I will rate your answer up or down! Poor decisions happen for many reasons - emo
ID: 109961 • Letter: I
Question
I will rate your answer up or down!
Poor decisions happen for many reasons - emotions, illness, fatigue, vision problems, pressing against limits, ignoring minimum fuel requirements, memory flaws, stress, alcohol, and others.
From your own experience or an aviation report, give ONE example of a risky flight decision related to any of those decisions. Use the DECIDE Model (detect estimate choose identify do evaluate)to identify and apply each part of the model in explaining your example. Hypothesize how you could mitigate this impact. Support your work with at least two reliable sources.
300 words
Explanation / Answer
Everyone who writes about aviation safety eventually comes around to the subject of risk management. The FAA wants CFIs to teach it using checklists, which is hardly realistic. There is simply not a formulaic answer to any question here.
The simple truth is that risk management can be done only through a deal the pilot makes with self. Just like you can tell a kid a thousand times not to venture out on an apparently frozen pond, you can tell a pilot a thousand times not to do this, that or the other hazardous thing, but in the end each individual has to come to a conclusion about what is risky, what is not, and what level of risk is acceptable.
Because bad decisions lead to accidents, we can speculate that a pragmatic pilot might be the best at dealing with risks. A good understanding of the risks and of the fact that, when improperly or recklessly done, flying can be extremely dangerous is also required. Finally, a strong sense of self-preservation is a definite risk-management asset. No checklist will ever take the place of these things.
It is a fact that the risk is lowest when flying a well-maintained simple airplane on a clear and calm day. Beyond that, the risk increases. I would hasten to add that, given our rules, airplanes, and pilots, the safety record plateau we have reached in recent years is likely to remain in place. Which is another way of saying that general aviation flying isn’t going to get any “safer.” That doesn’t mean that each individual pilot can’t improve his personal safety potential.
The best way to learn about risks without getting hurt is to look at the mistakes other pilots have made and learn from them. These are chronicled in the accident reports issued by the NTSB. In each case as well in a couple of generalized areas I will try to identify the point where the pilot went too far and even fancy footwork and a burst of brilliance would not have saved the day.
The pilot of a Mooney stalled and spun in, apparently while making a steep turn to try to patch up an overshoot of the turn to final. This happens and is easily addressed by never exceeding 30 degrees of bank below 2,000 feet. When the decision is made to “bend” an airplane around at low altitude it is likely to be bent, literally. The moment the pilot decides to try to salvage a bad approach is when risk peaks.
A Cirrus SR-22 pilot was flying an ILS at night in IMC and having some problems with aircraft control. The first approach attempt was botched badly enough that the pilot requested another try. After the request, the airplane entered a steep turn, the pilot transmitted “I need some help” and control was apparently lost for the airplane was completely out of control when it hit the ground.
You might say that the bad decision was made when the pilot opted to take off on a flight that he was ill-prepared to handle. I think, though, that if the pilot had asked for a time out, with a heading and altitude to fly on autopilot for a minute or two, while he got his bearings, the outcome might have been better. The risky moment might have passed. The accident reports contain a number of cases where a pilot persisted after an unsuccessful instrument approach and crashed on a subsequent approach. That can also be true in visual flying.
The pilot of a Cessna 172 did one go-around and crashed on a second approach to his home airport in good weather. It was an easy approach in a docile airplane but this pilot’s mind may have been elsewhere. The pilot had recently gotten a divorce, his business had failed and he was facing arrest on a felony charge. Just going flying with all those troubles in mind was the pilot’s big mistake.
I came across other examples of a second try being a fatal mistake.
One involved a Cessna 501 Citation flown by a type-rated private pilot. I was not aware that any training institution would rate a private pilot in a jet but apparently one did. If the pilot had insurance, which some don’t on older turbine airplanes, I don’t understand the thinking of the underwriter, either.
The weather was perfect and this pilot was headed for a 5,001 foot long runway with which he was not familiar. The airport was in a mountainous area. The surface winds were light. There were four passengers on board.
The airplane was too high on the first visual approach to the runway. The visual illusions in rough terrain can lead to such if the pilot is inexperienced in this area.
When the pilot decided to try again, the risk went out of sight as the pilot apparently tried to “make” it work. The next approach was steep and the nosewheel contacted the surface first, about half way down the runway. The main gear then touched, the airplane bounced, the sound of engine noise increased, the right wing contacted the runway and the airplane flipped and burned off the right side of the runway. For some reason, thrust reverse had been selected for the right engine only and this would have complicated an already uncontrolled touchdown. There was no established mechanical malfunction.
As kids we learned that if at first you don’t succeed, try and try again. The problem with this in airplanes is that the risk increases greatly when you do that. Maybe the saying should be modified to suggest doing something more easily managed than to keep trying that which bested you the first time.
Many folks say that all the high-tech equipment that is now available makes flying safer. I am not saying that it increases risk though that is possible as was illustrated by a pilot flying an A36 Bonanza.
