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The Importance of Checklists: 4 Accidents That Checklist Use Could Have Prevented


Photo 1981 by J-E Nystrom, Helsinki, Finland/CC 3.0

It’s human nature to be complacent. We’re all lazy, right? But aviation isn’t an industry that welcomes complacency, and even the slightest oversight on behalf of a pilot in command can mean the difference between a successful flight and an unsuccessful one.

My flight students get tired of me reminding them about checklists. Before we even get into the airplane, I can often be heard saying: “That preflight checklist is there for a reason.” And on downwind, every single time: “Before Landing Checklist.” Some people understand the tedious nature of checklists and accept it; others defy it.

Why don’t pilots use checklists? Probably because they don’t expect anything bad to happen when they don’t. After all, they’ve skipped a checklist- er, many checklists - before and nothing bad happened. Maybe they remember all of the items, after all. Or maybe it’s true that 999 out of 1,000 times, a forgotten checklist item still results in a successful flight, which reinforces the pilot’s belief that it isn’t complacency, but skill, that gets him back on the ground safely. Unfortunately, this couldn’t be more wrong.

We’d all like to think that we’d never end up crashing because of a forgotten checklist item. But here are a few examples of average pilots who failed to accomplish checklist items or otherwise got into trouble for a checklist-related item. We’re not any different. We’re not immune. At the very least, it’s embarrassing to end up like one of these pilots; at the worst, fatal. If using a checklist can potentially prevent you from embarrassment or death, shouldn’t we just use it?

Here are four accidents where proper checklist use would probably have prevented the accident entirely:
Gear Down and Locked
As seen on YouTube, the pilot of this Piper Aerostar twin-engine airplane landed without gear at Aero Acres Air Park in Port St. Lucie, Florida. And then, to everyone’s surprise, he took off again. You can see from this video that the airplane is coming in too fast and unstable, and the pilot decides to go around only after touching down. Unfortunately, the pilot not only forgot the gear, but he forgot his go-around procedures. The pilot claims that he intended to go around, retracted the gear and all of the flaps prematurely and sank to the runway. Once airborne, the pilot is said to have flown the aircraft all the way back to his home in Ft. Lauderdale- about 100 miles.

This is only one report of many, many gear-up landing situations. Pilots: Don’t forget your GUMPS checklist!

Flight Controls Free & Correct

Earlier this month, the NTSB released an animation highlighting the crash of a Gulfstream IV in Bedford, Massachusetts last year. The aircraft skidded off the runway after a failed rejected takeoff, killing seven people on board - two pilots, a flight attendant and four passengers. The reason for the crash? Failure to check that the flight controls were free and correct before takeoff, and subsequently failing to expedite a rejected takeoff once they determined the problem.

The NTSB report states: “A review of the flight crew’s previous 175 flights revealed that the pilots had performed complete preflight control checks on only two of them. The flight crew’s habitual noncompliance with checklists was a contributing factor to the accident.” Sadly, seven lives were lost because basic checklist procedures were not followed.

Water Contamination
There are several ASRS reports from pilots who have lived through off-airport landings due to engine failure. Many of these emergency situations are due to engine failure from fuel starvation. In many of those cases, water contamination was the culprit. In this ASRS report, a man describes his lackadaisical preflight habits after his Grumman Tiger engine quits due to water in the fuel tanks:

“Although I did not discover the water prior to takeoff, I have learned a valuable lesson. I feel that I had gotten complacent in my approach to the pre-flight in that I never found condensed water in my tanks before due to keeping them full at all times.” He admits to failing to sump the fuel carefully to check for water.

Got ATIS?
In the early days of flight training, it might not be apparently obvious why a student’s flight instructor emphasizes the importance of getting a current altimeter setting. If the flight is conducted in VFR, the altimeter can be off by 100 feet and it might not matter much. It’s not until a pilot flies an approach to minimums that he realizes the value of setting the altimeter correctly. Being 100 feet lower than you intend when you’re descending on an approach can mean crashing into the runway or just short of it.

