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Personal procedures you've introduced to your flying as a result of reading accident reports

I was watching an AOPA safety video the other evening on 10 things pilots should know.



It was all pretty obvious stuff that we all probably know already. But one thing got me thinking. The speaker talked at one point, about how accidents in the airlines tend to be ‘one time events’. That’s because (according to the speaker) all the airlines read all the accident reports. They identify the cause and introduce a procedure to catch the error, then build in redundancy to the procedure and then implement the procedure for all flights. The speaker was encouraging GA pilots to read accident reports, but not think “that could never happen to me” but rather think “what procedure can I implement from now on that would prevent me from making that mistake”.

I used to read lots of accident reports when I used to read the GA magazines. But since I stopped reading those, I’ve not really sought out accident reports in other places.

But maybe this would be a good place to share our own procedures that we’ve changed or implemented as a result of things we’ve learnt from reading accident reports. Hopefully we could learn from each other here.

To be clear, I’m not talking about “I won’t do stupid things like that” type of comments; but rather a procedure that we’d implemented that stands for every flight we make. Sort of a personal SOP designed to catch errors or prevent risk taking.

I have only a small few.

1. I read about an incident where fuel was lost in flight because the filler cap came off in flight. A short time later I read about another such incident. As a result, I’ve now a hard rule that I’m always the last person to touch the filler cap. If the refueler closed the caps or even another pilot who is along for the ride trying to be helpful, it doesn’t matter. I always re-open them myself and close them to make sure they are closed properly. Likewise once a tank is refuelled, I close the filer cap. I don’t refuel the other side and them come back to close the caps. That way as distraction doesn’t lead to me forgetting to come back to close the cap.
2. After reading numerous incidents of aircraft starting up (some even taking off) with the toe bar still attached, I’ve a personal rule that the toe bar is either stowed in its position in the aircraft or it is in my hand. This rule can be a pain at times. There is no dropping it to the ground to take a look at where I’m pushing the aircraft back to. No dropping the toe bar to the ground while I sign for fuel. If I need to walk away, the toe bar comes off and stays in my hand. Years ago I read about this being someone else’s procedure and decided to adopt it for myself.
3. Downwind checks are always completed on downwind, never carried over to base and never skipped. If necessary I’ll extend downwind, or go-around (not needed to go-around yet!). This came from reading so many accident reports where aircraft landed gear up. The underlying cause was distraction. The distraction generally arose from something more important than downwind checks, such as another aircraft cutting in front in the circuit meaning you had to try and make space to compensate, or perhaps a warning light had prompted an early return under pressure. Completing the downwind checks would have caught the error.
4. My last one is to do with fuel. The reports seem to be full of perfectly airworthy aircraft crashing because they ran out of fuel. The aircraft that I fly does not have a fuel totaliser and while it does have a fuel flow gauge, it’s too course to be very useful. So many years ago I carefully calibrated a dip stick by adding 10 litres at a time. For the next year or so, I carefully recorded fuel before and after every flight (to get fuel used), the taxi time, flight time, power settings used, altitude flown and tacho movement. I used that to build up an accurate picture of the fuel used. Using what I learnt, I found that I could predict the fuel used on a flight to within 5 litres 90% of the time, based solely on the tacho movement. In theory the aircraft has just over 5 hours endurance at the power settings that I use. But there were two flights in my batch of records where the fuel consumption was 10% more than the others. I don’t know why, but could guess that I didn’t lean so accurately, or flew longer in a climb or some other factor. But I decided to consider the aircraft as having a 4.5 hour endurance so as not to be caught out by one of those flights. I then considered that I never want to return to the airfield with less than 1 hour of fuel left in case I have to hold because of a blocked runway (happened to me once) or need to divert late in the flight. So I’ve drawn myself a hard limit of 3.5 hours of tacho time. I always plan to plan to land with no more than 3.5 hours of tacho time used, and have made myself a hard rule that if I ever reach 3.5 hours tacho time while in the air, then I land at the nearest airport, no matter how close I am to my destination.

So what have you guys introduced to your own personal rules and procedures as a result of reading accident reports? Maybe we could all learn from one another to expand our personal SOP.

EIWT Weston, Ireland

I concur with the fuel cap procedure! A few months ago after checking out my student before letting him fly solo cross country I jumped out of the Katana and filled out paperwork while he refueled. I then talked to him some more (from the right side) and finally let him do his stuff, walking back to the hangar. When I got there it dawned on me I had not closed the filler cap myself and ran back to the airplane. My student was just starting up the engine….with the filler cap put nicely on the left wing.

The downwind check is a good one too, but you need to have a downwind! Many years ago I landed a glider in Australia, my first flight in that 25m-wingspan-dream-of-mine. It was a nice 1hr final glide, the sun setting on the right, a beautiful evening, and a straight in approach. I saw the shadow of my glider appear next to me on the flat terrain and something was not right. It took a while to figure out what it was, but finally managed to get the gear out in time. Never came that close to forgetting it again so far.

