Showing posts with label abnormal conditions. Show all posts
Showing posts with label abnormal conditions. Show all posts

Tuesday, December 7, 2010

Embracing Hi-Tech


Since last April, I've logged around 300 hours of flight time and probably twice as many hours of ground training using the iPad. While the iPad isn't perfect, I've found it invaluable as:
electronic flight bag
note pad
logbook
book library
video player
E6B calculator
credit card reader, and more.

I can access practical test standards, present a lesson, quickly calculate aircraft weight and balance, access aircraft checklists, and get weather briefings. Sure it's taken some learning and adapting on my part, but the iPad has made me a more effective and efficient instructor (multi-tasking offered by the latest iOS4.2 is a big help, by the way). My students see me using an iPad, see its capabilities, and naturally test the waters by asking if they should be using one, too. My qualified answer is "Sure, if you want to."

Spare the Rod

Some instructors and pilots see this permissive attitude as heretical. It's a common practice for instructors to deprive student pilots of access to certain equipment as a way to focus their attention and promote learning in a scenario-based teaching approach. A student who spends too much time looking at their instruments instead of outside the cockpit might be helped by the instructor covering up those instruments. When first learning cross-country navigation, it's common for students to  navigate using a chart, the magnetic compass, and prominent landmarks before learning to use a GPS receiver or other radio navigation systems. Introducing pilotage as the student's primary mode is crucial because, GPS or not, they must ultimately be able to locate unfamiliar airports with their eyes. But this does not mean that all flight instruments are to be avoided or that GPS usage will make a pilot incompetent.

Where things go South is when instructors become obsessed with thinking that if some deprivation is good, more must be better. This can take the form of "When I was a young pilot, no one used a headset, my instructor smoked cigars inside the plane, and I had to navigate using compass, a stopwatch, and with one hand tied behind my back."


Riiight.

Meanwhile, back in the real world, most new training aircraft come equipped with GPS and autopilots, yet some instructors still pride themselves on refusing to let students use this equipment - ever. Pilots need to recognize this for what it is: kooky talk. Even the FAA requires instructors bestowing solo cross-country privileges on a student (14 CFR 61.93(e)(8)) to ensure the student is proficient with:
Procedures for operating the instruments and equipment installed in the aircraft to be flown, including recognition and use of the proper operational procedures and indications.


Getting Qualified

This gets to the qualified part of my permissive approach: Pilots must show they can competently use any equipment in the plane, understand the limitations of the equipment, have a viable back-up strategy if the equipment fails, and demonstrate they are proficient using the back-up strategy and that their piloting performance is not adversely affected. This applies to everything installed in the plane and, by extension, to any equipment the student decides to bring with them: E6B slide rule, electronic E6B, fancy calculator watch, handheld GPS, or iPad (or any EFB for that matter).

The obvious back-up for an iPad/EFB is a selection of paper charts and a good scenario for EFB users is the simulated failure of their treasured device. It's reassuring to know that one can still locate, unfold, and use a paper chart, or thumb through an Airport/Facilities Directory, or locate a chart in a terminal procedures book. If you don't use a skill, you'll lose that skill.

I teach student pilots to use the autopilot, if one's installed in the airplane and that includes recovering from a runaway trim scenario. Of course they must be proficient at hand flying, but using the autopilot to give them a breather on long flights can actually enhance learning and if it reduces fatigue, it's the safe thing to do. Flying with an autopilot isn't cheating, it's a different kind of flying that need to be understood and practiced. A student of mine was about to go for his check ride recently and he asked if he could use the autopilot while planning his in-flight diversion. My response was "Sure, tell the examiner what you're doing. Of course he may tell you that you may not use the autopilot ..."

Share the Wealth

There's more and more cool stuff out there everyday and a lot of it, used intelligently, can make flying safer, easier, cheaper, and more enjoyable. New stuff needs to be properly learned, understood, and managed. And that means instructors need to stay current and learn the new stuff rather than steadfastly embracing old school. From the beginning, change has defined aviation and the new stuff just keeps coming. Thankfully, there's no turning back.

Tuesday, November 23, 2010

A Few Photos ...

