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 Office of Aviation Safety Making the Right Decisions Kristi Dunks Senior Air Safety Investigator Western Pacific Region Sun ‘n Fun 2012
- 2. 2 Overview • The NTSB • General aviation safety and accidents • Aeronautical decision-making and risk • Case studies
- 3. 3 Who 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 General Aviation Safety • 1,435 GA accidents in 2010 • 267 fatal accidents resulting in 450 fatalities • NTSB working with FAA, AOPA, EAA, and others to improve GA accident rate • Better risk management and aeronautical decision-making
- 5. 5 General Aviation Accidents • What kind of pilots are considered “accident pilots”? • What quality do you think they might have in common?
- 6. 6 • All pilots are human • Like anything, GA has risks; pilots actively manage risks to avoid accidents • Many accidents involve a “chain of events” • Many risks can be mitigated before pilots leave the ground General Aviation Accidents
- 7. 7 Aeronautical Decision-Making • A systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances • Anticipate, Recognize, Act, Evaluate
- 8. 8 What is risk? • Exposure to the chance of injury or loss; a hazard or dangerous chance • Level of risk varies dependent upon the nature of flying
- 10. 10 Fuel Exhaustion • Part 91 flight • Cessna 180 • 2 minor, 1 serious injuries
- 11. 11 The Pilot • Private pilot • Returning from back country • 824 hours, 274 make/model
- 12. 12 The Airplane • All inspections current • Originally equipped with 30-gallon fuel tanks • Modified with 28.2-gallon fuel tanks • Pilot told by previous owner that 56.4 gallons usable fuel • STC indicated 51.4 gallons usable fuel • Placards on fuel selector and tanks
- 13. 13 External Pressures • Pilot reported no pressures to complete flight • On prior flights along same route, airplane had been refueled
- 14. 14 The Environment • Cross-country, personal flight • Flight over wilderness • Carried SPOT tracking device
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- 19. 19 Discussion • Decisions and risk factors • How could this accident have been prevented?
- 20. 20 Flight into IMC • Part 91 flight • Piper PA-28-235 • 2 fatal injuries
- 21. 21 The 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 The Airplane • All inspections current • Owned since new • VFR navigation and flight following
- 23. 23 External Pressures • Scheduled afternoon meeting
- 24. 24 The 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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- 32. 32 Discussion • Decisions and risk factors • How could this accident have been prevented?
- 33. 33 Controlled Flight into Terrain • Part 91 flight • Piper PA-28-181 • 1 minor injury
- 34. 34 The Pilot • Private pilot, instrument rating • Commercial certificate training • Night, solo, cross-country • Healthy and rested for the flight
- 35. 35 The Airplane • All inspections current • Advanced avionics • VFR navigation
- 36. 36 External Pressures • Pilot reported no pressures to complete flight
- 37. 37 The Environment • Mountain range east of route • Ensured checkpoints visible at night • Weather called for mountain obscuration
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- 45. 45 Survival Factors • Winter survival course • Assessed resources • Shelter • Visibility
- 46. 46 Discussion • Decisions and risk factors • How could this accident have been prevented?
- 47. 47 Supplemental Type Certificate • Part 91 flight • Schweizer 269C Helicopter •1 serious injury
- 48. 48 The Pilot • Student pilot • Day, solo, cross-country • Healthy and rested for the flight
- 49. 49 The Helicopter • All inspections current • STC installation for heater control • Another company helicopter had a heater installed opposite from the accident helicopter design • Fuel shut off controls were also designed opposite • Pilot sat on the left in accident helicopter, right in other helicopter
- 50. 50 External Pressures • Pilot reported no pressures to complete flight
- 51. 51 The Environment • Routine cross-country, solo, instructional flight • Similar flights had been completed with student and instructor
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- 56. 56 Discussion • Decisions and risk factors • How could this accident have been prevented?
- 57. 57 Takeoff Accident • Part 91 flight • Cessna 172RG • 2 minor injuries
- 58. 58 The Pilot • Private pilot • Day, personal, cross-country • Rested for the flight • 206 hours, 51 make/model
- 59. 59 The Airplane • All inspections current • Pilot familiar with airplane • Airplane owned by flight school • Maximum takeoff weight: 2,650 pounds, Gross weight: 2,767 pounds • POH notes leaning mixture for airports above 3,000 feet, mixture full rich
- 60. 60 External Pressures • Pilot reported no pressures to complete flight
- 61. 61 The Environment • Cross-country, personal flight • Originally departed from airport with field elevation of 331 feet msl • Departure airport elevation 6,609 feet msl • Density altitude 7,728 feet msl
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- 66. 66 Discussion • Decision and risk factors • How could this accident have been prevented?
- 67. Making Decisions and Managing Risks • Fundamental risk management is as important as good stick-and-rudder skills • Many risks encountered during flight can be evaluated before you leave the ground • Considering risks now, allows for easier decision-making later
- 68. • Identify personal limitations • Know the weather, on the ground and in the air • Understand your aircraft • Recognize external pressures • Practice skills through instruction and online resources Making Decisions and Managing Risks
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