NTSB presents: Making the Right Decisions


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NTSB Senior Air Safety Investigator, Kristi Dunks, talks about aeronautical decision making when a pilot plans a flight.

This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.

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NTSB presents: Making the Right Decisions

  1. 1. 1Office of Aviation SafetyMaking the Right DecisionsKristi DunksSenior Air Safety InvestigatorWestern Pacific RegionSun ‘n Fun 2012
  2. 2. 2Overview• The NTSB• General aviation safety and accidents• Aeronautical decision-making and risk• Case studies
  3. 3. 3Who is the NTSB?•Promotes transportation safety•Investigate for probable cause•Issue safety recommendations•Multi-modal: Aviation, highway, marine, railroad,pipeline, HAZMAT•Small federal agency
  4. 4. 4General Aviation Safety• 1,435 GA accidents in 2010• 267 fatal accidents resulting in 450 fatalities• NTSB working with FAA, AOPA, EAA, and othersto improve GA accident rate• Better risk management and aeronauticaldecision-making
  5. 5. 5General Aviation Accidents• What kind of pilots are considered “accidentpilots”?• What quality do you think they might have incommon?
  6. 6. 6• All pilots are human• Like anything, GA has risks; pilots activelymanage risks to avoid accidents• Many accidents involve a “chain of events”• Many risks can be mitigated before pilotsleave the groundGeneral Aviation Accidents
  7. 7. 7Aeronautical Decision-Making• A systematic approach to the mentalprocess used by aircraft pilots toconsistently determine the best course ofaction in response to a given set ofcircumstances• Anticipate, Recognize, Act, Evaluate
  8. 8. 8What is risk?• Exposure to the chance of injury or loss; ahazard or dangerous chance• Level of risk varies dependent upon thenature of flying
  9. 9. 9Determining Risk
  10. 10. 10Fuel Exhaustion• Part 91 flight• Cessna 180• 2 minor, 1 serious injuries
  11. 11. 11The Pilot• Private pilot• Returning from back country• 824 hours, 274 make/model
  12. 12. 12The Airplane• All inspections current• Originally equipped with 30-gallonfuel tanks• Modified with 28.2-gallon fuel tanks• Pilot told by previous owner that 56.4gallons usable fuel• STC indicated 51.4 gallons usablefuel• Placards on fuel selector and tanks
  13. 13. 13External Pressures• Pilot reported no pressures tocomplete flight• On prior flights along same route,airplane had been refueled
  14. 14. 14The Environment• Cross-country, personal flight• Flight over wilderness• Carried SPOT tracking device
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  19. 19. 19Discussion• Decisions and risk factors• How could this accident have beenprevented?
  20. 20. 20Flight into IMC• Part 91 flight• Piper PA-28-235• 2 fatal injuries
  21. 21. 21The Pilot• Private pilot, no instrument rating• Passenger also pilot, no longer flew• Day, VFR flight• Rested for the flight• Flew 3 hours in past 90 days
  22. 22. 22The Airplane• All inspections current• Owned since new• VFR navigation and flight following
  23. 23. 23External Pressures• Scheduled afternoon meeting
  24. 24. 24The Environment• Familiar route• No weather briefing obtained• Route crossed over hilly terrain• Low fog covering hills• Destination VFR• Precipitation forecast along route
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  26. 26. 32Discussion• Decisions and risk factors• How could this accident have beenprevented?
  27. 27. 33Controlled Flight into Terrain• Part 91 flight• Piper PA-28-181• 1 minor injury
  28. 28. 34The Pilot• Private pilot, instrument rating• Commercial certificate training• Night, solo, cross-country• Healthy and rested for the flight
  29. 29. 35The Airplane• All inspections current• Advanced avionics• VFR navigation
  30. 30. 36External Pressures• Pilot reported no pressures tocomplete flight
  31. 31. 37The Environment• Mountain range east of route• Ensured checkpoints visible at night• Weather called for mountainobscuration
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  36. 36. 45Survival Factors• Winter survival course• Assessed resources• Shelter• Visibility
  37. 37. 46Discussion• Decisions and risk factors• How could this accident have beenprevented?
  38. 38. 47Supplemental Type Certificate• Part 91 flight• Schweizer 269C Helicopter•1 serious injury
  39. 39. 48The Pilot• Student pilot• Day, solo, cross-country• Healthy and rested for the flight
  40. 40. 49The Helicopter• All inspections current• STC installation for heater control• Another company helicopter had aheater installed opposite from theaccident helicopter design• Fuel shut off controls were alsodesigned opposite• Pilot sat on the left in accidenthelicopter, right in other helicopter
  41. 41. 50External Pressures• Pilot reported no pressures tocomplete flight
  42. 42. 51The Environment• Routine cross-country, solo,instructional flight• Similar flights had been completedwith student and instructor
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  47. 47. 56Discussion• Decisions and risk factors• How could this accident have beenprevented?
  48. 48. 57Takeoff Accident• Part 91 flight• Cessna 172RG• 2 minor injuries
  49. 49. 58The Pilot• Private pilot• Day, personal, cross-country• Rested for the flight• 206 hours, 51 make/model
  50. 50. 59The Airplane• All inspections current• Pilot familiar with airplane• Airplane owned by flight school• Maximum takeoff weight: 2,650pounds, Gross weight: 2,767 pounds• POH notes leaning mixture forairports above 3,000 feet, mixture fullrich
  51. 51. 60External Pressures• Pilot reported no pressures tocomplete flight
  52. 52. 61The Environment• Cross-country, personal flight• Originally departed from airport withfield elevation of 331 feet msl• Departure airport elevation 6,609 feetmsl• Density altitude 7,728 feet msl
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  57. 57. 66Discussion• Decision and risk factors• How could this accident have beenprevented?
  58. 58. Making Decisions andManaging Risks• Fundamental risk management is asimportant as good stick-and-rudderskills• Many risks encountered during flightcan be evaluated before you leavethe ground• Considering risks now, allows foreasier decision-making later
  59. 59. • Identify personal limitations• Know the weather, on the ground andin the air• Understand your aircraft• Recognize external pressures• Practice skills through instruction andonline resourcesMaking Decisions andManaging Risks
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