Knowing how an altimeter works and accounting for altimeter error will only keep you out of trouble if you set it correctly. We’ve all heard stories of pilots being to low or too high during an approach into IMC. This compilation of NASA ASRS reports tells how altimeter errors can lead to altitude deviations, traffic separation violations and landing accidents.

The NASA report states, for example, that, “A helicopter accident resulting in four fatalities was attributed at least in part to an incorrectly set altimeter during a period of known low barometric pressure. The report from the Canadian Aviation Safety Board states: ‘The helicopter was being used to transport personnel to work sites across a large frozen lake. An approaching low pressure area with snow and high winds...reduced visibility to near zero in some areas. The pilot most certainly encountered adverse conditions and altered course to circumvent the worst areas. The aircraft was later found...wreckage was widely scattered. The altimeter showed a setting on impact of 30.05; the correct setting would be about 29.22, causing the altimeter to read about 800-850 feet high. The altimeter had obviously been set two days previously [apparently during a time of high barometric pressure-Ed.].’”

Incorrect altimeter settings can be fatal. Checklist procedures should always include getting the current altimeter setting occasionally during flight and always before landing.

Mastering the Go-Around


Every pilot knows that a good landing always begins with a good approach. But how does a pilot know when an approach is unstable? And what happens when the approach is unstable, but the pilot thinks he can salvage it? We all preach that a go-around is the simplest way to prevent a landing accident, but when was the last time you performed a go-around? Are you confident that you’ll respond the right way after a long flight, when you just want to go home, when you’re low on fuel, or when you just botch the landing?

A stable approach is one in which the aircraft is on glide path, on the desired approach airspeed, and configured appropriately for landing at a descent rate that will allow for a normal transition to land. Sounds easy enough, right? So why do so many pilots continue an approach to a landing, even after all of the warning signs of an unstable approach? And why are there still so many loss-of-control accidents during the approach and go-around procedures?

The stable approach is so important that most commercial operators require a go-around in the event of an unstable approach. For most airlines and commercial operations, if the approach is not stabilized by a certain height above the ground (sometimes 1,000 feet and sometimes 500 feet, and sometimes there are requirements for each), the pilot must execute a go-around. Stable approaches are a big deal, and one that the professional aviation world does not want to tangle with. In general aviation, however, we often don’t have these standard operating procedures written out for us by a company. Most of the time, we’re on our own. If we’re IFR, we can and should use the FAA’s guidelines, which state we should “…depart the FAF configured for landing and on the proper approach speed, power setting, and flightpath before descending below the minimum, stabilized approach height; e.g., 1,000 feet above the airport elevation and at a rate of descent no greater than 1,000 feet per minute (fpm), unless specifically briefed.” For light aircraft pilots, the FAA basically tells us to maintain a proper glidepath visually. But we should still note that an unstable approach means one that is too high, too fast, or not in a normal position to land (i.e., excessive maneuvering is needed to land) and if any of those conditions exist, we should execute an immediate go-around.

We all want to make the first landing work. We don’t want to go around, maybe because it wastes time, wasted fuel, or just because we have too much pride and want to be able to land in any condition. But perhaps part of the problem is that we just don’t practice go-arounds very often, and not often enough. We don’t get familiar with them. We’d rather sacrifice the aircraft, sometimes even our own life, to get the airplane on the ground rather than waste a few more minutes to try again, or risk a go-around, which seems like a hazardous maneuver to those who have not mastered it.

Going around isn’t always the best option, but most of the time it won’t hurt. And when it’s the better option, you should absolutely be ready to accomplish one.

Commonly a student or a certificated pilot doing a flight review will blow off the go-around as if it’s an easy maneuver not worth practicing. Be careful about this; I’ve found that many pilots will bust a check ride or flight review for bad go-around procedures. To simplify this maneuver, I teach the 5 Cs, which work well for many types of general aviation aircraft (but check your aircraft POH for proper procedures!)