I continue to be impressed with the iPhone4's built-in camera. I mean, it's not a Leica M9, but it's a heck of a lot cheaper and pretty simple to use. Plus, I always seem to have it with me. Some of these photos capture a bit of the joy of being in flight, others have sentimental value, and others are simply ... utilitarian.

Enjoy ...


Between Layers
A beautiful sight on a rare, solo flight ...

More layers ...

Odd shaft of light, near Danville

Strong pressure gradient, near Mt. Diablo

Who says GPS never fails?
Where did all the satellites go?
All better a few minutes later.
New Commercial Multi Pilot

Sunset over SF Bay

Somewhere on the SCK RNAV 11L approach
Parade of Clouds

Friday, November 19, 2010

The Problem with Checklists

Having finished reading The Checklist Manifesto, which deals with how checklist procedures can and have improved the delivery of medical care, I found some thoughts on aviation checklist procedures bubbled to the surface. The author, Atul Gawande, credits aviation as the inspiration for implementing checklist procedures in medicine. While there's no doubt that checklists help pilots complete complex procedures, the mere existence of a checklist doesn't immunize us from disaster. Pilot and aircrew performance is tightly linked to the quality and appropriateness of the checklist as well as checklist discipline. And let's not sidestep the whole issue of having to face a situation for which no checklist exists.

Appropriate and Useful

A fellow freight pilot once observed that there are just two kinds of mistakes that pilots can make: Those that embarrass us and those that can damage the airplane and/or kill us. An airline pilot friend once confided that he realized he could make errors in the cockpit at any time. His goal was to uncover any errors and correct them before they became a safety issue. For checklists to be an effective first line of defense against fatal mistakes, they must contain the crucial tasks and actions that apply to the situation at hand. Once a good checklist has been made available, pilots have to follow it. Here's a video a horrific accident during the test flight of a turbine conversion for the Caribou. The crew apparately neglected to remove the control lock, with deadly results.




One of Gawande's central themes is that the development of useful and appropriate checklists is aided by organizations that exhibit teamwork, continuous enhancement, and decentralized control. Gawande cites a study where a checklist was developed for the medical procedure of inserting central line. The steps were simple but it turns out that some of the crucial ones were often skipped, resulting in a high rate of infection, complications, and even patient death. When a checklist was developed for central lines and adhered to, the rate of infection dropped dramatically, survival rates improved and (here's what got a lot of attention) hospitals saved a ton of money. Interestingly, it was nurses who often reminded doctors when they were about to make a mistake, like forgetting to don a surgical mask or use a sterile drape.

The sort of cooperation being suggested by Gawande, where decision making, process improvement and double-checks are performed by people on the front lines, is not always what happens in aviation. Top-down organizational structure is often the rule in aviation, with the FAA being at the top of the heap. When I flew freight, I was astonished to learn that the checklists for our aircrafts' optional equipment weren't included in the regular manufacturer's checklist. Checks that needed to be done every day were strewn throughout the Supplements section of the Approved Aircraft Flight Manual. Creating a company checklist seemed like the answer, but that would have required a lot of time, effort and money since the checklist would need to be ... wait for it ... approved by the FAA. So there were procedures in the manufacturer's checklist that were incorrect or missing and the FAA's regulations (the ones supposed to ensure safety) condoned an environment where required equipment checks were easily forgotten or skipped altogether. At least this gave us something to talk about during recurrent training.

Gawande's glowing view of aviation checklists aside, I'd be remiss if I didn't point out that many aircraft manufacturer checklists are woefully inadequate, incomplete, and in some cases they even contain incorrect information. One manufacturer's After Landing checklist for a late-model aircraft in which I instruct contains just one task: FLAPS UP. Don't mistake this simplicity for elegance, because in point of fact it is inadequate. Checklist procedures continue to be spread throughout Approved Aircraft Flight Manuals, due to the manner in which aircraft and their components are certificated, and this may lead a pilot to incorrectly conclude that all of the manufacturer's checklist content is irrelevant. 

The good news here is that student pilots (and certificated pilots, too) flying under 14 CFR parts 61 and 91 can develop their own checklists. Just ensure that whatever checklists you develop contain, at their core, the manufacturer's checklist items. Creating your own checklist can be a great learning experience, but borrow an idea from Gawande's book and have some other pilots and instructors check your work for accuracy and completeness.

