NTSB presents: Personal Flying


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NTSB Board Member, Earl Weener Ph. D, discusses why all pilots need to focus on their personal flying habits.

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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  • What is the issue? U.S. hasn’t had a fatal large commercial aviation accident since February 2009 but different in the world of GAEach year, hundreds of people -450 in 2010- are killed in GA, and thousands more are injuredHighest aviation accident rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operationsMost distressing element of these statistics is that the causes of accidents are almost always a repeat of the circumstances of previous accidents
  • A declining trend in both total and fatal GA accidents is evident across the decade despite the diversity of flying that is represented by these data.
  • This chart plots total and fatal GA accident rates across all segments of GA. The flatness of these curves across the decade suggests that the modestly decreasing trend in annual accident numbers was primarily due to a reduction in flying.
  • These are the top defining accident events in fatal business, instructional, and personal flying accidents.
  • Defining accident events for fatal business flying accidents.
  • Defining accident events in fatal instructional flying accidents.
  • Defining accident events in fatal personal flying accidents.
  • NTSB presents: Personal Flying

    1. 1. Personal Flying:How Safe DoYou Want to Be?Sun & FunLakeland FloridaMarch 30, 2012Earl F. Weener, Ph.D.NTSB Board Member
    2. 2. 2Most Wanted List10 issue areasReviewed annuallyObjective – bring focuson need forimprovements
    3. 3. 3Why GA on the Most Wanted List?• NTSB investigates approximately 1500 GAaccidents per year• Overall GA accident rate flat– Has not improved over the last ten years– Air carrier accident rate decreased almost 80%• Personal flying accident rate– Increased 20% over last 10 years– Fatal rate increased 25% over that period• GA Personal flying safety needs attention
    4. 4. 4All GA Accidents14921402 1370 1389 1303 134912151364 12921204345325 345 35231432130828827527302004006008001000120014001600180020002000 2001 2002 2003 2004 2005 2006 2007 2008 2009Numberofaccidents Fatal Accidents Non-fatal
    5. 5. 5GA Accident-involved Fatalities01002003004005006007008002000 2001 2002 2003 2004 2005 2006 2007 2008 2009Numberoffatalities
    6. 6. 6GA Accident Rates012345672000 2001 2002 2003 2004 2005 2006 2007 2008 2009Accidentsper100,000flighthoursTotal FatalEstimated from the GA and Part 135 Activity Survey, 2000-2009
    7. 7. 7Defining Fatal Accident Events• Loss of Control in Flight• Loss of Control on Ground• Abnormal Runway Contact• System/Component Failure – Powerplant• Controlled Flight into Terrain• Unintended Flight into IMC• System/Component Failure – Non-Powerplant• Fuel Management• Collision on Takeoff or Landing
    8. 8. 8• Corporate– Accident rates approaching that of the airlines.• Business– Total and fatal accidents show a modest decline,substantially below the overall GA accident rates.• Instructional– Total accident rate is slightly below the average forall of GA, the fatal rate is substantially lower.• Personal– Total and fatal accident rates have risen, both ratesare substantially above the average of all GA flying.Accident Rate Difference
    9. 9. 9Accident Rates per 100k Flight Hours024681012142000 2001 2002 2003 2004 2005 2006 2007 2008 2009Accidentsper100khoursAll GACorporateBusinessInstructionalPersonal
    10. 10. 10Fatal Accident Rates per 100k Flight Hours0. 2001 2002 2003 2004 2005 2006 2007 2008 2009FatalAccidentsper100khoursAll GACorporateBusinessInstructionalPersonal
    11. 11. 11Business Flying, 2007-2009All accidents – Loss of control (in-flight or on the ground) accounted for thelargest portion, followed by system/component failures.Fatal accidents - Loss of control in flight accounted for the greatest proportion,followed by controlled flight into terrain and collisions on takeoff or landing.001245120 2 4 6 8 10 12 14Loss of Control on GroundSystem/Component Failure - Non-PowerplantFuel ManagementSystem/Component Failure - PowerplantCollision on Takeoff or LandingControlled Flight into TerrainLoss of Control in FlightNumber of Fatal Accidents
