RV Accident Probable Cause Listings

[scrollF4]

Regarding Doug's new sticky on RV accident probable causes:
http://www.vansairforce.net/AccidentsAndSynopsis.htm

I have to give DR a big atta-boy for creating this sticky. I believe Doug is putting real sweat into giving us what many want and all need: A safe place to discuss aircraft accident lessons learned. It’s a SAFE place because it helps us deal with FACTS without speculation. Forgive the long discussion, what follows is my reason for firmly supporting Doug’s Posting Rule #2:

Firstly, I do believe discussions on aviation mishaps have a time and place here in the VAF. Key phrase: Time and place. Consider my background: I am the former Director of Safety for USAF’s Air Combat Command, and the previous Chief of Aviation Safety for the Air Force. I was responsible for executing Safety Investigation Boards for every Air Combat Command mishap. The F-16 that overran the runway at Oshkosh? My staff executed that safety board for my 4-star general boss, who was the convening authority.

Of all the lessons I have learned in my career, and particularly as a flight safety officer, this is the single most important: You NEVER know what you don't know. Without the benefit of all the evidence, no amount of speculation is EVER accurate. Speculation (particularly on open media) taints investigation boards, inaccurately sways public opinion, feeds media sharks, and ultimately threatens GREAT harm fon an otherwise innocent pilot and his/her family. I spent a tremendous amount of effort keeping interested parties (including big scary generals and congressmen) OUT of my safety boards’ proceedings.

I had one advantage: Military safety boards are conducted under what’s called Safety Privilege. That’s an extension of presidential privilege granted by the Supreme Court to the Department of Defense for safety investigations…that’s SAFETY investigations, not legal investigations. Under Safety Privilege rules, the results cannot be released to the public: Not that it’s classified secret, but it just can’t be released outside the DoD and the actual parties involved in the type of aircraft or command. Why? Two words: Mishap Prevention. Safety Investigation results can only be used for mishap prevention. Not for punitive or litigation purposes, not for the media, but ONLY for mishap prevention. Knowing these protections are in place helps witnesses (including the pilot) to more eagerly assist the investigation…they will not get hammered for mistakes admitted to this investigation board.

So when the media reports that the Air Force has announced the results of their accident board, they are actually releasing the results of a SECOND independent investigation conducted by the Judge Advocate (JA). Yep, that’s the one that involves lawyers, and is used for media, punitive, and litigation purposes. The witnesses are read their rights. The JA’s board doesn’t exist for mishap prevention (it doesn’t even generate safety recommendations). In fact, the JAG’s accident board exists specifically to protect the Safety Board’s privilege. All military services follow this construct, in accordance with DoD instruction and Supreme Court edict.

So why do I agree with Doug? Because ill- and un-informed conjecture is the same as mis-informed conjecture, and it’s all poisonous. That’s why after four+ years as a member of this VAF forum, you have never seen me write about fresh mishaps. People have this inner need to guess and build opinions, but I don’t pass up a perfectly good opportunities to keep my mouth shut and listen.

I strongly disagree with any sort of discussions about an OPEN mishap investigation. So when SHOULD we discuss a mishap? Once the investigation has concluded and the results are released, THEN we have an obligation as pilots to discuss the results in the interest of mishap prevention. At that point, we should definitely discuss it, but I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator’s report, because therein lay the facts. I also submit: Rather than casting darts at what the pilot did, didn’t do, or should have done, we serve each other better by addressing how we can avoid the same calamity if we face a similar situation. What if I face that S-VFR weather in my Skyview-equipped -7A and one of my ADAHRS units has crumped? Would I also flip my -7A on that same grass runway if it’s wet?

Here, Doug has created a process to feed the latest info from CLOSED investigations with the investigators’ statements of probable cause. Now we can discuss these and what-if the event until we're blue in the face.

Thank you, DR. You’re really working hard to satisfy the needs and wants of the VAF masses.

Fly safe, and CHECK 6!

[DanH]

Colonel, I agree with 96.5%.

Here's the other 3.5:

...but I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator?s report, because therein lay the facts.

Do you truly think the civilian investigative bodies are infallible, or always do complete investigations of experimental crashes?

No sir, I don't.

[scrollF4]

Dan,
I can't disagree with you. However, right or wrong, they are the only entity in the chain that received exposure to the entire body of factual evidence. With that in mind, I'm compelled to base my conversation on their findings.

In any case, once its final, start talking.

[meloosifah]

I have to agree with Dan on this one - the civilian investigating entities are usually not as thorough as what we see in the service. Meaning that a little post-closure speculation helps us all identify where WE may have gone astray in a similar situation. If all we discuss are the exact findings we will inevitably miss an opportunity to learn, teach and/or improve our own methodologies. Think of a new pilot who has never experienced anything like the incident in question and perhaps doesn't even know what COULD lead to the incident - discussing what MAY have gone wrong that would lead to the final result, whether it directly is made clear in the investigation report, brings awareness to the specific set of risks inherent to that phase of operation.

Just my humble opinion...

[ed. If the probable cause has been published, then you're free to discuss all you want! And thanks for the comments. v/r, dr]

[Mike S]

Sid, well said.