I guess a good thing is to set yourself hard limits and adhere to them, no matter what. I´ve done two pretty stupid things (CAVOK forecasted, reality looked much differently) and once was prevented from doing another by a very experienced guy sitting next to me.
Also, don´t put your priority on abiding by the regulations when things get dicey. It´s perfectly safe and often a better choice to climb into safety if you´re appropriately equipped and current rather than trying to stay low and seemingly legal.

EDFE, EDFZ, KMYF, Germany

Another fuel cap checking advocate here.

For the downwind check, what I found useful shortly after doing my PPL was to mentally change the name of this. It’s not a downwind check, its a pre-landing check. You might not always have a downwind leg, but you will always be pre-landing at some point! Then the trick is to pick a useful place to trigger it. I don’t consider gear and prop as part of this, as that will be covered in normal approach procedure and double checked using reds/blues/greens or GUMPS or whatever you prefer, so for me the pre-landing check is really the largely auxiliary stuff, which for me includes carb heat check, mixture, temps and pressures, fuel, fuel pump, brakes, doors, seatbelts etc that sort of thing. I tend to do this when I transfer to tower/local field frequency, or if on a longer flight I will just get it out of the way when descending to an altitude (from a FL), as it doesn’t really hurt to do it that bit earlier. Really it’s about finding a trigger that works for you.

Another one for me is that I always fly with the pitot heat on. Most of my group don’t do this, but I prefer to for two reasons. Firstly, it’s one less thing to forget if I find myself in conditions for which it is required. Secondly we have an annunciator light in field of view at all times when it’s not switched on, and that irritates me.

I think a lot of accidents and incidents happen because something was forgotten, or something was omitted which was required on this occasion which maybe wouldn’t normally be, perhaps such as doing a performance calculation if you are used to flying from large runways. To me the best way to militate against this is to get into a routine of doing stuff every time, regardless. Once you are in a routine it is not laborious to do this, and requires little extra effort and may just spare you some blushes some day.

United Kingdom

I’m a big proponent of the towbar one.
At our club they weren’t stored in the aircraft but on the hangar wall. And for me it was always disconnect the tow bar. And whenever i saw a club airplane in the hangar with the tow bar attached i always disconnected that one.
Leaving it attached on the hangar is just a small step away from leaving it attached on the ramp, wich is a small step away from taxiing with it.
At the Air Cadets we also had to remove the removable tail wheel al the time when not manoeuvering the gliders.

I also always check the fuel level directly from the tanks, never from the guages, and definitely not from the totalizer.

EBZW, Belgium

FlyingAppel wrote:

And whenever i saw a club airplane in the hangar with the tow bar attached i always disconnected that one.
Leaving it attached on the hangar is just a small step away from leaving it attached on the ramp, wich is a small step away from taxiing with it.

Ah… you see to my aeroclub leaves the tow bar attached to the aeroplane in the hangar and so do the owners of the other aeroplanes I fly in – So I have a rule of “Check visual with towbar before engine start”… ie I can actually see it behind me in the aeroplane or I can see it leaning against the wall in the hangar from the cockpit, and if I cant see it I get out and look for it – which I have done on a couple of occasions.

Regards, SD..

Pirho wrote:

Another one for me is that I always fly with the pitot heat on

One thing I was taught right now is to never leave the pitot heat on for extended periods of time, if it’s not really indicated to do so. Because it really draws a lot of current. On ground you’ll burn your fingers in a minute, so whenever starting into bad conditions, it’s on the line-up check to not have it on waiting on ground. In flight it’ll be cooler, of course.

Germany

+1 for the towbar. At our aeroclub we tend to have 2 towbars. 1 always remains in the plane the other, after towing the aircraft out at home base is hung on hooks on the hangar door so that it can be seen from the aircraft. Once the aircraft is pushed into the hangar the towbar is disconnected and laid horizontally in front of the nose wheel. I think this comes from the fact that when attached in the hangar, people kept tripping over them. Checking the position of both towbars is always part of my pre start up check list. Fortunately, taxing with towbar attached is not something that has happened at our club, as far as I know, but it is often featuring in FFA REX reports.
This last couple of months the biggest feature in these reports appears to be inadvertent flight into “P” zones. And please forgive me for mentioning yet again, that these zones are not all ZITs and are treated differently, and into controlled airspace including class A.
We all know we should not do it and finding out why we do is taxing many club pilots. The consensus seems to be one must be very careful about changing your mind when in flight. EG When you have planned to go from A to B and return to A to not suddenly decide to go to C or make a slight detour to look at a chateau or something without thoroughly planning it.
Fuel or lack of it was a problem some years ago in accident or incident reports. SOPs for most clubs went from rough calculations eg fuel required without wind plus 10% to more precise calculations and adding a supplementary amount for the pilot’s nerves. Also mandatory landing fuel on board was introduced as was minimum take off fuel.

