What I Learn from Misfortune

I am inveterate reader of accident reports. I look at preliminary reports from the FAA almost daily; I look at final reports on incidents that I am interested in; I study categories of accidents for specific learning purposes; and I enjoy reading ?there I was, on a wing and a prayer?? type articles in magazine and on the web. Some may call me a pessimist, or worse?but I believe very strongly that the best way to learn is from experience, and since we don?t all want to learn from our own mistakes, learning from the mistakes (or misfortunes) of others is always going to be less painful and more efficient.

So what do I look for when I peruse mishap and incident reports? I look first for patterns - what, in general are things that are giving people trouble? Interestingly enough, landing accidents (gear collapse and running off the runway) are a major contributor to the overall accident count. Rarely do they result in injury, but they are certainly costly. So less #1 - never let my guard down while landing or rolling out! Additional patterns - experimental aircraft have an unfortunately high occurrence rate of power failures. Note I said ?power?, and not ?engine?, because when you read the final reports, it usually turns out that lack of fuel to the engine was the real culprit - even though there was usually fuel on board. The moral I take away from this? Lots of builders decide that they can build a better fuel system than Van?s (and many can) - but the truth of the matter is, it is just about the simplest you can devise, has been used for decades in most single-engine low-wing GA planes, and is hard to beat without adding components - and more things that can go wrong. What do I learn? It reinforces my belief that there are some things to experiment with, and some things best left alone - unless that area of experimenting is your main goal in homebuilding, in which case, you better be prepared for problems!

Next, of course, is the area of low-altitude stall/spin accidents. Usually fatal, these loss of control accidents teach us to be extremely vigilant when down low and maneuvering. The fact that they keep happening, and keep happening are constant reminders to stay sharp, focused, and cognizant that we have to keep the wing flying. (And then there the low-level aerobatics accidents - more than any of us woudl want to admit, and easily fixable with a little bit of personal discipline...) It?s like the constant briefing-closing reminder ?Let?s all be safe out there? - you need to hear it every day!

Reading accident reports and incidents need not put you in the category of the macabre - indeed, it is a matter of survival to constantly remind yourself that very few people begin a flight with the intent to crash - they thought that everything was going to be fine - but something went wrong. I would be willing to bet that simple awareness - the constant reminder of things that can go wrong - can probably deter a huge number of potential accidents. It is when we become complacent and nonchalant about aviating that we are asking for trouble. I?ve scared myself back to a very ?focused state? more than once in my flying career when the unexpected snuck up and I wasn?t prepared. Study, categorize, and tell yourself that ?I can avoid this kind of mishap if only I?..? and then fill in the blank. By itself, it won?t protect you from 100% of the pitfalls and mishaps out there - but if it reduces your chance of an incident by 50%, wouldn?t it be worth it?

How do others learn from the misfortunes of others? What do you do with these reports to keep you, your passengers, and your airplane intact?

Paul

same thing

I do the same thing you do. I read the accident reports often, and I really like columns like "I learned about flying from that." I really think there are only two kinds of people in this respect -- those who learn from the experiences of others and those who have to pee on the electric fence for themselves!

As a very low time pilot in training, I read these also trying to figure out how to avoid possible problems. Always easier to learn from others.

Same here, for the same reasons.

L.Adamson -- RV6A

Accident Reports

If you don't have time to read pretty much every RV Accident Report ever posted, you don't have time to build an RV. If you buy an RV and don't review those same reports, you need a different hobby.

I take a little different approach to the "There I was" and NTSB naratives.

Those with thin skin move on now, because I am going to shave near the bone here, and some folks are not going to like it.

Magazines have "There I was" columns because they have the highest readership in the magazine. (I write for magazines, and I know this to be fact.) These columns equal $$$$ in the business. The magazine feels good because they feel like they are promoting safety and then the pilot reads the column and the wheels fall off the wagon.

Many pilots read these columns like this: "That guy was an idiot, I would never do what he did because I am not an idiot, therefore, I don't have a problem and I am safe."

This is called rationalization. The "I would never do that, It won't happen to me" mentality.

New Flash boys and girls. Flying is dangerous. Lets be clear about that. Just yesterday on Yahoo news the listed the most dangerous jobs. Pilot was #3 on the list. When you consider that more than half the commercial pilots in America are airline pilots and they almost never crash, that makes being a non-airline commercial pilot by a large margin the deadliest career in America.

