SoCAL February 2001

March 2001
SAFETY REVIEWS
SoCal
Riverside
SAFETY SEMINARS
For Socal Area
For Long Beach Area
For Los Angeles Area
For Van Nuys Area
For Riverside Area
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What if...

Thinking Safety

The causes of aircraft accidents labeled Controlled Flight Into Terrain (CFIT) most often hinge on the human performance in the cockpit. Human factor research points to ways we can make ourselves safer in the flying environment.

Learning to fly is a heavily conscious activity. For some of us, this learning is relatively simple and quick and for others, more slow and deliberate.

Eventually, our learning allows us to direct the aircraft where we want it to go. We can fly at the altitude and speed required for that flight. Best of all, we understand the scratchy sounds coming from the radio. We put the knowledge and skill we master into our flying safety kits.

Our minds work in two distinct modes, conscious and automatic. In conscious mode we exercise choice and critical review. We notice the results of our actions and adjust our behavior if we want.

For instance, taxiing an airplane when we were first learning required conscious effort. With time and practice, we were able to taxi while listening for air traffic control instructions, monitoring other aircraft and noticing runway signs and markings. In other words, we had moved into a more automatic mode.

With automatic behaviors, complicated tasks are done quickly and many tasks tackled at one time. Meanwhile our conscious mind is relatively free for other jobs.

When we perform, besides the automatic and conscious modes, we operate in three activity zones as well: These zones are:

Knowledge based activities
Rule based activities
Skill based activities.

Skill based activity is quick and gives us a wide set of patterned responses. Knowledge based activity is slow and limited to one task at a time. Although limited, knowledge based performance affords us many options for correction, adjustment and creative solutions. It's good for learning but not effective if we have an emergency requiring immediate action.

In an urgent situation or when we come upon a nonstandard flying event, the limited patterns of skill based performance are not sufficient. If we to go to knowledge based behavior-where more options are available, we might run out of time before we create a solution for the situation. It's when neither option is appropriate we move to rule based performance.

In rule based performance, we notice a need to modify preprogrammed behavior and take into account observed change. We are faced with a problem we've dealt with before or been trained to deal with.

It is called rule-based level because we apply memorized or written rules. We would think "if (this situation), then do (these actions)." In applying these rules, we operate by automatically matching the signs and symptoms of the problem to some stored knowledge structure. We use conscious thinking to verify whether or not this solution is appropriate.

Rule based actions provide us with safety margins best suited to responding in the complicated technological environment of aviation and best fitted to us as human performers. Here is a way to make its power part of your mental safety kit. Play the game of "what if" with yourself, with friends and with an instructor.

What if...I started out for the airport and had a minor car accident on the way?

What if...as I did my walk around, I noticed my hangar neighbor was hosting her grandchildren?

What if...the engine missed a little during run-up and the mag reading was...?

Our minds work for or against us. What if...you used your mind today so that when you are faced with an urgent situation, you will already have practiced the skills, worked through the knowledge and have a series of responses ready? They could save you and your passengers from harm or injury.
Kathleen O'Brien Powell

Human Factors in CFIT Accidents

Exploring the Research on Sleep and Fatigue in Pilot Performance

Traditionally, after accidents and loss of life, new rules are implemented and technologies developed to prevent that particular type of accident happening again. These measures are after the fact and meant to provide a new measure of safety.

Human performance in aviation accidents has been studied intensely since the late 1970's. Both military and academic institutions have discovered important information about how we operate in the aviation environment. The safety meetings at Torrance, Buena Park and Long Beach this month will focus on human factors in controlled flight into terrain (CFIT) accidents and explore the most recent research about sleep and fatigue and how those factors impact performance in an aircraft.

Managing High Performance Aircraft

Strategies to Keep You Ahead of Your Airplane

Jason Karlin, will conduct the meeting at Orange County Airport on Thursday, February 15th, and the Long Beach CFIs Only Meeting on Tuesday, February 27th.

Based on his experience as a flight instructor, a King Air and jet pilot, Jason will discuss strategies for practicing cockpit resource management in any high performance aircraft. Whether you are an experienced pilot in sophisticated aircraft or a beginner thinking about transitioning to the next aircraft up from a trainer, you will find great ideas that can make you a wiser and safer systems manager in your aircraft.