This relatively low time pilot (343 hours) with limited instrument flying experience (32 hours in two years) was on a long cross-country flight. His Bonanza had both Nexrad and lightning-detection equipment. Using this, and talking with controllers about the weather, the pilot decided to fly through an active line of thunderstorms.
Nearing the weather, the pilot reported that a cell had filled in but there was still a gap in the line about 10 miles north. The pilot attempted to fly through that gap and nothing further was heard from him.
The airplane broke up in flight, with the wreckage spread over a mile on the ground. An overlay of the Bonanza’s track on a weather radar plot showed that the pilot tried to fly through a Level 5 (heavy) thunderstorm cell. That almost never works.
Radar imagery in the cockpit is fine but there is enough of a delay in what the pilot sees to make use of it quite risky in a dynamic thunderstorm situation. When a relatively inexperienced pilot makes a decision to penetrate an area of weather using this information, the point of no return can be quickly passed.
As airplanes get older, expensive maintenance becomes a larger part of the risk management challenge. Yes, you can get a fine and complicated twin for not much money, but can you afford to care for it properly? In recent times there has been a rash of accidents in older 400-series Cessna twins to illustrate this. A recent look at Trade-A-Plane showed a number of 421s available for under $200,000 with almost as many (39) for sale as 310s (46). A 421 would today sell new for well north of $1.5 million so the temptation to buy that much luxury for under $200,000 would be strong. It would be a great family airplane, too, which was the case in the accident I am about to tell you about.
The 33-year old 421 was cruising at Flight Level 210 in good weather when the pilot declared an emergency. He had a rough-running right engine and was diverting to a suitable airport that was only 10 miles away. The pilot subsequently reported that he had shut down the right engine.
The airplane was descending out of 17,000 feet as it arrived over the divert airfield where the pilot circled as he descended. Everything appeared to be unfolding smoothly as the pilot entered a downwind leg. The airplane was about 2,200 feet AGL when abeam the runway threshold.
Then the pilot started giving altitude away and was down to 600 feet when three miles from the approach end of the runway. Two hundred feet per mile would be a shallow approach slope and the airplane was either on, or turning onto final when it rolled inverted, crashed and burned. The pilot, his wife, and their five children perished. The pilot not only gave away altitude, he gave away airspeed and then everything else as well.
This approach and landing should have been a piece of cake and one could only speculate that the situation might have involved less risk if both engines had failed. Then the pilot could have glided serenely in for a dead-stick landing.
As an aside, the left engine had been overhauled by a fine shop right before the pilot bought the airplane. The right engine had been overhauled by a less well-known shop well before that, long enough ago that the failure of the cam gear due to lubrication distress should not have been related to that overhaul. The 421 engines have a great need for expensive maintenance, and a lot of it.
In a far more recent event, a 32-year old Twin Commander turboprop 690 crashed on its second approach to a Tennessee airport in bad weather, according to a press report. It was also reported that there was a family of four on board. From the appearance of the wreckage, control of the airplane was obviously lost.
Now, I am going to segue into a discussion of why I think some of the notions that pilots harbor can lead to those risky moments. Those last accidents in twins illustrate something I have been discussing for years.
Statistically, twins are no safer than singles and by some measures they have proven to be less safe. Yes, if a twin pilot is sharp, he can handle an engine failure. Apparently most twin pilots don’t do well at this and your chances of being done in by an engine failure are higher in a twin than a single. It is almost as if a pilot can buy a twin and fly it safely until an engine fails. Then, boom.
There are valid reasons to buy a twin. Compared with big-engine singles, they climb better, go faster, and have more payload. I think, though, that ego satisfaction outranks those things as the reason pilots like twins. Flying and arriving in a twin is simply good for any pilot’s ego. I always loved to fly them.
The riskiest part of twin flying comes when a pilot does something in a twin that he wouldn’t do in a single. All Part 23 propeller airplanes are created equal and viewed as equals by things like weather and flight envelopes. A pilot is operating in a high-risk zone if this is not acknowledged.
Any other thought about “buying” safety is a risky one. The Cirrus experience clearly demonstrates this. No manufacturer has been as aggressive in offering the latest high-tech equipment and the Cirrus is the only certified airplane you can get with an airframe parachute as standard. Yet the Cirrus fatal accident rate is no better than that of like airplanes even though the much younger Cirrus fleet flies with all the goodies. That is no reflection on the airplane but it does say a lot about the risks that pilots take in the airplane.
I always put the latest high-tech gadgets in my airplane, autopilot excepted. I liked the simple ones of those best. But despite all the good things, including vertical profile radar, weather in the cockpit, ground prox, and traffic information, I never thought there was a safety advantage over the basic nav/com equipment it was originally equipped with except in one area. Traffic. I did value that. I did, however, enjoy the hell out of flying with the rest of the good stuff.
An extremely risky moment comes when a pilot flies with this thought: “I think I can make it.” Overconfidence is not good but a basic high level of confidence is required of a pilot. We need to know what we are doing and do it well. If there is any doubt, don’t.
The final risky moment I’ll share with you applies to motorcycles, hot cars and pickup trucks as well as airplanes.