    12. 12. 12252578881161220 20 40 60 80 100 120 140Collision on Takeoff or LandingSystem/Component Failure - Non-PowerplantSystem/Component Failure - PowerplantLoss of Control in FlightAbnormal Runway ContactLoss of Control on GroundNumber of Fatal AccidentsLoss of control on the ground or in flight and abnormal runway contact (e.g.,hard landings) accounted for the great majority of defining accident eventsfor instructional flying accidents in both fixed-wing airplanes and helicopters.Instructional Flying, 2007-2009
    13. 13. 13Personal Flying Accidents941861 849 888 832 845 807867 811 814226216 241249217 235211207198 20602004006008001000120014002000 01 02 03 04 05 06 07 08 09NumberofaccidentsFatal Non-fatal
    14. 14. 14Personal Flying Accident Rates024681012142000 2001 2002 2003 2004 2005 2006 2007 2008 2009AccidentRatesPercentageper100khoursFatalTotal
    15. 15. 15Personal Flying, 2007-200925344563752500 50 100 150 200 250 300Fuel ManagementSystem/Component Failure - Non-…Unintended Flight into IMCSystem/Component Failure - PowerplantControlled Flight into TerrainLoss of Control in FlightNumber of Fatal AccidentsTotal accidents - loss of control in flight and on the ground and power plant failurewere the most common defining events.Loss of control in flight accounted for the greatest proportion of the fatal personalflying accidents.
    16. 16. 16Alfred Sheinwold“Learn all you can from the mistakesof others. You won’t have time tomake them all yourself”
    17. 17. 17Accident Chain-of-Events• An accident is typicallythe end of a sequenceof events• Interruption of thischain-of-events couldeliminate the accident• Look for opportunitiesto break the chain
    18. 18. 18Loss of Control in Flight
    19. 19. 19Loss of Control In-flight• Accident #LAX08FA300• Beechcraft A36• Approach to KCRQ, Carlsbad CA airport,331 ft msl• One person onboard, fatal• Weather – 100 ft ceiling, ¼ mi visibility,wind 280 degrees at 5 kt• ILS 24 minimums 200 ft ceiling, ¾ mivisibility
    20. 20. 20Loss of Control In-flight• Pilot– Private certificate– Instrument rating 2 months prior– Nine hundred hours total time– No instrument training in accident aircraft• Aircraft– No apparent malfunctions– Adequate fuel
    21. 21. 21Loss of Control In-flight• Accident sequence– ATC cleared for ILS approach RW 24– Tower issued “low altitude alert” andadvised pilot he was south of localizer– Two minutes later pilot stated he was“aborting” the approach– One minute later pilot stated “I’m in trouble”
    22. 22. 22Loss of Control In-flight• Radar tracks– Two miles from approach end RW24airplane crossed LOC at 800 ft headingsouth– Track started tight left-hand turns– Altitude fluctuated between 600 and 1100 ftmsl– Last radar return showed airplane at 900 ftmsl and 56 kt ground speed• Wreckage confined to initial impact area
    23. 23. 23Loss of Control In-flightProbable CauseThe pilot’s failure to maintain controlduring the instrument approach andattempted go-around
    24. 24. 24Controlled Flight into Terrain
    25. 25. 25Controlled Flight into Terrain• Accident NYC08FA138• Cirrus SR22• Night IFR Departure Front RoyalVirginia, KFRR, 709 ft msl• Two fatalities – pilot & son• Weather – Winchester, KOKV, 15 mi S– Wind 340 deg at 4 kt– 3 mi visibility in rain– Broken 2,400 ft, overcast 3,000 ft
    26. 26. 26Controlled Flight into Terrain• Pilot– Private Certificate, Instrument rating– Estimated total time – 193 hours• Aircraft– Airplane total time less than 300 hrs– No apparent malfunctions– Flight data extracted from PFD system
    27. 27. 27Controlled Flight into Terrain• Accident sequence– IFR clearance – direct COGAN intersection,climb and maintain 4,000, expect 5,000 10minutes after departure– Prior to takeoff, Desired Course set to 050deg, approximate direct course to COGAN– Airplane departed RW27– GPS waypoint COGAN selected duringtakeoff roll– Aircraft path continued west, consistent withGPSS not selected