SoCal Aviation Safety Seminars

The Aviation Safety Programs Offered by the FAA are Free and Qualify for Wings and AMT Awards. For up to date information on the status of these seminars and to make online reservations visit www.awp.faa.gov/flightstandards

Socal Seminar Times are from 7:00 to 9:00 PM unless otherwise noted. No reservations are required unless noted by *. Never a fee. - For more information contact the Safety Program Manager listed in the FSDO area heading containing the event in question. All FAA Safety Seminars satisfy the requirements of AC-61.91H; the Pilot Proficiency Awards Program (Wings) and /or the Aviation Maintenance Technician Awards Program; AC-65-25A.

What We Need to Know About Keeping Healthy We are calling on the community of physicians from our area to discuss issues around staying healthy. Sponsored by the programs at Long Beach Memorial and its affiliated hospitals, you will hear about the latest research in prevention and care. The programs will focus on topics specifically for maintaining our health as active pilots. Some subject areas that will be discussed are:

In the year 2000 there were 32 aircraft mishaps that fit the definition of an aircraft "accident" within the Riverside FSDO's area of jurisdiction.* This number locally reflects what we keep hearing about the "big picture" accident rate, they are becoming less frequent.** In fact, 32 is the least number of accidents in a single year as far back as our local FSDO records show (20 years). That is a significant reduction from the numbers seen early-on during that 20 year span which initially showed 55 accidents per year followed by a very slow annual decrease. I would like to believe this reduction is at least partly a result of our FSDO safety program. A decrease in general aviation activity may also be a factor.

Of the 32 accidents,8 involved fatalities in which 11people lost their lives. That is a rather high percentage involving fatalities (25%). One of the most glaring aspects of analyzing the 32 mishaps was the high number that occurred in conjunction with flight training. Of the total, eight happened in the training environment (25%) - five during dual instruction flights (two fatal) and three during student solo (one fatal). That is an alarming trend. This office has never seen those kinds of numbers involving flight training. What it means is up for speculation. It may reflect something to consider regarding the flight instructors who are active within our district. Maybe the more experienced among them have moved on to the pilot hungry airlines leaving in their wake the less experienced.

Another alarming fact emerged from last year's accidents, 14 occurred because of engine failures; one a fatality. This increasing trend of engine failures was also noted during the analysis of the 1999 accidents. This high number of engine failure related accidents appears to indicate a problem with aircraft airworthiness. The numbers did not show experimental aircraft as having more airworthiness issues than production aircraft. It did reveal that experimental aircraft were involved in 25% (eight) of the total accidents, two were fatal. This may only reflect the increasing use of experimental aircraft in general aviation.

The most unusual fatal accident of the year 2000 occurred to a ground handler assisting with docking a blimp. Two ground handlers collided as they ran to grab a line hanging down from the docking blimp. One fell to the ground striking his head and subsequently died. This was a very unfortunate mishap and demonstrated a need for protective headgear when working in that environment.

There was a notable decrease in weather related accidents. There were no mishaps from attempted VFR in IMC. This is a good thing because this type of accident almost always results in fatalities. The only mishap which was weather related was during an instructional IFR flight in IMC in which a student and instructor failed to follow the published missed approach procedure and flew into rising terrain.

Overall, 2000 was a good year for aviation safety in Riverside and San Bernardino Counties. What can be learned from these accidents is; (1) the continuous need for giving any aviation operation proper care and attention; (2) take nothing for granted regarding an aircraft's airworthiness; (3) always take the most conservative approach to decisions regarding flight operations; and (4) at regular intervals get recurrent training and practice on what to do when engines fail.

* This article is about aircraft accident and not aircraft incidents. There are numerous aircraft mishaps, which occur that does not fit the finite definition of an aircraft "accident" per the NTSB.

The NTSB Part 830 defines an accident as follows:
"Aircraft accident means an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intentions of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage."

The NTSB defines death, serious injury, and substantial damage as:
"Fatal injury means any injury which results in death within 30 days of the accident.

"Serious injury is any injury which (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures fo fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second or third degree burns, or any burns affecting more than 5 percent of the body."

"Substantial damage means damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowlings, dented skin, small puncture holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered substantial damage for the purpose of this part."

Although there is some subjectivity in borderline damage cases, these definitions do clarify what is considered an aviation "accident". It might be important for readers of this article to realize that few gear-up landings fit the definition of an aircraft accident.