Learning from others’ mistakes

Amidst the rubble of a fatal King Air crash, accident investigator Greg Feith found something strange: A Velcro strip on the panel.

When he asked the pilot’s wife what it was for, she told him that her husband would put an alarm clock there, set for 15-minute intervals. During his regular flights from Oklahoma to Wyoming, the pilot would doze off, relying on the alarm clock — or his wife — to wake him. “I wasn’t there this time to wake him up,” she said sadly.

When Feith told this story during a safety seminar at Oshkosh this year, you could see heads shaking throughout the packed auditorium. But you can bet that every pilot in the crowd learned from that King Air driver’s mistake.

Periodically, we are criticized for running Accident Reports in General Aviation News. “After all,” critics say, “you don’t see accident reports in boating magazines or car magazines. They sell the sizzle, the fun, the sport.”

When letters run, invariably they are followed by more letters from pilots and CFIs thanking us for running those accident reports. “This helps us learn from other people’s mistakes,” they say.

And if the crowd at Oshkosh was any indication, pilots are very interested in learning from others’ mistakes. Feith’s seminar was a two-fer, with Part 1 on the first day of the show and Part 2 on the second day. Both seminars, titled “Lessons Learned From 20 Years with the NTSB,” were packed to standing room only capacity.

Feith, an engaging speaker, illustrated his talk with lots of examples of pilot mistakes, complete with horrific photos of mangled planes.

“Nobody wants to talk about crashes,” he told the crowd. “But my job is to look at the bad side and take those lessons to make flying safer. ”

The No. 1 problem? Communication. How much is being communicated, how much is being absorbed and — most important — how much is being utilized?

“We have information overload,” he said. “We need to determine what is important.”

Decision making is critical to safe flying. But learning to make good decisions takes continuous training and lots of experience in the cockpit.

“When I show up, I have to decide if you made a good decision,” Feith said. “But if I’m there, you didn’t make a good decision.”

Flying into a thunderstorm, hesitating before making a decision to go-around or flying when you’re too tired or stressed to make a good decision have all been factors in fatal accidents.

“It’s not the big things that kill you,” he said. “The little things accumulate to lead to disaster.”

A missed item on a checklist, a passenger in the back seat threatening to throw up, a plane — or bird — that pops up unexpectedly — those momentary distractions can spell disaster.Feith has been to many accidents when a plane has encountered nature — and the plane lost. What would you do if there was a deer on the runway? You don’t have a horn to alert the deer, so you better have a plan on how to deal with this exact situation. Did you hear about the Beech Baron owner who hit a goose in flight? The entire top of the plane sheared off. “Are you prepared to handle that kind of devastation?” he asked the crowd.

How about that first flight after maintenance? Do you assume that your mechanic did everything just right? “As much as I like my mechanic, he is human,” Feith said. “Mechanics can get distracted and sidetracked as well.”

All of this isn’t to scare you into never flying again — it’s to make you aware that disaster can start with something as simple as a strange noise. “It’s a dark night and you hear a strange noise,” he said. “Anxiety starts to filter in. The noise gets worse. That takes your big field of vision and narrows it to just that noise. As you concentrate on the noise, the plane wanders off altitude. Often in accidents, the airplane was capable of making it, but something took the pilot’s mind off what he was trying to accomplish.”

Pilots often take umbrage that Feith — and most NTSB accident reports — point to pilot error as the leading cause of accidents.

“Sorry folks, but we have some very reliable planes and equipment out there,” he said. “The weak link is the interface with the pilot.”

Learning from the mistakes of others can help pilots strengthen that link. There are other things you can do.

“Never assume anything,” Feith said. “You have to have a plan and always think ahead. Pilots tend to be reactionary rather than visionary. You always have to be thinking ‘what if?'”

Janice Wood is one of four people who contribute to this column.

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