Safety Alerts

The Safety Board targeted five areas that come up frequently in accident investigations as subjects for five Safety Alerts and a series of videos featuring regional air safety investigators sharing their experiences and observations, while providing advice on how pilots and mechanics can avoid mistakes.

The first Safety Alert is titled, "Is Your Aircraft Talking to You? Listen!" It notes that more accidents involving powerplant system or component failure could be avoided if pilots were better attuned to indications of growing mechanical difficulty and more responsive to small issues so they don't become in-flight emergencies ending in accidents. It cites a Beech 36 engine which, it suggests, was trying to tell the pilot all wasn't well prior to the accident.

The accident occurred shortly before 4 a.m., while the pilot was flying the RNAV/GPS approach for runway 24 at Bowman Field Airport, Louisville, Ky. The airplane had taken off from Chicago's Midway Airport. The commercial pilot, who had 2,300 hours and was the only person on board, was killed. Weather was reported as six miles in mist with an 800-foot overcast and wind from 330 degrees at three knots. The pilot reported an emergency due to "engine failure." The airplane went down in an open field in a golfing community.

A mechanic at Bowman Field told an investigator that he saw the airplane on the field, and he had seen it fly on several occasions, and knew the engine had been recently overhauled. Several weeks before the accident, the mechanic talked to the pilot when the pilot was conducting a ground run. The pilot said that he was having an oil pressure problem and asked the mechanic about oil pressure adjustments. The mechanic explained the system to the pilot and advised him to have the problem checked out.

A worker at an FBO at Midway said the airplane landed there just before midnight and the pilot ordered fuel. After taxiing out for departure, the plane came back to the FBO and the pilot said there was a problem. The airplane was put into a hangar and the pilot contacted a maintenance facility on the airport. The maintenance facility was unable to work on the airplane until morning, so the pilot had the airplane pulled out of the hangar and managed to start the engine after several attempts. The airplane departed Midway at about 2:20 a.m.

The NTSB said the probable cause of the accident was the pilot's continued operation of the aircraft with known deficiencies. Contributing to the accident was the improper sealing of the engine case during overhaul. A number of parts were fractured, including the crankshaft.

The Beech 36 accident also is the centerpiece of another Safety Alert, "Mechanics: Manage Risks to Ensure Safety." The Safety Board calls on mechanics to carefully follow maintenance and inspection procedures and always use up-to-date manuals and instructions from manufacturers. The Safety Alert also mentions an accident involving a Piper PA-46-310P which had departed Santa Monica, Calif., on a dual instruction flight to Lake Havasu City, Ariz.

During climb to cruise, the pilot receiving instruction noticed a drop in manifold pressure. He advanced the throttle, which brought the manifold pressure back up to where it had been. Then, there was a loud bang and the engine lost power. They were able to get some power from the engine through the use of the boost pump and manipulation of the throttle, but the engine ran roughly.

Both the pilot and instructor were injured during a forced landing in an open field near Ontario, Calif. The investigation found that a clamp hadn't been properly positioned in accordance with manufacturer's instructions during induction system maintenance, allowing the induction tube elbow for the numbers one, three and five cylinders to move.

The NTSB's Safety Alert called "Prevent Aerodynamic Stalls at Low Altitude" suggests that pilots could avoid low-level stalls if they were honest with themselves about their ability, or lack of it, to recognize an impending stall, had a better understanding of angle of attack and avoided being distracted while maneuvering at low altitudes. "Resist the temptation to perform maneuvers in an effort to impress people, including passengers, other pilots, persons on the ground, and others via an onboard camera. 'Showing off' can be a deadly distraction because it diverts your attention away from the primary task of safe flying," says the NTSB.

In the Safety Alert "Reduced Visual References Require Vigilance," the NTSB points out that about two-thirds of all general aviation accidents that occur when the visibility is down are fatal, often being preceded by spatial disorientation or involving controlled flight into terrain. The Safety Alert describes an accident at Perris, Calif., involving the ATP-rated pilot of an Aero Commander 680FL who had logged 33,000 hours. The pilot was flying from Palm Springs to his home base at Chino, Calif., a distance of about 63 miles. It was VFR at the departure airport, but marginal VFR en route.

The accident occurred at about 10:00 a.m. No flight plan had been filed. No record could be found of the pilot having received a weather briefing. After being forced to descend to stay under a ceiling of 1,000 feet AGL while going through a mountain pass, the pilot radioed air traffic control and requested traffic advisories. Shortly thereafter, he requested an IFR clearance. Before the clearance could be issued, the aircraft struck mountainous terrain. The NTSB determined that the probable cause of this accident was the pilot's decision to continue visual flight into instrument meteorological conditions.

The NTSB suggests that pilots need to be honest with themselves about skill limitations, no matter how many ratings they hold and hours they have logged. Pilots should not allow external pressures such as the desire to save time or money, or not disappointing passengers, to influence decisions. The Safety Board reminds pilots that even visual weather conditions can be challenging at night. "Remote areas with limited ground lighting provide limited visual reference cues for pilots, which can be disorienting or render rising terrain visually imperceptible.

For night VFR flights, use topographic references to familiarize yourself with surrounding terrain. Consider following instrument procedures if you are instrument rated or avoiding areas with limited ground lighting (such as remote or mountainous areas) if you are not," the Safety Alert says.

In the fifth Safety Alert, "Pilots: Manage Risks to Ensure Safety," the NTSB notes that effective risk management involves developing good decision-making practices, knowing how to use all resources available to you, recognizing and coping with stress and fatigue, and being honest with yourself about your skills, proficiency and attitudes. The Safety Alert points out that accidents occur when several small risks aren't identified or managed and become a dangerous situation.

The Safety Alert highlights an accident at Crystal Lake, Ill., in which all four people on a Cirrus SR20 were killed. The private pilot, who didn't hold an instrument rating and had logged only 207 hours, was conducting the flight from Marion, Ind., to DuPage Airport (DPA), West Chicago, Ill.. At 9:58 a.m., the pilot contacted DPA tower. The airplane was approximately two miles south of the airport at that time. The controller advised the pilot that the airport was IFR. About 30 seconds later, the pilot radioed that he had inadvertently flown over the airport. The controller then cleared the pilot to reverse course and land at DPA. At 10:02, the pilot informed the controller that he no longer had the airport in sight. The controller provided a suggested heading to DPA.

At 10:04, the pilot asked if there was another airport with better visibility because he did not "want to get in there and get stuck all day." The controller noted that Chicago Executive Airport (PWK) about 20 miles northeast was reporting VFR. The controller asked if the pilot wanted to be transferred to Chicago Approach for help getting to PWK. The pilot replied, "I'm still trying to decide if I want to try to land at DuPage or not . . . would you think that's a good idea or not." When the controller asked the pilot if he was IFR qualified, the pilot replied that he was in "FR training and I've let this get around me."

The pilot was subsequently handed off to Chicago Approach and, after starting out for PWK, decided he didn't want to go there. He told the controller that he didn't "...want to mess with the weather...I'm gonna get out...and I don't want to get stuck in here." The controller transmitted, "frequency change is approved," and the pilot acknowledged. The airplane continued maneuvering at low altitude, about 1,800 feet MSL, until it entered a steepening right turn. A witness saw the airplane descending in a 70-degree nose-down attitude.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, N.Y. 10602-0831.