Running head: “SAFETY PILOT” AND “NEVER AGAING” ANALYSIS

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS Dionela Orozco Universidad Tecnológica de Panamá, Escuela De Aviación y Logística Florida Institute of Technology, College of Aeronautics

Author note This paper was prepared for AVT 4301, Aviation Safety-Panama, taught by Dr. Ballar. M. Barker

“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS Abstract Human factor is one of the most important issues in regard of safety and risk management ,In general aviation human error is common due the facility of handle low loads and fly easier trips, Pilots get bad habits and their behavior can increase the chances of failure in flight, not be able of make a good decision can produce serious accidents and incidents, Do not have the complete information and work with inaccurate data is also common among pilots in general aviation it results in a risk taken every time they’ve flown , latent conditions can be placed for a long time but when it is combined with a bad decision or action could result in a loss; nowadays efforts have improved the aviation safety over the world , but the major challenge is change the bad mindsets and behaviors of the aeronautical personnel to achieve a culture of safety

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS Safety Pilot Starting the reading of the article we can notice that before the series of errors the Pilot in command has had a friend asking about whether one more passenger wouldn’t affect the flight because of the weight and balance. Even if his mind was apparently distracted there was an external little warn, At this point is possible that it wasn’t the first time he was avoiding doing the correct preflight process so maybe he could has received a flight training but his mindset was bad , the concept of safety was under his macho attitude. His friend also advised him to get a weather briefing and file a flight plan , He did a call from the airplane with his cellular telephone , this form to file a flight plan is incorrect but it is unbelievable common among pilots, most in general aviation. PIC responsibility Paragraph 91.103 of the federal aviation regulations says this under the heading of Preflight Action: "Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include: "For a flight under IFR or a flight not in the vicinity of an airport, weather reports and forecasts, fuel requirements, alternatives available if the flight cannot be completed, and any known traffic delays of which the pilot in command has been advised by ATC."

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The weight and balance subject is a main issue in the case, the pilot filled the airplane with no sense of safety, the flight was overloaded, and all manufactured limitations were over permissible limits (CG, TOW, and ZFW). The airplane took off but to become airborne and climb to level off the engines must have required more power consequently more fuel consumption.

“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS FAR 91.103 says that the PIC also needs to be familiar with winds, temperatures, takeoff and landing distances, aircraft performance, airport elevations, runway length and slopes, gross weight, etc. “The only way that you can really comply with these requirements is to develop a plan, and carefully execute what you've planned. As a pilot, you are required to do all those things before every flight.” (Wally Miller, 2010) FAA Form 7233-1 is better known as the FAA Flight Plan form. It is shown in Figure 51-2 of the current Aeronautical Information Manual (AIM), it’s simple to fill and it hasn't changed for more than 20 years. “What you put down on that form is far more than just more paperwork. A good flight plan is your ticket to a smooth flight, with no glitches that haven't been at least considered”. (Wally Miller, 2010). Then in-flight, the forecast conditions reported for his route were IMC (instrument meteorological conditions) the article says: the pilot could have received a weather report from an unofficial source but in fact in those conditions the pilot wasn’t able to conduct VFR operations , Why Fly VFR in IMC conditions? Perhaps the pilot thought he could avoid the weather and later the conditions would improve at the intended destination Despite the weather conditions, the flight was destined to fail from the beginning with the poor preflight, first of all the weight and balance. If the pilot had done a good aircraft performance check He would have noticed that the airplane would run out of fuel before the arrival. The sum of events obligated the pilot to enter in the poor weather conditions during a emergency situation because of the low fuel and also near the mountains, the controller asked

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS the pilot if the pilot was capable of IFR Flight and his response was “yes” but he couldn’t be able to follow and maintain the indications such as headings and altitudes, How does a pilot explain not being capable of maintain instructions? The airplane was already unbalanced not only because of the overload but because of the snow, the Seneca was flying in icing conditions, the pilot was not IFR trained, creating a hazardous situation at the end. Notice that the pilot almost got the runway but he lost the heading and stopped communicating with the controller , He did big changes in course and lost altitude, then finally the airplane crashed , last moments the pilot could has had spatial disorientation due to the changes in tracking headings or the pilot could started making more bad decisions such as not being capable of see the runway and has planned land in other field, But with an unbalanced airplane that was running out of fuel the most probably is that the airplane entered in a stall and it was unable to recover. Human being is susceptible to poor judgment, the motivations affecting ones resolutions can vary a great deal sometimes it increases the pilot desire to accomplish the mission. In general aviation, the simple desire to get home afflicts even the most conscientious pilots. The article doesn’t explain the attitude of passengers They should have thought that the pilot was reliable and professional He had 2200 flight hours , most experienced pilots tends to make serious errors because overconfidence and not be against the boss(complacency), protecting their jobs Finally the best options to the pilot were: do preflight preparations well because it was the right thing to do and the legal thing to do and also evaluate the risks. He accepted the risk but it wasn’t correctly avoided or mitigated enough, He should have stopped the mission when the extra person showed up and if he had known the poor weather conditions at least.