Good pilots do small stupid things all the time and the links in the accident chain get hooked up and they get hurt. It is a fact. We want to pick one link in the chain that we can say. "I never do that so the problem is solved." It is not that easy.

The next time you read an accident report, read it like this: "That guy was probably a good guy, and maybe even a better pilot than me and he went out and did something stupid, or made a simple mistake, and got killed. What in his life or in his mind caused him to lapse from his normal actions and do something that got him killed? And more importantly what mistakes have I made or do I make that could be the genesis of an accident chain that could hurt me?"

You don't believe it. Read an accident report that involves a friend who you knew to be a good pilot. Unfortunately nearly everyone in our business has at least one friend who killed themselves in an airplane and not all of them were idiots. In my case, I have way too many, and lots of them were much more capable pilots than me. We anquish over the facts, parce the details, look for holes, but the reality is, a good pilot who was a good guy got killed and we can't understand why. A much more thought provoking process, than saying, that guy was an idiot, and I am not so I have no worries.

If you can read the "There I was," and NTSB reports like the pilot was a good friend who was a good pilot, you will learn a lot more from them. That makes it really hard, but much more educational. If you find yourself saying, "what an idiot," you're just rationalizing, and that's a waste of time.

Tailwinds,

Doug Rozendaal
Standing by with my asbestos underwear.....

Save yourself, lose the airplane

Like most pilots, unfortunately I have lost several people to aviation accidents. I have also spent a great deal of time reading accident reports and dealing with the litigation consequences that result from these accidents.

The most important lesson that I have learned is that surviving an accident, no matter power failure, electical failure, or the like, is the most important result. Too many times the issue idea of landing the plane, often at the nearest airport, is the concern of a pilot during an emergency. Especially with experimental airplanes, after spending countless hours riveting and building, the thought of landing the plane and causing substantial damage is very tough to cope with. But more often than not, landing off field and damaging the plane, will result in an accident with non-fatal injuries. Where as pushing an underpowered airplane to make that runway that is just a bit further or that nice open pasture that may be within gliding distance has the potential to lead to deadly stall and crash fatal accidents.

Looking back to the many hours of instruction in flight school planes, it was drilled into us during simulated engine failures that you get best glide speed and find a suitable place to land immediately. And you go to there and land, be it a wheat field or an old county road. It's important not to forget these fundamentals when we transition into our own planes, even the ones we built. The thought of seriously damaging an airplane is tough, but walking away and then dealing with the insurance company is a much better outcome.

Stupid pilot tricks

Paul,

3 years ago I went to an FAA safety meeting in Georgia and the FAA spokesman discussed the fatal GA accidents the previous year for the state. In all but about 5%, the pilot did STUPID things.

Looped a plane (not acrobatic rated) and lost a wing, buzzed houses and hit something, get there-itist and ran out of gas, assumed the plane had gas and didn't open the gas cap and look in the tank, failed to drain the sump, flew in IMC when the ceiling was less than 200, used a nail as a yoke lock and forgot to take it out, etc....

One point he made that in almost every case, 1 event lead to another and then another and then the accident. Everyone there had a dumbfounded look on their face...."how could someone be so stupid!!"

He used a perfect example of 3 buckets. Luck, experience, and knowledge. We are always putting in the experience and knowledge buckets, but only taking out of the luck bucket. As we put in the experience and knowledge, we build confidence. With confidence, pilots begin to by-pass or ignor things they were taught early on. Near miss - take some from the luck bucket. Eventially, the luck bucket empties and boom - the accident.

As Larry Geiger has on his signature, we all need to be careful out there.

Although I rarely come out and say it it quite the way you did Doug, I pretty much agree with your approach. Very few pilots set out on a flight with the intention to crash. They went out, had a chain of events occur, and ended up in a bad place. The reason I read, study, and interpret accident reports is to figure out how they got there - and how easy it would me t get there in the same fashion., because it is true - we are ALL capable of making mistakes that lead us to a bad end. I usually don't bandy around the words "Stupid" and "Idiot", because I realize that if I fail to learn the lessons of others, they could just as easily be applied to me!