France

dublinpilot wrote:

The speaker talked at one point, about how accidents in the airlines tend to be ‘one time events’. That’s because (according to the speaker) all the airlines read all the accident reports. They identify the cause and introduce a procedure to catch the error, then build in redundancy to the procedure and then implement the procedure for all flights.

Yes, but mostly because they can.

Maybe it’s only me, but I’m getting rather sick and tired of GA being compared with airlines. Airlines!!! There are literally no similarities. We don’t fly the same mission over and over again. We don’t have time to get proficient in every single little detail of every single flight – because – we don’t fly the same mission over and over again. Airline pilots are professionals. Their only mission on this earth is to bring a whole bunch of people safely form A to B. Now, they better use lots and lots of resources to do exactly that, because that IS their job.

We are not professionals, not most of us at least. We fly predominately for our own amusement and recreation. Our “missions” vary greatly and we have limited time and resources to plan for each and single one of those. Nevertheless, looking at any statistics for GA, we find that (google):

  • About 70% of all accidents are pilot related (the rest predominantly engine related, which also for most parts can be sad to be pilot/owner related (maintenance) + zero fuel)
  • Of those 70% about 75% are f*ck ups done during landing/take off phase

What this tells me is that:

  • 80-90 % of accidents are pilot/owner related. Cannot handle the plane adequately and/or cannot maintain/check the plane adequately. We are talking about the very basics here. Stick and rudder + basic understanding of the systems, engine in particular.
  • About 50% of all accidents happens because the pilot did something wrong during landing/take off.

Where would it be natural to start improving the statistics? By looking at airlines? NO! Why on earth would that help? The only thing that will help is to attack the problem head on, and that is to:

  • Improve landing/take off skills for every single pilot
  • Improve handling skills in general.
  • Improve understanding of systems/engine/maintenance for every pilot.

There obviously is a lack of basic stick and rudder- and systems skills among GA pilots. I’m sure talking about everything else is fun for many, but if the statistics is going to improve, what’s needed to be done is staring us in the face.

Are CPL/ATPL pliots better at this basic stuff than us GA pilots? Well I can only talk form my own experience. Among other things I have been an UL instructor for some years now. Here in Norway the rules are such that every pilot wanting to have a UL license, must have have some basic understanding of systems and maintenance that goes outside the PPL. This is because ULs are maintained by the owner. In practice this is done orally, one to one conversation and walking around the plane etc. In addition every pilot must have 1-3 hours of instruction to get used to the low wing loading and “non EASA” handling that many of these planes have. I have had several PPL pilots do this, and several ATPL airline pilots with thousands of hours, FIs, fighter pilots, all sorts of pilots really.

My experience is that ATPL pilots are considerably better with the basics than the average PPL pilot. They simply are better at handling the aircraft. Why? because they have more hours or has had better training? I don’t know. It’s rather funny actually. I used to be of the impression (for no good reason actually) that airline pilots only were good at pushing buttons They are all good pilots, at least that is my personal experience. If PPL pilots on average were this good, the accident statistics will plummet for sure. Lots of very good PPL pilots also, it’s just that the average gets pulled down by many not so good.

If it’s anything we should learn from the airlines, it is to handle the plane properly IMO, not all this other unimportant things, that only gets important once the basics is taken care of.

The elephant is the circulation
ENVA ENOP ENMO, Norway

It´s perfectly safe and often a better choice to climb into safety if you´re appropriately equipped and current

That is a really good advice, as long as you can keep wings level and climb above terrain or turn back, life expectancy goes nicely toward your fuel endurance, failing to do that life expectancy goes back to handful minutes which one is better off “saving” to cover short period of 1min it takes takeoff & land at +/-500fpm or turn back at Rate1

Most people who crashed while scud running (loss of control, hitting terrain, VFR in IMC, unstable approach, landing & takeoff) have tried to fit 120kts flying in tight corners of terrain & clouds & airspace way more than 1min bellow sector altitude, beyond 1min it’s hope rather than calculated flying…

The view one has to take is not that “they would never scud run” or “will never go VFR in IMC”, they will do one day, so it’s a matter of knowing what to do before hand and getting their priorities

The same goes for reading accident reports, they explains what happens (high explanatory power) but have less value predicting outcomes or answer what one should do? (low predictive power)

There was a flight by two aircrafts flying VFR in UK in bad weather, one did not make it (the accident report talks about hitting terrain, one of the 4 CFIT accidents in UK ), the other safely landed, it’s worth understanding what happens in 2nd flight as well

https://assets.publishing.service.gov.uk/media/5f5a372fe90e07207d61d859/Piper_PA-28-161_Cherokee_Warrior_III_G-WAVS_12-18.pdf

Last Edited by Ibra at 17 Oct 09:32
Paris/Essex, France/UK, United Kingdom
87 Posts
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