to feel chaotic. Important verification steps were missed and according to the NTSB, a critical procedure that could have prevented the mishap was misapplied.

NTSB investigators found the fuel selector switch in the Debonair on the dry auxiliary tanks, and the fuel indicator switch on the main tanks.Remote and ragged mountainous terrain reduces the odds of surviving an off-airport landing because opportunities to dissipate energy and avoid sudden impact are limited. On this particular flight, survival odds were further limited by small risk factors that lurk quietly in the background for many GA pilots. These risks are dismissed so routinely they go unnoticed, but they remain precariously perched until a triggering event fells them in sequence, like a line of dominoes. They exacerbate a bad situation into tragedy.

The pilot was not on flight following and did not file a VFR flight plan. Either one of these would have helped rescuers locate the downed airplane hours earlier, sparing pilot and passenger from hours of exposure in subfreezing temperatures. The airplane was equipped with a legacy 121.5 MHz emergency locator transmitter instead of a more modern 406 MHz ELT. Newer, 406 MHz ELTs utilize satellite communications, are monitored more thoroughly by rescuers, and transmit information packets that include position. Rescuers advise a 406 MHz ELT or personal locator beacon transmitting on the same frequency will bring them to within yards of the crash site. The Debonair’s 121.5 MHz ELT wasn’t noticed until more than 12 hours after the crash, and then it took rescue teams hours to home in on the signal and locate the airplane.

The Debonair was not equipped with shoulder harnesses. An NTSB study found that fatalities in similar accidents could be reduced by 20 percent through use of shoulder harnesses; the severity of injuries could be reduced by 80 percent. Shoulder harnesses would have braced the pilot and passenger in the Debonair and reduced impact trauma.

Flight safety is optimized when the pilot is ready, the airplane is ready, and the environment is suitable. It’s not enough to make this assessment using ideal circumstances, assuming everything goes right. Pilots must make these assessments expecting problems. Pilot readiness must include systems knowledge and proficiency in abnormal procedures under pressure. Aircraft readiness must include survival and rescue aids such as seat belts, medical kits, items to protect against the elements, and modern ELTs or PLBs.

We fly remarkably reliable airplanes. Most system anomalies are pilot-induced. We can enhance our flying by addressing aircraft problems with an expectation that we’ve made an error and working to find and correct it. In the unusual circumstances where we haven’t made an error, our preparation will make all the difference.

Web: airsafetyinstitute.org

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