Familiarity Breeds ... Complacency

Assuming you have correct and complete checklists, there is another issue to address. Do the same routine countless times and you'll find you tend to skip using the checklist, do the tasks from memory, or use a flow check or mnemonic. Variety is the spice of life and I think it might even be the key to safety. There's emerging research that indicates what we have always suspected; endless routine is booooring and it can actually keep our brains from performing well.

On the ground, I still recommend using the checklist as a do-list, but that doesn't mean you can't have a passenger participate by reading the checklist to you. In the air you can mix things up by alternating between the checklist and a flow check or a mnemonic backed up with the checklist. Mix up your procedural routine and you may find checklist procedures to be less onerous, just be sure you don't skip any steps in the process.

I'm a big fan of Foreflight's Checklist app for the iPhone (it works on the iPad, too). What's nice about this app is that it's hard to lose your place as you check off items. Should you miss something, the app takes you right back to the first thing you skipped. If you discover a missing task or want to change the order of tasks, you can edit a checklist on the spot; no need to print out a new version, laminate it, etc. I fly a lot of different aircraft types and the checklist app really helps me keep it all straight without carrying a gazillion paper checklists.




Infrequently Used = Easily Forgotten

With abnormal or emergency checklists, we're faced with the opposite problem of routine checklists. Under stress and time pressure, these seldom-used checklists can make us feel confused and clumsy. The answer is to review these checklists by doing some arm chair flying from time to time, imagine an abnormal or emergency situation, then work you way through the checklist. You can also practice this in a simulator, just like the airlines do. Review emergency and abnormal checklists once a month and you'll be less likely to be flummoxed should a real emergency occur in flight or on the ground.

Designers and engineers can't anticipate every possible situation that a pilot or flight crew might face, so there isn't a checklist for all possible abnormal or emergency situations. Several years ago, flying in the wee hours of the morning of course, I heard a single, loud chirp every few seconds combined with annunciator lights flashing on and off. After a few confusing minutes (it didn't help that I'd barely gotten 6 hours of sleep in my 8 hour rest period), I determined the generator was being tripped off-line and then coming back on-line, all on its own, over and over. A quick review of the checklists showed there was no defined procedure for this problem. I followed the "generator offline" checklist as best I could and thankfully there was a standby electrical system. When I got on the ground and described the problem to maintenance, their first reaction was "That can't be!" Eventually the root cause was found and it did turn out to be an oddball failure.

I've witnessed numerous landing gear system problems for which there was no checklist. Most aircraft have emergency landing gear extension procedures, but many do not have checklist for situations like the landing gear failing to retract or only two out of three landing gear being extended. One of the most potentially dangerous situations you can face in single-pilot operations is an abnormality or emergency for which there is no checklist. This is where pilots try to use their knowledge of the aircraft systems to decide the correct course of action, in effect creating their own checklist in the moment.

The key in these situations is don't be in a hurry. Think very carefully and avoid impulsively jumping to any conclusions or simple explanations. If you have another pilot or a passenger on board, involve them in the process even if that only means you talking out loud and them listening to your thought process. You can learn a lot by listening to yourself talk.

Pessimistic or Realistic

It's been said that a good pilot is a pessimist, but I think being a realist may be better. Avoid an overly optimistic or inflated view of your skills, your knowledge, or your currency. Remember that there are mistakes that can embarrass you and mistakes that can kill you. The only thing standing between you and a fatal error just might be an open mind and a good checklist.

Saturday, November 21, 2009

Surprise, Surprise

The concept of automation surprise has been around for years in the large aircraft world and now it's part of the GA aircraft that you are flying or might soon be flying. Automation surprise occurs when a system, such as a GPS receiver and/or autopilot, does something the pilot neither expected nor intended. The result is that the aircraft deviates from an assigned heading, route, altitude, or approach path and the pilot may lose situation awareness, too. Actually, it's the pilot-in-command who is considered to have deviated, not the plane or it's systems and blaming the machine is an argument that's probably not going to hold water. With all the technically-advanced GA aircraft out there, automation surprise is now something that GA pilots must understand and be ready to handle.