  • C- CRAM:Full/climb power, props forward, carb heat off
  • C- CLIMBSet the Vx or Vy climb pitch attitude and CLIMB! So many of us get distracted during a go-around procedure and we fail to climb! And keep in mind that if you have the aircraft trimmed for a slow-airspeed descent, adding full power will cause the nose to pitch up. Be ready to add forward pressure on the controls to counteract this pitch-up moment and prevent an elevator trim tab stall.
  • C- CLEAN Retract gear and flaps as necessary. In some aircraft, you’ll want to retract the first 30-40 degrees of flaps right away. For many common training aircraft, you’ll wait until you get to a safe altitude and airspeed, after the climb has been established, and retract flaps in increments, stabilizing the aircraft in the climb each time. Many people get excited and want to retract the flaps either all at once or just too early in the game. Cram, climb, and thenclean it up.
  • C- COOLOpen the cowl flaps and lean the mixture, if necessary.
  • C- CALL You’ll probably need to make a radio call, whether it’s to notify other traffic in the pattern at a nontowered field, or to announce your missed approach with the towet or with approach, but radio communication should only come after flying the airplane to a safe altitude at a safe airspeed and navigating to where you need to go.

Often, I witness students or certificated pilots botch not just a landing, but the resulting go-around procedure, as well. Practice this maneuver to proficiency – a bad landing isn’t something worth salvaging, but you’ll need to keep flying the airplane and properly execute the go-around if you want to be successful the second time around.

The Importance of Accident Investigation

This semester I am taking a class that is required for my major called “Aviation Safety Programs.” I did not know much about this class before the first day, besides that we would be learning how to be safer and more cautious pilots in our flight operations. Now that the first week of classes has come and gone, I am looking forward to this class more than most of my others. The basic setup of this class is that we will be reading and watching videos about aircraft accidents and analyzing what went wrong. We then write 250-500 words a week about a factor of the accident that stuck out to us. A large percentage of our final grade is calculated from a presentation that we each give about an accident that is randomly assigned to us.

This may sound grim, but it is so important to sit down and work through exactly what caused a deadly accident to happen so that you can avoid the same mistakes in the future. Whether it is pilot error, instrument malfunction, or an accident caused by ATC, knowing how to understand and avoid the same fate is paramount to creating safer skies.

For example, the first accident that we investigated was Colgan Air flight 3407. As 40+ aviation students anxiously watched the projector screen, we were shown a video that recreated the accident with a 3D model of the aircraft and instruments visualizing what the black box had recorded. Additionally, this video had real audio from ATC communicating with the copilot shortly before the accident. It was disturbing to hear, as it made the accident seem so much more real.

After watching the video, we opened discussion to what we believed went wrong. Was it icing? Was it the captain who had previously failed stall awareness training? Was it the first officer who had been working so much between flying and being a waitress that she was deliriously tired? It is important to consider all of these factors and logically work through why this was a bad decision/scenario. We then read the NTSB report and discussed how they came to their conclusions.

This is the infamous accident that lead to the House Transportation and Infrastructure Committee introducing the “Airline Safety and Pilot Training Improvement Act of 2009.” Many things changed in the world of professional aviation after this law was passed. Regulations governing pilot training became much more strict. Additionally, the hour requirements for a pilot to earn their ATP rating changed from 250 to 1500. Although both pilots had several thousands of hours of training, the distraught families of the victims who pushed for these updates to regulations simply wanted to try and ensure something like this never happened again.

As you can see, the aftermath of this accident was colossal. It had a huge impact on the aviation industry as a whole, the effects of which aviation students will witness firsthand for years to come. Had the NTSB reported that the cause of the accident was icing with minimal other factors, perhaps the outcome would have been different. However, we cannot be sure of this. The important thing to gather from this is that the entire accident could have been avoided if the pilots had stopped the sequence of bad events from early on.

The "Decide" model is often used to evaluate in-flight emergencies. Having a prior knowledge of events that have lead to accidents can assist with logical thinking when evaluating impeding danger.

Each accident starts as a chain of events. Imagine dominos in a line. When you knock down one, others start following after quite quickly. One of the things we will be doing in my class is identifying which moments leading up to the accidents are dominos. We will analyze where it starts, what makes it worse, and what the ultimate result is. I think that this is fascinating, and it is extremely important for all pilots to examine aircraft accident reports to become better informed and prepared in case they recognize something that could be a domino.