    28. 28. 28Controlled Flight into Terrain• Flight path– Total time of flight 80 seconds– First 40 sec, runway heading, climbing 900to 1,000 fpm– 25 sec, vertical speed decreased to 0 fpm,– then up 2200 fpm,– then decreased to 700 – 750 fpm up– Airplane reached 2,200 ft msl and 140 kt ias– Last 6 sec, steep descending turn to left, rollto 95 deg and pitch to 27 deg down
    29. 29. 29Controlled Flight into TerrainProbable CauseThe pilot’s failure to maintainclearance from rising mountainousterrain, and his failure to turn towardhis assigned course during initialclimb. Contributing to the accidentwere the low ceiling, reducedvisibility, dark night conditions andrising mountainous terrain
    30. 30. 30System Failure – Powerplant
    31. 31. 31System Failure - Powerplant• Accident ERA09FA093• Beechcraft 36• Night IFR approach, Bowman Field,KLOU, Louisville, KY• One fatality – pilot• Weather– Winds 330 degrees at 3 kts– Ceiling overcast at 800 ft– Visibility 6 miles in mist
    32. 32. 32System Failure - Powerplant• Pilot– Commercial Certificate, SEL/MEL– Flight Instructor rating, SEL– Instrument rating– Approximately 2300 hrs total flight time• Airplane– Total airframe time – 6274 hours– Engine IO 520, 58 hours since overhaul– Pilot observed oil pressure problem– Mechanic advised to have problem checked
    33. 33. 33System Failure - Powerplant• Accident sequence– Prior to night departure from MDW, pilotnoted problem with airplane– Maintenance not available until morning– After several attempts, pilot managed to getengine started and departed for KLOU atabout 0220– Nine miles out on RNAV approach to KLOUpilot declared “Emergency” due to enginefailure
    34. 34. 34System Failure - Powerplant• Aircraft right wing struck tree at height ofabout 30 ft along side a golf course• Aircraft came to rest invertedapproximately 175 ft from tree• Front section of cabin roof crushed in• Fuel recovered from left tank, right tankseparated from aircraft• Initial examination revealed enginewould not rotate
    35. 35. 35System Failure - Powerplant• Engine teardown– Crankshaft and counterweight assemblyfractured through at forward fillet radius of#2 main bearing journal– #2 main bearing journal showed scoringconsistent with bearing rotation– #3 main bearing journal fractured at rearfillet area
    36. 36. 36System Failure - Powerplant• NTSB Materials Lab found presence of silkthread patterns and gasket making material onsealing surfaces of the main bearing bosses• Material not part of engine manufacturermaintenance documentation, TCM SIL 99-2B• #2 main bearing boss severely damaged onboth halves, including rotation mechanicalgouging and deformation of the boss areabehind the bearing, including mushroomingdeformation of the boss
    37. 37. 37System Failure - PowerplantProbable CauseThe pilot’s continued operation ofthe aircraft with known deficiencies.Contributing to the accident was theimproper sealing of the engine caseduring overhaul
    38. 38. 38Unintended Flight into IMC
    39. 39. 39Unintended Flight into IMC• Accident DEN08FA141• Cessna 182T• Four fatalities – pilot and 3 passengers• VFR flight from Steamboat SpringsColorado to Brenham Texas• No record of weather briefing or flight plan• Impacted terrain on Mt Guyot, nearGeorgia Pass, Park County, Colorado• Weather – IMC in general area
    40. 40. 40Unintended Flight into IMC• Pilot– Private Certificate, SEL & MEL– Instrument rating– Total flight time – 1576 hours– Instrument time – 154 actual, 40 simulated• Airplane– Garmin 1000 with XM weather & stormscope– 1492 hours total time– No evidence of pre-impact anomalies inengine or airplane systems
    41. 41. 41Unintended Flight into IMC• Accident flight – NTSB meteorology analysis– At departure marginal VMC with overcast aboveand scattered clouds at and below flight level– Weather at accident site deteriorated rapidlyafter departure– Pilot likely encountered level 2 thunderstorm– Lost control and impacted terrain• Approximately 55 degrees nose down• Wings level– Wreckage located at 12,300 ft msl
    42. 42. 42Unintended Flight into TerrainProbable CauseThe pilot’s failure to maintain aircraftcontrol after inadvertentlyencountering instrumentmeteorological conditions.Contributing to the accident werethe pilot’s failure to obtain a weatherbrief and the severe weatherconditions.