While I don't pretend to be a human factors expert, I've both witnessed and been on the receiving end of automation surprise on several occasions. Most of the surprises I've seen in GA aircraft resulted from the pilot making mode errors - not fully understanding the consequences of their knob twisting and button pushing. Yet I have also seen deviations result from equipment failures and even from shortcomings in the design of an instrument procedure. There can be a seemingly endless number of ways for things to go wrong in a complex, automated environment and while we may want to never make any errors, mistakes are going to happen. I'll provide just a few examples of how things can get out of hand when technology is busy making the pilot's job easier and what you can do when the magic turns evil.

Operator Error
Here's a mistake I've witnessed many pilots make with the two-axis KAP-140. ATC instructs "... climb and maintain 7000." You decide it's time for George to do some flying. So you press and hold AP for 1.5 seconds, then press HDG, then select 7000 feet, then press ALT, and are subsequently confused as to why the KAP-140 won't allow you to use the UP button to select a vertical climb rate.



The key is understanding that the KAP-140 goes into VS (vertical speed) mode by default when your press the AP button. The mistake was pressing ALT, which engages altitude hold mode irrespective of the altitude you just dialed in - an odd design, to say the least! Pressing ALT a second time restores VS mode and allows you to enter a vertical climb rate. The problem is that the second time you press ALT to enter vertical speed mode, the altitude you selected is not armed. That means you'll climb, but the KAP-140 will not capture the selected altitude and if you're not paying attention, you'll bust your clearance. Blast!

Having your own SOP (Standard Operating Procedure) for autopilot use, combined with actually looking at the modes being displayed, can help circumvent this problem. A better knobology sequence would be: Dial in 7000 feet, pitch up for the desired climb rate, press and hold AP for 1.5 seconds, then press HDG, then press ARM. This results in the following KAP-140 display: HDG [AP] VS 7000 ALT Armed. The KAP-140 will climb at 500 feet per minute, fly the bugged heading, and level off at 7000 feet.

Unexpected Mode Changes
In an effort to make the pilot's job easier, Garmin's G1000 will automatically switch the navigation source from GPS to a localizer on an ILS, LOC or LDA approach. Interestingly, the G1000 won't automatically switch back to GPS for the missed approach procedure - you must manually switch the navigation source back to GPS. While this may sound like a good feature, it actually creates unintended consequences in aircraft equipped with a Bendix/King KAP-140 autopilot. Here's the setup.



You're flying the Concord LDA RWY 19R approach, approaching from the South, you've requested pilot navigation, Travis Approach has approved, and you're cleared to "cross KANAN at or above 4000' cleared LDA 19 right approach." You've selected and activated the approach on the G1000 with KANAN as the IAF. Your KAP-140 autopilot is engaged in NAV and ALT modes and it is flawlessly tracking a direct course to KANAN.

Crossing KANAN, the GPS sequences to fly the procedure turn and the KAP-140 continues to do a great job. You select 2500 feet, press ALT to enter VS mode, press DN a few times to command a 400'/min descent, and remove some power to keep the airspeed under control. The GPS and the KAP-140 turn the airplane to the outbound procedure turn, then after a minute, they turn the airplane inbound to intercept the approach course.

Reaching 2500 feet, you restore some power and the G1000 then automatically switches the navigation source to the localizer. If you're not observant, you will miss this mode change. The HSI needle changes color from magenta (for GPS) to green (for the localizer) and the switch in navigation source causes the KAP-140 to silently enter ROL mode. That's right, there's no aural alarm to alert you that this mode change has happened, just ROL flashing on the KAP-140 display - which is out of your primary field of view. If you don't realize the KAP-140 is in ROL mode, the airplane will fly right through the localizer. Ooops!

One SOP you could use to prevent this is to always change the KAP-140 to HDG, manually change the navigation source to the localizer, and follow the GPS prompts to manually command the procedure turn using the heading bug. Once you've turned inbound to intercept the localizer, press NAV and the KAP-140 will capture the localizer course.

Missing the Missed Approach
The Garmin G1000, as well as the 430/530 GPS receivers, can help you fly the missed approach using GPS navigation as long as everything goes as planned. For an ILS approach, the GPS must handle two possible cases: The full ILS and a localizer-only approach. The GPS considers the MAP to be at the runway threshold, even though the MAP on an ILS is technically at decision height, on glide slope, and on the localizer course.