I want to encourage every pilot out there, whether it is their profession or they fly for fun, to begin paying attention to accident reports. It can be difficult, as most pilots have an “it won’t happen to me,” attitude, but doing so will help make flying safer for yourself and everyone around you.

Pilot Cell Phone Use: Don't Be That Guy


Photo: Jorge Quinteros/Flickr/CC BY-NC-ND 2.0

Let's talk about your iPhone. It's no secret that the selfie craze has made its way into the cockpit. And why not? As pilots, we get to witness so many beautiful things from a few thousand feet in the air - the sun reflecting off of a puffy cloud layer, a gorgeous sunset against a vast horizon, the city landscape on a foggy morning. We have a great view - some of us are lucky enough to call it our office and get to see it daily - and we should feel free to snap a photo and capture a memory from time to time. And what harm is done by answering that text while we're at it?

But are pilots overdoing it with the selfies and other cell phone distractions? Are we are putting the safety of our flight at stake when we stop to snap a photo or text a friend?

David Yanofsky, a writer for Quartz, seems to think so. In a recent article detailing the "Pilots of Instagram," Yanofsky calls out a number of pilots for violating the sterile cockpit rule and FAA policy on portable electronic devices (PEDs). Yanofsky, whose article made him wildly unpopular among aviation professionals in the social media world, brings attention to yet another way that pilots might become distracted in the cockpit, but he was widely criticized for bringing negative attention to something that really isn't a problem. An airline pilot who snaps a photo of the clouds from 30,000 feet probably isn't creating any sort of hazard at all. Common sense tells you that the short attention diversion in this scenario is really no different than if a pilot glances at his watch for a moments or looks down to read a chart, or is otherwise engaged in conversation with her copilot. But common sense - and a will to survive - should also tell us that taking selfies while flying an approach just shouldn't happen.

The trouble is that often times where common sense should prevail, it doesn't. And there are at least a few cases to prove it. Selfies, or using personal electronic devices for texting has been a contributing factor during a few recent plane crashes.

In Denver last year, a pilot made a series of errors in judgment and crashed after stalling his aircraft during an approach. He and his passenger both died. Soon after, the NSTB reported that the pilots had been taking selfies while in the pattern. At night. In low IMC. Using the flash. We all shake our heads in disbelief, but I'm guessing this person thought of himself as a smart guy. And maybe he was a smart guy. Common sense can clearly escape the best of us if it means we get an awesome photo to share in Facebook. (The pilot also happened to be flying at night and in IMC without meeting the currency requirements for either… but that's another story.)

In 2011, four people died when a medical helicopter operating a commercial flight crashed in a field in Missouri. The helicopter ran out of fuel, and the NTSB listed "the pilot's distracted attention due to personal texting during safety-critical ground and flight operations" as a contributing factor.

More recently, it was reported that a student pilot is suing his flight school, claiming that his instructor was on FaceTime during a simulated engine emergency last December, causing an accident that left the student in critical condition and killed the instructor. The NTSB accident report does not mention the pilot's use of his phone during the flight, but the student's lawyer says they're suing.

In 2014, the FAA issued a Final Rule that restricts Part 121 (airline) pilots from operating any electronic devices for personal during flight operations. The rules states that pilots are only allowed to use company-issued devices for tasks that are directly related to the operation of the flight, for safety-related purposes or for company communications. But this rule does not apply to Part 135 or Part 91 operations. General aviation pilots are allowed to use cell phone and iPads during flight, for which most of us are grateful. After all, where would we be without ForeFlight? And how convenient is it to use our phone to call for a clearance instead of relying on an RCO? And, of course, it's nice to be able to capture a beautiful sunset on camera every now and then.

But we should not be taking selfies on final approach at night and in IMC, or during any other critical phase of flight. And we should really try to limit our cell phone use during flight to aircraft operations and emergencies only to ensure we don't lose focus on the task at hand and find ourselves the recipient of an FAA violation or worse, a fatal accident.

