What we can learn from accident reports

Among the most popular features in General Aviation News are the NTSB accident reports and excerpts from reports made to the Aviation Safety Reporting System (NASA reports).

When we publish these, we always note that the reports are “intended to help pilots learn from the misfortunes of others.”

There’s also a lot to be learned from our readers, who share their tips and tricks after reading those reports:

In reply to the NTSB Accident Report, “Cirrus pilot hits power lines,” Hordur Ingolfsson comments: “There are lessons to be learned from this incident. My teacher drilled to ‘look out for the lines’ if you go this low, regardless if the reason is justifiable or not (search and rescue, animal counting, or good old rule breaking fun that nobody admits) and suggested to ‘trim a bit up pressure’ on the controls. Add any amount of complacency to any low flying and you have fatal mixture.”

In reply to the NTSB Accident Report: “Pilot crashes while training for a tailwheel endorsement,” Leigh Smith says: “This ground loop and all ground loops happen because pilots are not taught to land in a crosswind correctly. As you get slower the ailerons need to be moved to the stops into the wind as you roll out. All ground loops happen because the pilot didn’t use enough aileron into the wind.

“I will land my RV-7 in a 20 knot direct crosswind any day, but you have to move the stick towards the aileron stops into the wind. I teach this kind of flying and what I see all the time is the pilot lands nicely, then they relax on the ailerons. You must keep moving the ailerons slowly into the wing to the stops.”

In reply to the ASRS Report, “And I walked away from the plane,” DA says: “A good pilot is surprised when nothing bad happens on takeoff; a bad pilot is surprised that something bad did happen.”

And Budd Davisson adds: “About pulling the prop control back on a constant speed prop for increased glide ratio: This doesn’t always work. It depends on the prop and the airplane. Once oil pressure is lost, which will happen with a real engine failure, as opposed to pulling the engine to idle, some props go coarse, some go fine. Where the prop control is at that moment has no effect.

“It’s important that a pilot know what’s going to happen when his prop governor loses the ability to govern because it is getting no oil.

“And all aircraft that can be landed power off should be landed power off often enough that the pilot/student has a working visual knowledge of where his airplane is going to go with no power. This should be part of the CFI’s tool kit for all students.”

In reply to the ASRS Report, “Mechanic’s error leads to MayDay call,” Robert says: “Aircraft owners and pilots need to be mindful that maintenance errors create significant hazards and must act accordingly. The most likely time for an aircraft to suffer a mechanical problem is on the first flight after maintenance. Be thoroughly skeptical any time an aircraft comes out of the shop. Your preflight and post-flight maintenance test flight are the last line of defense against maintenance errors.”

In reply to the NTSB report, “Obstructed vent outlets lead to fuel starvation,” Wylbur Wrong offers this lesson: “Check the logbooks for the plane carefully. This plane had not had an annual inspection for more than 14 years. Looking at the logs in the NTSB report, the last annual was in 2007, followed by at least one 100 hour inspection. To fly it for maintenance would require a ferry permit, if the local FSDO would issue one. And that’s if I understand the process correctly.

“Secondary, from personal experience, have an IA inspect the aircraft going toward an annual to find any problems BEFORE buying the plane. It can prevent you from buying a project (one where you have to fix several deficiencies to make it airworthy).”

In reply to the NTSB Report, “Hole in brake line leads to accident,” Warren Webb says: “I’ll have to admit I don’t always do it, but a brake check as part of the pre-landing checklist may have alerted the pilot that the brakes were not functioning correctly. An adequately long runway could then be used for the landing, followed by an engine shutdown immediately after landing as necessary.”

In reply to the ASRS report, “Near miss blamed on pressure from ATC,” Cary Alburn says: “All of us learn from our experiences. The most important lesson this pilot should have learned, or re-learned, is what he was taught early in his student training: When you’re the PIC, you make the decisions, not ATC, not other pilots. Whether ATC pressured the pilot to cancel early, he didn’t have to do that if he didn’t want to.

“But in any event, any pilot making an IFR approach or departure from a non-controlled airport has to use extra vigilance to avoid conflicting traffic. It’s probably a good idea to keep ATC and CTAF up at the same time on separate radios, but I suggest that in many small GA airplanes, the #2 radio is often an older nav/com and is used more as a backup or to monitor ‘guard’ rather than as an active part of communications, because of the flip-flop button in the #1 radio, which allows using alternate frequencies on the same radio. Not only has that been my process, but as I’ve watched many other pilots handle their radios, that’s their process as well. #1 is to use; #2 is for backup or to monitor guard.

“Several years ago, I was in a similar situation, only I was the one on the ground waiting for release, hoping an incoming would cancel. This was at Durango-La Plata County Airport (KDRO) in Colorado. I had taxied out listening to CTAF, then switched to Denver Center to pick up my clearance. I stayed on the Center frequency after getting it, because I had to wait for release for an incoming Citation. He called, said he was 20 south, the airport in sight, so cancelling IFR.