For these GPS receivers to suspend waypoint sequencing, you need to fly over the MAP at the runway threshold. Only then can you press the OBS key (or softkey) to re-enable waypoint sequencing, switch the navigation source back to GPS, and fly the missed approach using the GPS. If you don't fly over the MAP, waypoint sequencing won't be suspended and you'll need to do some more work to activate the missed approach. If you don't understand this GPS behavior, you could find yourself very confused at a high workload moment. Do'h!

Procedure Problems
Though rare, automation surprise may occur due to the way an instrument procedure was designed. This is exactly what happened to a pilot I was flying with recently on an approach I had flown many, many times before. The thing is, it had been quite a while since I flew this approach and the procedure had changed. Here's what happened.

The pilot requested the Sacramento Executive ILS RWY 2 practice approach with the published missed approach. Approach responded "... cross COUPS at or above 3000, cleared ILS 2 practice approach." The pilot selected the approach and activated it with COUPS as the initial approach fix. The autopilot was engaged in NAV mode and flew us to COUPS. What happened next was both dramatic and unexpected.




Reaching COUPS, the GPS commanded a 41 degree heading change to the left from a 015 track to a 334 track to navigate to the newly added Computer Navigation Fix (CNF) UBIYI: A 41 degree heading change for a leg that is only 0.2 miles long! The groundspeed was only 110 knots, but there was no time for GPS turn anticipation to smooth this out. As soon as the GPS commanded a turn to the left, it commanded a turn back to the right as the airplane blew through the approach course. It happened so fast that we both wondered what was wrong. Was this a GPS error or an autopilot error?

No sooner had we begun to doubt the automation, the plane was headed back to intercept the localizer. You have to look really closely at the chart to see that the GPS and the KAP-140 were just trying to fly the approach as it is coded. I emailed the FAA to suggest they take another look at the unintended consequences of the change that was made. Good idea!

Ounce of Prevention
The primary ways a pilot can prevent automation surprise are both simple and straightforward:
  • Know your own limits with regard to currency/proficiency
  • Know thy aircraft's equipment
  • Monitor what the automated systems are doing
  • Stay ahead of (or at least be in synch with) ATC's game plan
  • Maintain situational awareness
  • Develop and use SOPs (standard operating procedures)
  • And be prepared to catch and correct errors.

I'd like to be able to tell you that the average pilot can fly a G1000-equipped aircraft once a month and maintain instrument proficiency. Sadly, this is usually not the case. Unless you are practicing regularly with a G1000 PC Trainer or other simulator, you'll get rusty - fast! Part of this erosion of skill is due to the vast number of features the G1000 offers, but much of the problem lies in the user interface's annoying design that requires you to recognize subtle changes in operational modes. I don't want to mince words here: The G1000 and other GA GPS receivers are not easy to use. They require regular use and practice for pilots to maintain proficiency.

PC-based simulators can be an effective and inexpensive way to maintain your instrument chops, but you need to have a plan. Sitting down and just screwing around is not going to serve you well. As they say in the music world: "If you play when you practice, you'll practice when you play."

A suggestion I've made before is to treat your autopilot and GPS like you would a low-time private pilot. It's okay to trust the systems, but monitor them to ensure they are doing what you intended. This is particularly important during transitions to climbs, descents, level-offs, turns to a heading, and intercepting and tracking a navigational course. So periodically interrupt whatever you were doing to ensure George is still flying the plane the way you intended. Did it capture the altitude you programmed? Has it intercepted the navigational course you intended? Is the autopilot still operating in the mode(s) you intended? If not, promptly drop what you are doing, intervene, fly the plane, and then try to determine why or George will trim you into a stall, flying you into the ground, or take you off course.

Remember that you are the last line of defense when automation goes bad. Never, ever forget that fact.

Monday, March 30, 2009

'Chute First ...


I've read with great interest some assertions about Cirrus aircraft, the pilots who fly them, and whether or not the airframe parachute makes the Cirrus pilot safer or just emboldens them to take risks. By now most of you know that on Sunday, March 15, 2009, a 64-year old instrument-rated private pilot flying a new Cirrus SR22 elected to deploy his aircraft's airframe parachute shortly after takeoff from Montgomery County Airport in Gaithersburg, Maryland. He departed runway 34 and his plane came to the ground about a half mile from the airport, no injuries were reported on the ground, the pilot walked away, and the aircraft was substantially damaged. It's dangerous to generalize, but I feel compelled to make some observations about this particular accident, the pilot's decision to launch into the weather, the efficacy of Cirrus door latches, and under what conditions a Cirrus pilot should consider deploying the 'chute.