Very closely aligned with the way things operated in my former life as a fireman.

Speculation before the investigation was finished was very often just simply wrong.

It takes a lot of training and experience to dig all the facts out of a pile of smoldering ashes-------whether the remains of a plane or house. Letting the experts do their job is how the truth can best be found.

[luddite42]

Originally Posted by DanH

Do you truly think the civilian investigative bodies are infallible, or always do complete investigations of experimental crashes?

No sir, I don't.

Hardly. Some GA accidents get embarrassingly short shrift. I know of a banner tow crash involving an engine failure after a pickup attempt. NTSB probable cause listed as "pilot?s failure to maintain adequate airspeed while maneuvering near the ground, which resulted in an aerodynamic stall". No mention at all of the engine failure and that crash pics clearly showed one prop blade folded under the airplane, buried in the dirt, and the other blade without a scratch on it. Engine not running. NTSB was never onsite. I guess some crash reports are phoned in by whoever shows up onsite from the local FSDO. I would not expect manpower or money exists to perform detailed investigations of every GA crash.

[Chkaharyer99]

Doug, thank you very much for collecting and illustrating the RV Accident Probable Cause data in such a comprehensible format. There's so much to learn.

I am an old (53 years old) new pilot (160 hours TT, 20 hours RV-8), so not much to contribute but lots to learn from all of you. I don't want to learn any of these lessons the hard way but rather through the experiences of others. Avoidance is key.

In review of the data under the heading, "Broad Base of Flight" the info provided is very telling.

Is there a simple way to categorically (electronically) sort this info by, "Landing", "Takeoff", "Go Around", "Approach"...?

Can this info be easily imported into an Excel spreadsheet?

[ed. Yes! Just tap Ctrl-A in your browser, then Ctrl-C, then paste into Excel. Play w/the data then as you wish. v/r,dr]

My thought is to take one subject (landing) at a time and learn how to best mitigate against an accident in that category then move to the next one down the line.

Can someone offer a better approach?

Thank you again,

[Paul Tuttle]

Right on mike.

Originally Posted by Mike S

Sid, well said.

Very closely aligned with the way things operated in my former life as a fireman.

Speculation before the investigation was finished was very often just simply wrong.

It takes a lot of training and experience to dig all the facts out of a pile of smoldering ashes-------whether the remains of a plane or house. Letting the experts do their job is how the truth can best be found.

[DanH]

I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator’s report, because therein lay the facts.

Please allow an example. Our own Ted Chang suffered an inflight fire after a fuel line b-nut allowed a leak. The report mentions (1) smoke in the cockpit, (2) that the floor burned through, and (3) identifies the b-nut as probable cause.

However, it doesn't investigate the cause of smoke so bad that Ted had to jettison the door. It doesn't mention that the smoke/fire in the tunnel continued to smolder on the ground, or that the fire department had some difficulty getting it to stop. It also fails to mention that the floor burned through only in the narrow area under the tunnel.

We only know these things because Ted, a good and honest man interested in the safety of his fellow pilots, supplied photos and information directly to the group. He had insulated the tunnel with Thermozite, a polyester fiber mat with an aluminum foil reflector. It was sold by a popular vendor as "firewall insulation", which is like saying napalm can be used as bath soap.

Here's the point...a rule, self-enforced or otherwise, required strict adherence to only the information found in NTSB/FAA reports may miss valuable safety information.

[ed. I think I have mentioned this a few times before, but will again. Once the probable cause is published, PLEASE discuss it! If more information comes out, we all benefit. This case you describe here is a great example of that, and thanks for the feedback Dan! v/r,dr]

[jrs14855]

Originally Posted by luddite42

Hardly. Some GA accidents get embarrassingly short shrift. I know of a banner tow crash involving an engine failure after a pickup attempt. NTSB probable cause listed as "pilot?s failure to maintain adequate airspeed while maneuvering near the ground, which resulted in an aerodynamic stall". No mention at all of the engine failure and that crash pics clearly showed one prop blade folded under the airplane, buried in the dirt, and the other blade without a scratch on it. Engine not running. NTSB was never onsite. I guess some crash reports are phoned in by whoever shows up onsite from the local FSDO. I would not expect manpower or money exists to perform detailed investigations of every GA crash.

The NTSB reports have recently started adding a "disclaimer" to the prelims, stating that investigators may or may not have traveled to investigate---. The reality is that most GA accident investigations are done by the FAA FSDO Office. Their investigators may have reasonable accident investigating training and skills, all too frequently they do not. The information they produce is then passed on to the NTSB, the NTSB eventually produces a final report, nearly always with a probable cause.
I know of one very widely publicized EAB fatal where the FAA, "aided by an EAA Chapter member" investigated the accident. There were an unusually large number of witnesses to the accident, many of them very qualified. Everyone except the FAA and NTSB knows that the cause of the accident was fuel exhaustion on takeoff. The probably cause is listed as engine failure for undetermined reasons.
It also appears the NTSB is getting further behind on final reports. They are very quick to use "continued VFR into IFR conditions, even when there is no evidence to support this. But an accident that occurred in the same month still remains open, approaching two years now.