Don't be that guy. Don't be the guy taking selfies on final approach. Don't be that guy using FaceTime in the middle of a training flight. Don't be that guy messing with the GoPro at 300 feet on upwind because you forgot to turn it on during the preflight. Don't be the guy that dies in a plane crash, leaving photos or video footage of your mistakes in your wake.

Maybe we should just put down the phone, look out the window and enjoy the view.

Is Your Co-Pilot Depressed?


Photo: NIMH

In light of the Germanwings Flight 9525 crash in which one of the pilots locked the other out of the cockpit and then intentionally flew an Airbus A320 into a mountain in the French Alps, killing all 150 people on board, the issue of mental health in pilots has resurfaced.

After the captain of the aircraft got up to use the restroom mid-flight, 27-year-old co-pilot Andrews Lubitz locked him out and refused to allow him back in. Then he reportedly programmed the autopilot to descend from an altitude of 38,000 feet down to 100 feet with the intention of crashing into the side of a mountain along the way.

Investigators reportedly found an anti-depressant medication in the apartment of Lubitz, along with other evidence that suggested the Germanwings first offficer was seeing a doctor for depression.

Lubitz had not informed the airline of this most recent bout with depression, but people who knew him have come forward to say that he was suicidal at one point. And, according to an ex-girlfriend, he had a temper. But how could anyone have known that this person could commit such a heinous act?

CNN reported that Lubitz passed an aviation medical exam in 2014, which a Lufthansa official said didn't test mental health. But even if the exam did covered mental health issues in depth, what pilot would admit to depression or mood disorders knowing that he'd lose his job? For many pilots, flying is a life-long dream - a career that they've worked hard for - and to know that depression, suicidal thoughts or a more severe mood disorder would essentially disable them from flying professionally and perhaps even as a hobby, would be a tough pill to swallow. Because they'd lose their jobs, careers, and for many, their livelihood, most pilots who have experienced depression or other symptoms of a mood disorder or mental health issue, will, sadly, fail to report them.

The National Institute of Mental Health (NIMH) states that mental illness is common in the United States. In 2012, according to the NIMH website, about 18.6 percent of adults in the United States had some form of mental illness (not including those related to substance abuse.) Luckily for the traveling public, most of them are not suicidal.

We can probably assume that this statistic carries over to the pilot career profession, although statistics pertaining to pilots with a mental illness won't reflect this same trend due to the nature of the job. We rely on self-reporting procedures, and when a pilot's career is on the line, chances are good that he or she just won't report it.

Eighteen percent of adults in the United States have some sort of diagnosed mental illness. This could be anything from minor depression or social anxiety to bipolar disorder or suicidal behavior. To be more specific, the NIMH says that a Serious Mental Illness (SMI) occurs in about four percent of all adults. A serious mental illness is defined as one that interferes with normal life activities and results in "serious functional impairment."

So, according to these numbers, somewhere between four and 18 percent of people in general have some sort of mental illness. This means that if you're a pilot, up to one out of six pilots you fly with could be suffering from some sort of mental illness. Luckily, very few of these people are also suicidal, and flights continue to operate safely every day.

Germanwings Flight 9525 was, perhaps, a case that could have been prevented. But what's the fix for depression in pilots and the failure to self-report? Better mental health screening for pilots? Better working conditions? A mandate for two pilots in the cockpit at all times? (Most or all U.S. airlines already employ a strategy of this kind, by the way.) Take the human element out of the cockpit altogether?

While we need to do all we can to prevent another tragedy like this from occurring, how far will we go, or how far should we go, to save ourselves from… ourselves? "Better" mental health screening could lead to even less reporting by pilots. Two pilots in the cockpit will help, unless the second physically overtakes the first one. And can we really take the human element out of the equation altogether? Even RPAs - remotely piloted airplanes - are flown by humans on the ground. If one of these pilots were to be suicidal, they could still fly the airplane into a mountain.

Is there a solution to making certain that a suicide mission like Germanwings 9525 doesn't happen again? Or is there a certain element of risk - a low probability/high consequence risk like an aircraft suicide mission- that we must accept as human beings functioning in a world with other human beings? Or is there a happy medium? What are your thoughts?