The pilot involved in this particular accident was reported to have had 320 hours total time and I'm assuming, given his age, that he came to flying later in life. None of the reports I've read give any specific numbers, but given his total time and the fact that his last certificate was issued in June of 2007, it seems reasonable to assume that he didn't have much experience with solo flying in IMC. A low time pilot with a powerful and capable aircraft can be a dangerous, sometimes even deadly combination, and this accident would seem to reinforce that belief. And let's be clear that while this accident happened to involve a Cirrus, most any brand of high-performance aircraft will do.

An important part of instrument training involves making a competent go/no-go decision. Heck, it's explicitly called out in the Instrument Rating PTS as something the candidate must demonstrate. I sat on the ground a few years back with a Cirrus owner while we waited for the weather to clear. The radiation fog was thick and the surface winds were gradually starting to increase and mix out the fog, which made waiting all the more uncomfortable. But wait we did because, parachute or not, the conditions did not meet my minima for departure.

Turn in your hymnals to 14 CFR 91.175 and you'll find specific departure weather restrictions for aircraft operating under 14 CFR 135 and 121. Taking off under conditions with zero visibility and zero ceiling is not expressly forbidden when operating under part 91, but that doesn't mean it's a good idea nor does it mean that if you do so and you run into problems that you won't be scrutinized for violating 14 CFR 91.11 (Careless or reckless operation) - endangering the life or property of another. In our Me First society, it is easy to forget that our actions may indeed have adverse effects on others. This is where an instrument instructor's job of teaching risk management begins.

The accident pilot elected to launch with a reported ceiling of 400 feet and 2 miles visibility. Shown above are the takeoff minima published for Gaithersburg, which don't specify any ceiling or visibility. That means the 14 CFR 91.175 standards of 1 mile visibility for aircraft with two engines or less apply to part 135 and 121 operators. Technically the accident pilot was not prohibited from departing since he was operating under part 91.

The absolute lowest personal departure minima for a single-engine aircraft that I recommend to pilots I train for the instrument rating are pretty simple: The surface weather observation must be equal to or better than the highest circling minima (ceiling and visibility) for the airport, just in case an emergency return is required. In a twin-engine aircraft, I'm still pretty conservative and recommend the conditions be no lower than the highest straight-in minima of all non-precision approaches available at the departure airport.

When I flew freight in the Caravan, my company's procedures allowed us to depart in some really crummy conditions. On several occasions, I departed when the greater Bay Area was blanketed fog and with low IFR conditions at all nearby major airports. And you know what? It gave me the creeps every time I did it.

I've never flown into Gaithersburg, but a quick review of the available approaches show the following circling minima.

GAI NDB RWY 14 - 1 SM vis & 1380 feet MSL, 841 feet Height Above Threshold
GAI VOR RWY 14 - 1 SM & 1200 feet MSL, 677 feet HAT
GAI RNAV (GPS) RWY 14 - 1.5 SM & 1020 feet MSL, 481 feet HAT

In case you're wondering what I'm getting at, the low-time instrument-rated accident pilot took a pretty big risk when he chose to depart with 2 miles visibility and an overcast ceiling of 400 feet at an unfamiliar airport.

I've written before about my experiences with the door latches on a Cirrus SR22 that I used to fly. Quite frankly, I found the performances of these door latches stinks. Cirrus, in an apparent quest to make the aircraft seem as much like an automobile as possible, tried to implement a slam-and-shut-style automobile door. This just in: A high-performance single-engine aircraft is not a car. My experience showed me that the latches on an SR22 G2 must kept adjusted just right by a mechanic and the pilot had best ensure the doors are secured, top and bottom, before taking off. Interesting, the door latches on an older SR20 that I used to fly had a very positive door mechanism with a latching handle.