    43. 43. 43Fuel Management
    44. 44. 44Fuel Management• Accident ERA09FA289• Beechcraft A36• Pilot & fwd passenger – fatal; two aftpassengers received minor injuries• IFR flight plan; VMC conditions• Flight from Destin, FL to Newnan GA• Accident location was Beauregard, AL• Weather – scattered at 3,900 ft, 10 milevisibility, winds 120 degree at 5 kts
    45. 45. 45Fuel Management• Pilot– Private Certificate, SEL– Instrument rating– Total flight time – 1,618 hours– Instrument time – 110 actual, 26 simulated• Airplane– Recently turbonormalized engine– Osborne Tip tanks (approx 10 gal per tank)– 752 hours total time– No evidence of pre-impact anomalies
    46. 46. 46Fuel Management• Accident sequence– Second leg of trip– Picked up 3 passengers at intermediateairport– In cruise at 7,000 ft, engine lost power– Restarted, but subsequently lost power again– Forced landing approach to pasture– Collided with trees and large rolled bale ofhay
    47. 47. 47Fuel Management• Post accident investigation– Fuel selector to right tank – 1 qt fuel present– Right tip tank breached but contained 4 ½gal– Left fuel tank separated from airplane– Left tip tank breached but contained ½ gal– Before trip• 74 gal usable in main tanks• 20 gal usable in combined tip tanks• 25.4 gal drained to make weight & CG
    48. 48. 48Fuel Management• At takeoff for 2nd flight leg, about 48.6 galin mains and 20 gal in tip tanks• Performance calculations indicated thatmore than 48.6 gal would have beenused by point of initial loss of power• Likely used all main fuel but not tip fuel
    49. 49. 49Fuel ManagementProbable CauseThe pilot’s improper fuelmanagement, which resulted in atotal loss of engine power due tofuel starvation.
    50. 50. 50Summary• Pilot proficiency– Launch into hard IMC with new instrumentrating and no instrument instruction inairplane– System operational confusion on IFRdeparture– Fuel system mismanagement leading toforced landing• Airworthiness– Takeoff night IFR with known deficiency
    51. 51. 51Summary• Preparation & planning– Launch into weather with destination forecastto be below minimums– Launch VFR into IMC conditions with no IFRflight plan or recorded weather briefing• Decision making– Numerous points where a different decisionwould have lead to a different outcome
    52. 52. 52You can try this at home• NTSB accident filesare on-line• Many recent accidentDockets are on-line– Factual reports,– Interviews– Photographs• www.ntsb.govhttp://www.ntsb.gov/doclib/reports/2011/ARA1101.pdf
    53. 53. 53Douglas Adams“Human beings, who are almostunique in having ability to learn fromthe experience of others, are alsoremarkable for their apparentdisinclination to do so.”
    54. 54. 54A Personal DecisionThe equipment we fly is capable of muchgreater safety than many pilots achieve.At what accident rate do you want to operateby yourself or with family and friends; downwith the Corporate and Business operatorsor at the Personal level?It’s your choice! GACorporateBusinessInstructionalPersonal
    55. 55. 55