Last year I gifted my readers with stories of men and women pilots who acted heroically, and lived to tell about it.
This holiday season I’m going in a different direction. The Aviation Safety Reporting System reports I chose this time come from pilots who, in their own way, shot themselves in the proverbial foot.
Failure to Plan Equals a Plan for Failure
Our first intrepid soul noticed that the right fuel tank on his twin-engine aircraft appeared to have a slow leak. His mechanic suggested that he run the right wing tank dry by feeding both engines from that tank, to make it easier for the mechanic to make the necessary repairs. The pilot obliged.
“I was on a practice GPS approach over the Gulf, when both engines stopped at 2,000 MSL and several miles offshore,” wrote the pilot.
The dual failure was with the plane at least 40% full of fuel. The pilot tried to stop cross-feeding. Only the left engine restarted.
“I believed, based upon Shadin and JPI fuel flow gauges, that there were approximately 20 gallons remaining in the right bladder,” he said in his report.
His mistake was relying solely on gauges. In fact, the bladder tank was empty. Pilots are taught to use time flown to back up fuel gauge indications. Shadin and JPI gauges could read wrong simply because the pilot didn’t reset them after filling up.
The pilot managed to restart the left engine, but it was only producing partial power.
He wrote: “The left engine had been in the shop several times over the last year over poor power output, so I was distracted with the functioning engine operating rather than diagnosing the right engine.”
As a result, he didn’t realize his problem was simple fuel mismanagement, so he didn’t try to restart the right engine. He also failed to feather the right propeller after shutting down that motor, allowing aircraft performance to further deteriorate.
The pilot limped to the airport slowing losing altitude. He landed successfully.
In his analysis he concluded, “This is about concurrent problems in a near-emergency, which does happen in emergencies.”
I would conclude that pilot failed in his analysis. This wasn’t about concurrent problems in a near-emergency. It was about a pilot who accomplished his intended mission and was not prepared to handle his own success.
He chose to run his right bladder tank dry by feeding both engines from it. When that worked, he failed to plan for what to do next. The next step should have been to cross-feed both engines from his left fuel tank.
Three Strikes and…
This next pilot decided that adding two more obstacles to his departure was the best way to resolve the first one.
He began his report: “Engine start very slow/sluggish. Three revolutions of prop, then stop. One revolution to start on second attempt, normal run-up, and warm-up.”
Because things had gone so smoothly there, he requested downwind takeoff despite knowing “winds were more than 10 knots per the Automated Terminal Information System (ATIS),” he wrote. Fully aware of the winds were against him, he then requested an intersection departure.
On the takeoff roll, he noticed his airspeed remained 10 knots below normal takeoff speed. He also verified engine RPMs were at 2,000. Full power for those conditions in that aircraft was 2,500 RPMs. He chose to abort.
“Hit brakes, wheels locked and airplane turned to skid. Released brakes for directional control and braked intermittently to point of almost locking brakes. S-turned down runway to increase drag and braking effectiveness. Used full aerodynamic braking.”
When none of that stopped him before approaching the end of the runway, he decided to lock up the brakes and turn the plane to the right to avoid wrecking straight ahead.
“The plane went off runway and hit ground ice/snow/mud in a sideways position, stopping at a ditch.”
The pilot was not injured. The status of the aircraft was not indicated. Nor was a conclusion submitted. Perhaps the pilot felt all was self-evident?
Carry On, My Wayward Tow Bar
An SR-22 pilot took off with the tow bar still attached to his nose gear. The trip started with the pilot parking outside of the maintenance hangar instead of the parking lot. That threw him off his own routine.
“I performed the normal preflight with the aircraft still inside the hangar, and then proceeded to open the door and pull the aircraft out by hand, utilizing the tow bar,” he wrote.
He then transferred the gear from his car to the Cirrus’s rear baggage compartment, parked the car in the hangar and closed the hangar door. Without doing a final walk-around, he started the aircraft and taxied away.
“After the normal run-up and pre-takeoff checks, I taxied into position and began the roll for takeoff,” he wrote. “Just after rotation prior to liftoff, I felt a slight jolt and immediately realized what had happened.”
He climbed in the pattern, assessed his situation and, seeing no traffic, decided to land on the downwind runway. He landed safely. The tow bar departed the aircraft on nose gear contact with the runway. The pilot concluded this could have been avoided had he stuck to his normal preflight routine.
And Silliness Ensued
A Beechcraft B-58 pilot lost his cool during an approach. He was on an IFR flight plan and new to the aircraft’s Garmin 750 and 500 panel.
He wrote, “I got confused on setup for waypoint intersect. Broke out of clouds and got further confused…. Realized lined up for wrong airport and contacted Tower.”
The understanding controller vectored the pilot to the proper airport. The pilot landed too fast for the length of the runway. His hard braking caused him to blow a left tire.
“No damage other than to my ego and the tire,” he observed.
In his report, he concluded, “Silly pilot errors caused by overload and the domino effect of multiple tasks. Clearly, I was overloaded for what should have been an easy approach and landing caused by the confusion of learning the new system and the need to be at a location on time.”
It cannot be stated often enough how important it is to chair fly a new avionics system and, once aloft, aviate, then navigate, then communicate.
A Lesson for the Teacher
A multi-engine student pilot asked his MEI to demonstrate an engine failure on the takeoff roll. The MEI thought it was a good idea.
The MEI lined up the aircraft on the end of the runway, advanced the throttles and began the takeoff roll.
“As the airspeed showed ‘alive,’ I fully retarded the left throttle. The aircraft immediately started a strong veer to the left at which time I think I tried to fully retard the same throttle since my hand was currently on the left throttle only.”
The aircraft ran off the left side of the runway and sent a runway light flying into the air, significantly damaging the right propeller.
The MEI concluded, “I feel the primary cause of this incident was my inappropriate reaction to the quicker than expected veering of the aircraft to the left. A secondary cause may have been an inadequate briefing of the procedure.”
Measure Twice, Depart Once
A Cessna 150 pilot admitted questionable judgment was the reason he had to file a report.
He landed on a small airstrip in the bend of a river. Both ends of the runway were flooded by unusually high river water.
The weather in that part of Alaska had been warm that week, increasing glacial melt and raising the level of the river, which defines both ends of the landing strip.
“After landing, and having found the landing tighter than I expected, I paced off the strip and found it to be about 800 feet long,” he wrote.
According to his aircraft operating manual, the plane needed 748 feet to become airborne.
“As the aircraft was well under max gross weight, and since the strip ended at the water’s edge, with no tall obstructions ahead, I determined that a takeoff was possible and planned to accelerate in ground effect over the water if needed.”
Upon rotation, he found his aircraft performance to be anemic. He could not establish a climb.
“The tires touched down into the water, costing needed airspeed several times. With the conditions of deteriorating airspeed and lack of climb, it became apparent that the aircraft would not attain a flyable condition, and I elected to do a controlled descent into the water.”
He cut the throttle and landed in the water.
“The windshield blew inward from the pressure of the water, and I exited the aircraft as it sank,” he reported.
The aircraft then floated downstream about a mile before washing up on a sandbar.
The pilot ends his report with a nod to environmental protection: “No injuries or damage to property other than the aircraft occurred, and no oil or fuel leakage or oil slick was noted in the water.”
