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The Statistical Analysis of 'Old and Bold Pilots'

by Jeremy Cox 29. June 2010 13:40
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A morbid and unwanted world record is the one that which is awarded to an aviation disaster, based upon the number of people that were killed as victims of this event. Tenerife Airport, in the Canary Islands is still the unfortunate holder of this record. I won't go into the gory details other than to remind you that two tourist-loaded B747's collided on a fogbound runway in 1977. Five hundred and eighty-three perished. It can be argued that the World Trade Centre attacks constitute the largest aviation disaster where more than 4,500 unfortunate souls perished on September 11th, 2001.

 

It has been said by several accident investigators, that it takes between 6 and 9 separate breakdowns, failures, lapses, mistakes, etc to all coincide (i.e. To all occur to together) before disaster can strike (excluding Terrorism.) I have always been intrigued by this number, and therefore thought that we could explore this claim, together both as a reader, and as a writer, therefore here goes:

 

It appeared to me that the very best place to get these statistics was from the National Transportation Safety Boards’ own website, at their “query” page for the ‘Accident Database & Synopsis’ archive. Go to the following site:

 

http://www.ntsb.gov/ntsb/query.asp

 

Once there, I only concentrated on ‘Fatal’ accidents that have been investigated, and concluded by the issuance of a ‘Final Report.’ My search was limited to 2009, therefore all of the following are separate ‘Fatal’ aircraft accidents that include my count of causal factors:

 

December 2009 fatal accident involving an Aztec: Low time pilot, no weather briefing, night time, low ceilings, reduced visibility, uncontrolled airport, gusty winds, no instrument approach, and no runway lights. = 9 Breakdowns/Failures/Lapses/Mistakes

 

Another in December: an A36 Bonanza: Elderly pilot, early AM before dawn, low ceilings, fog, poor runway markers, off- course on a Gnav approach.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

November accident involving a Moore Skybolt: Low time pilot, showing off to friends, low altitude, slow speed, high bank angle, high nose up attitude.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

October accident involving a restored Aeronca: pilot with heart condition (stint installed), sunset-sun in eyes, low level, low speed, and abrupt maneuvering.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

Another October accident involved a Robinson R22: Low time pilot, early AM/dark, fatigue, prescription medicine, history of alcoholism, and falsification of records.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

A September accident of a Cessna 182 involved fog, a low ceiling, special VFR clearance, rapidly deteriorating weather conditions and prescription medicine.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

Another September accident involved two aircraft in a midair collision, a Cessna 152 and a Piper Cherokee 180: Simulated instrument practice with a student look out, foreign language/poor English, busy training area, and poor radio procedures.

= 4 Breakdowns/Failures/Lapses/Mistakes

 

In August a Boeing E75 Bi-plane crashed under the following circumstances: the weather conditions were very hot, and the terrain was high above sea level; the pilot was lost (attempting to map read) and had his head in the

 cockpit rather than outside watching for high-terrain, the engine was not producing enough power to clear terrain and a subsequent wing stall.

= 5 Breakdowns/Failures/Lapses/Mistakes

 

A post independence day accident in July involving a Czech built ex military jet trainer/attack L-29 crashed during a formation sortie with similar aircraft. The fatal parameters involved were as follows: Low altitude and prescription medicines.

= 2 Breakdowns/Failures/Lapses/Mistakes

 

In May an Aero Commander 500 was lost after dual engine failure, caused by the following factors: a faulty fuel indication system, fuel exhaustion, and the decision to turn back to the runway after the engines failed.

= 3 Breakdowns/Failures/Lapses/Mistakes

 

A crash of a Cessna 421 Golden Eagle was caused by several preventable factors, which were: Agitation of the pilot, inaccurate and sloppy addition of engine oil to the RH engine, and loose/worn exhaust flange mounts. The RH engine caught fire on climb out. The pilot was 80 years old and suffered from carbon monoxide poisoning due to the in-flight fire. = 4 Breakdowns/Failures/Lapses/Mistakes

 

In March a Grumman American AA1B hit terrain in a mountainous region because of: a low time pilot, consumption of alcohol, heavy rain and heavy snow fall, failure to obtain a weather briefing, and inadvertent flight into IMC in darkness.

= 6 Breakdowns/Failures/Lapses/Mistakes

 

February brought the industry the controversial issue of flight experience averages of pilots employed within the commuter airline business when a Colgan Air DHC-8 crashed in Buffalo, New York. Even though many readers are very familiar with the circumstances of this accident, it is still worth reviewing what they were, along with how many were involved to culminate in this tragedy: Crew experience, fatigue, night IFR, failure to respond to stall stick shaker alarm, inappropriate flap use, and low speed flight at low altitude. = 7 Breakdowns/Failures/Lapses/Mistakes

 

Finally (no pun whatsoever is intended here), we examine the January accident that involved a corporate-2 crew flown 690 Aero Commander: Heavy icing conditions, over gross take-off weight, and out of balance c of g.

= 3 Breakdowns/Failures/Lapses/Mistakes

 

After collating the Breakdown/Failures/Lapses/Mistakes numbers, the following pattern emerges:

 

14 separate ‘Case-Closed’ events chosen (unfortunately there are many more listed at the NTSB Website.)

 

The total number of Breakdown/Failures/Lapses/Mistakes equaled 73.

 

Therefore 73/14 = 5.2; or…

 

For every Fatal Aircraft Accident, here in the U.S.A., on average it takes five (5) Breakdown/Failures/Lapses/Mistakes for the accident to occur.

 

Don’t let this lull you into a false sense of security, because in some of the older cases that I read, it only took one (1) Breakdown, Failure, Lapse or Mistake for the accident to happen.

 

Physiologically for me, it was quite harrowing, I must say, to have read about all of these horrific reports detailing ‘death and destruction’ in an aircraft. I hope that your sleeping improves over-time after visiting the NTSB site.

 

As an unknown pilot once stated: “There are old pilots and there are bold pilots but there are no old, bold pilots.”

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Jeremy Cox



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