“ATC immediately released me, so I switched back to CTAF, announced I was departing 21, and started rolling toward the runway. I assumed, if the Citation was 20 south, that I had at least five or six minutes to depart (180 knots is 3 nm/minute). Whether the Citation announced any other position in the pattern, I don’t know, but I didn’t look as carefully along the approach path as I should have, and as I rapidly approached the hold short line, I heard, “we’re landing here, sir!

“Was it close? Not really. But it was a lesson — don’t assume anything. Always look for any aircraft on approach. Maybe the Citation was closer than 20 south, maybe he was moving at 250 knots or even more.

“Lots of maybes — in my case, and in the reporting pilot’s case. So we learn.”

Howard Tobin adds: “I also learned that lesson the hard way. A couple of years ago I was flying a veteran on a Veterans Airlift Command compassionate flight. We were going to a smaller airport that was adjacent to a larger military airport in an area unfamiliar to me.

“When the controller pointed out the airport I mistakenly was looking at the larger military airport and canceled my IFR flight plan. Before I realized my error I had transitioned the protected airspace of the larger airport.

“When I corrected and landed at the smaller airport I got a call leading to a discussion with the FAA. Fortunately, nothing terrible, but a lesson learned. Hold that IFR flight plan as long as possible.”

In reply to the NTSB Accident Report, “Fuel starvation brings down Globe,” Nate D’Anna notes: “Fuel flow instruments help and are relatively inexpensive as aircraft equipment goes. I had a Grumman AA1A for years that had sight tubes on the sides of the cabin. This system appears to be simple, however it is not the greatest. During flight, the fuel sloshes around, which can indicate a full tank on one tank and zero on the other. Attempting to balance the airplane to straight and level for an accurate reading can be difficult, even in light turbulence, so I used to time fuel consumption to switch tanks every 30 minutes.

“After purchasing a JPI fuel flow instrument, life changed for the best. It accurately provides total fuel on board, fuel flow in gallons per hour, total gallons used, and indicates a flashing alarm as to reserve fuel remaining per the parameters you program into the system. It can be connected to an onboard GPS to indicate fuel remaining to reach your destination. Best investment I ever made and accurate to within tenths of a gallon. As a backup, I still used my digital timer and switched tanks every 30 minutes.”

Mitch adds: “One never knows what will happen in flight. I always have full tanks for a long flight and at least tab fuel for local flights. Learned early in my beginning to fly: Switch tanks every 30 minutes, keep it balanced, and fly safe!”

In reply to the NTSB Accident Report, “Maintenance personnel fail to detect damaged aileron cable,” Jerry King notes: “Sounds to me like the problem originated from a binding/frozen cable pulley. Individual cable wires with flat surfaces and smearing are indications that the cables were rubbing across a stuck pulley for a very long time, eventually reducing their cross-sectional area and weakening them to the point where tensile fracture occurred.

“During annual inspection, every flight control cable pulley needs to be checked for binding. Proper examination often needs to be performed through a small inspection plate opening by feel. In addition, look for flat spotting of cable wires shortly before and after each cable pulley with a strong flashlight.

“My technique for verifying cable pulley bearings are good through an inspection plate is to lift the cable from the pulley with one finger and spin the pulley using other fingers. Because of cable tension, this method only works well when pulleys are not accomplishing much in the way of a directional change of the cable, but instead are used more for guidance as they are in much of the control systems of my 172.

“Pulleys providing about 90° of cable directional change need to be closely observed while someone else is moving the controls — again, closely examining cable wires at either side of the pulley. A single broken wire strand sticking out of a cable is a big clue that you need to look deeper.”

And, finally, from the ASRS report, “Fuel exhaustion surprises first-time Archer pilot,” Michelle comments: “I read this with sympathy and interest as a relatively new pilot who learned entirely in Piper Warriors and Archers — except for the one time I flew a 172 and experienced the ‘both’ fuel selector variance.

“A few more learnings to offer from this story. If the inference is correct that the pilot didn’t switch tanks until the two hour mark (a pilot more familiar with a 172 or self balancing fuel airplane might not have this protocol by default ) then the plane was likely flying significantly out of balance for an hour. This would have negatively impacted performance in a way ForeFlight could not predict. It’s very possible that the calculations were correct, but a pilot without a habit of switching tanks every 30 minutes or so would not necessarily be guided into factoring that into preflight. It’s maybe important to note that not only does this protocol support better fuel efficiency as you aren’t correcting for a heavy wing vs. light wing, but also increases safety at slow speeds. Landing a plane dramatically out of balance is inherently trickier.

“My second point is on the use of gauges. It’s unclear how accurate the visual check of fuel was initially or if a dipstick was used. Assuming the weight of passengers prevented a full fuel takeoff, it means using another manner to determine fuel on board initially.

“As is now obvious, relying on gauges alone is not great. It is not shocking to me at all that the gauge would show five gallons but in fact be empty. We installed a JPI fuel and engine monitor that is very reliable for inflight calculations and is a great investment for this reason.

“I appreciate this story as I hope my future flying includes lots of other types of airplanes and it’s a good lesson in reviewing and learning protocols that aren’t found in a POH.”