I like your overall approach though - look at the accident pilot as if he were a good Friend - or yourself. Watch yourself get sucked into the situation. And then figure out how to recognize that you are headed down that path, and how you would get out of it.

when pilots have a mishap, and their first reaction was "how did THAT happen?!" it is clear evidence that they weren't paying attention. To the situation at hand, or the lessons of the past.

Paul

Doug: That was very well said. No need for the asbestos.

Paul: Excellent points and all I can say is that I 100% totally agree. Maybe it would be of value if we had a safety theme here at VAF; a new topic that might be changed a couple times a year where the membership talks about problems that are statistically popping up within our flying community. The ones like Doug points out that tend to be taken a bit too lightly. Just thinking out loud...

I find it truly disheartening that there is at least one GA fatality EVERY DAY in this country. It can happen to anyone, regardless of experience.

Personally, I subscribe to Aviation Safety magazine. No advertisements and dissenting opinions from readers are published regularly. I also read as much as I can from other publications.

Does this make me safer? I don't know, but it does keep the danger of my hobby in the front of my mental file box so that when I am tempted to skip something on preflight or push my personal limits, that little man in my head has much more authority to guide my ultimate decision.

bsacks05 said:

I find it truly disheartening that there at least one GA fatality EVERY DAY in this country. It can happen to anyone, regardless of experience.

Personally, I subscribe to Aviation Safety magazine. No advertisements and dissenting opinions from readers are published regularly. I also read as much as I can from other publications.

Does this make me safer? I don't know, but it does keep the danger of my hobby in the front of my mental file box so that when I am tempted to skip something on preflight or push my personal limits, that little man in my head has much more authority to guide my ultimate decision.

Click to expand...

It is disheartening. In the Warbird would we have 10 fatalities per year. I have gone back 15 years and it is like clockwork. The warbird community is a very small group and every year, at least 1 of those folks is a close friend of mine.

Bsacks is on the money here. He acknowledges our business is dangerous, and he has a little guy is his head.

My little guy sits on my shoulder and when I am fixin' to do something stupid he writes the accident report and reads it to me.

"An ATP CFII MEI and Designated Pilot examiner, with a pocket full of type ratings and over 8000 hours and xxxx hours in type did blah blah blah and was fatally injured."

It is amazing how incredibly stupid something sounds when he reads it to me in that context.....

Some will say people who hear voices need some treatment. That should be no surprise, all pilots need treatment.

Tailwinds,
Doug

I like hobbies that are on the edge, but...

Great thread, great posts Doug, Paul and others...

I've raced cars, sandrails, motorcycles, 4 wheel drives and snowmobiles. I grew up on a ranch and rode horses and worked cattle, anyone who knows that life knows the hazards. I did technical rock climbing for 10 years. I have spent a lifetime in the worldwide drilling and boring industry and I have seen firsthand the results of what can happen when you commit even one seemingly inconsequential unsafe act or forget the dire consequences that are so near to us at every moment. I work near potential danger every day and I play near danger in all of my hobbies.

I've always had hobbies that are "on the edge"...

A few years ago, I had an "ah hah" moment reading Gen. Chuck Yeager's autobiography...whatever you may think of Chuck Yeager, here's what I gleaned from that...Chuck Yeager personally witnessed many horrible aircraft accidents during his career and was always afraid of crashing and burning...the last thing he thought about before beginning a flight were the graphic consequences of making a mistake...of not being methodical.

I guess that's where I've always been when I fly or race. I've always spent a few moments before getting in or on and graphically considered the ramifications of being unsafe. I've always asked myself the question...are you ready, prepared and committed to do this? I must admit, I have failed at times. I have, at times come too close to crossing the "fun barrier." It is scary to reflect on those times... each of them have been huge learning experiences for me. None of us are perfect...and that is why we must commit ourselves to professionalism and safety every day and in every thing that we do. We can never eliminate the risks...but let's not get hurt as a result of our own actions.

Anything we can do to bring safety to the forefront will help us. The company I work for is committed to safety. Every meeting or conference call, internal or external must begin with a safety related topic. You might think a policy like that to be childish, (I sure did when it was first implemented) but it has brought about big changes in our safety record. Nothing is more important than keeping the focus on safety, in everything that we do.