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS
Never again

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This is a case where two pilots described themselves as inexperienced pilots, they weren’t from the region where they were flying but as good pilots they organized the trip and gathered all information available, it seemed to have good weather but there was a possibility of poor weather conditions close to bethel (their intended destination). Local pilots were uncomfortable with the weather. The part of United States they were flying was Alaska one of the most dangerous to fly because most part of the year is covered of snow and ice , Alaska has special aviation regulations and unexpectable weather conditions , in fact it is not a place to be an irresponsible pilot. Notice that this incident was in 1979, more than thirty years ago the evolution of safety thinking was in development; “As aircraft became more modern, the thinking shifted to “human factors”.” (C. Rodrigues, Clarence and Stephen K. Cusick, 2012, p. 140). There were a series of accident in the 1970s which identified human error as the cause of major air crashed. Since 1979 the first steps to managing safety issues as CRM were showed up most in airlines in United States (C. Rodrigues, Clarence and Stephen K. Cusick, 2012), but in general aviation the steps have been slower, these pilots were at that time of change of mindsets and behaviors in aviation over the world. The Airplane took off and climbed up to 10000 feet , the article says that they saw a tanker and later it disappeared because of the clouds , the article doesn’t show any weather briefing but it shows that was summer time , at this season average temperatures in Alaska are about 20° C at sea level, making simple calculations if the rate of decreasing temperature in troposphere is about 2°C per 1000 feet it means that at 10000 feet they lost 20°C in addition

“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS they entered in clouds; temperatures inside clouds are even lower than ceiling and visibility ok(CAVOK). Simple math show that they should have been worried about ice and even they should have thought about to avoided or mitigated that risk. Last words at the article explain that the pilot didn’t get a complete weather briefing but even if accurate info had been received about the freezing conditions at the route, their overconfident would have made them go to fly, because they saw the Local pilots were more than a bit leery about that flight and they weren’t experienced in that area. The pilots decided to picked up an IFR clearance as they were entering in clouds, there were no VOR to cross-check their position so they started estimating, continued the flight the rpm started to drop and following that losing altitude, first reaction of the pilots was check for carburetor icing then they applied carburetor heat but the airplane was still losing altitude. The pilots didn’t know that was happening at first but they were in calm and working together , they couldn’t maintain a flight level and then they realized that their airplane was covered with ice , also they noticed that they were flying beyond the highest terrain and over a part they were thinking it was fairly flat. The pilots had lack of situational awareness; it has been identified as a contributing factor in many accidents and incidents. Although the weather conditions, the pilots were capable of survive due to their performance dealing with the emergency if we use the Four Stage Pilot Performance (Topic 5A, Aviation Safety Course, 2012) in order to analyze the case, it shows that, They failed Stage 1: information flows to the pilot: these pilots missed the signs of icing and the airplane had minimal instrumentation, they couldn’t identify the situation so it increased the probability of making a poor decision.

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS Stage 2 processing of information: at the event of drop of RPM they thought it was the carburetor, because of the airplane continued losing altitude they got scared but then they handled the emergency and flew the airplane. Stage 3 Decision-making process: at this point the pilots decided that they would try lower the gear at about 1000 feet AGL and make a controlled crash landing. Stage 4 implementing Decisions: They continued flying toward the Bethel VOR and used it to try to get the runway, there was no control tower, but they announced their intentions in a common traffic advisory frequency. The outside temperature climbed above freezing and they could see the runway .finally their controlled crash landing was on the runway. These pilots were extremely lucky because the temperature increased a last moments and they also had good communications at the cockpit. But in conclusion before the flight they both pilots made a poor decision due to the incomplete information and invulnerability attitudes. There is a known thought among pilots it says “superior pilots use their superior judgment to avoid situations requiring the use of their superior skills”.

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS References C. Rodrigues, Clarence and Stephen K. Cusick. (2012). Commercial Aviation Safety (Fifth ed.). United States of America: McGraw Hill. Committee on the Effects of Aircraft-Pilot Coupling on Flight Safety, National Research Council. (1997). nap.edu. Retrieved from National Academies press: http://www.nap.edu/catalog.php?record_id=5469#toc Curtis, Dr. Todd. (1999-2000). Airsafe.com. Retrieved from Understanding Aviation Safety Data: http://www.airsafe.com/analyze/chap6_curtis.pdf Wally Miller. (2010). FILE A FLIGHT PLAN. Monument, Colorado, United States. Retrieved june 13, 2012, from AOPA Pilot / Flight Training: http://flighttraining.aopa.org/students/crosscountry/articles/4779.html

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“SAFETY PILOT” AND “NEVER AGAING” ANALYSIS Annexes

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