So a door popping open on a Cirrus is not uncommon and the AFM even has a procedure for handling it - abort the takeoff if you can, otherwise reduce your speed and land as soon as practical. A door popping open can be distracting as hell, especially to a low-time pilot, but the slipstream will keep the door mostly shut. You just need to reduce the airspeed and return to land. Of course, returning to land is going to be a lot easier if you at least have circling minima.

When I flew the Cirrus regularly, I followed all the recommended Cirrus Airframe Parachute System (CAPS) procedures. This included removing the safety pin from the activation handle before takeoff and installing the safety pin after landing. If you don't remove the pin, you simply can't be ready to deploy the parachute quickly in an emergency. I've read of several fatal accidents involving Cirrus where NTSB investigators, combing through the wreckage, found the CAPS safety pin firmly in place on the deployment handle.

Even though I followed the CAPS procedures and I regularly reviewed the deployment procedures, my mindset when flying the SR22 was that CAPS deployment was going to be an absolute last resort. The AFM gives some suggested situations where CAPS deployment is warranted:
  • Mid-air Collision
  • Structural Failure
  • Loss of Control
  • Landing in Inhospitable Terrain
  • Pilot Incapacitation
After the door opened, the accident pilot reported that his intention was to turn back and land at Gaithersburg. The accident pilot says the plane entered an unusual attitude and he let the airspeed get low, the aircraft stalled and started to enter a spin. The accident pilot said he had pressed the magic button (the autopilot Level button) to get the plane stabilized, but decided he couldn't wait for the magic button to do its magic. He was also concerned about entering restricted airspace nearby and was unfamiliar with the Gaithersburg airport environment. So he pulled the 'chute.

I'm glad he's okay and that no one on the ground was hurt, but this all seems so preventable. Low time pilots in high-performance aircraft with airframe parachute systems can learn a lot from this accident. "'Chute first" is a potentially dangerous and definitely expensive procedure. The hard questions need to be asked and answered on the ground, before the clouds are approaching, the door has opened, or the engine has quit and you feel the urge to pull that T-shaped handle.

Sunday, March 1, 2009

Uncertain Conclusions

This post concerns serious business, so I'll start with some levity.
A salesman, a hardware engineer, and a computer programmer were in a company car traveling down a steep mountain road when the car's brakes gave out. Miraculously, the driver was able to bring the car to a stop by turning off the engine and using the emergency brake.

As they piled out of the vehicle to assess the damage the salesman declared, "We should call the company carpool and have them dispatch us a brand new company car."

The hardware engineer shook his head and said, "No, we should take this car apart, find out what went wrong, get new parts, and fix this car."

The programmer rolled his eyes and opined, "No, no, no. We should take this car back up the hill and see if it does it again."

There are limits to inductive reasoning, especially when one tries to draw conclusions based on a very small sample of events. It's easy to draw a conclusion from experience, but that conclusion could be invalid or incomplete, depending on your experience and, among other things, luck. Pilots often receive in-depth training in aircraft systems and that can lead them to believe they can troubleshoot or fix problems in flight, but don't forget an important part of aeronautical decision making: Have a solid respect for what you don't know and avoid making unnecessary and risky assumptions.

Consider the procedure for resetting a popped circuit breaker while flying an aircraft, a practice that is now virtually prohibited in commercial aviation but may still be widely practiced in general aviation aircraft. A related problem involves flying an aircraft with non-essential, inoperative equipment that hasn't been removed or deactivated. The NTSB has concluded that both of these issues likely led to the crash of the Cessna 310 I mentioned in my last post.

Like many things, the FAA's regulations don't make the process of dealing with inoperative equipment a simple matter. There are seven (count 'em!) steps you may need to follow to be legal.
  1. Does the aircraft in question have a minimum equipment list (MEL) and, if so, is the thing that's inoperative required on the MEL? If yes, the aircraft is grounded and corrective action is required. If no, then skip to step 6. If your aircraft doesn't have an MEL, then ...
  2. Does the thing that's inoperative appear in the aircraft's original equipment list as being required for certification? If yes, the aircraft is grounded and corrective action is required. Otherwise ...
  3. Does the thing that's inoperative appear in the aircraft's Kinds Of Operation Equipment List (if the aircraft has one) found in the Limitations Section of the AFM for the planned type of operation? If yes, the aircraft is grounded and corrective action is required. Otherwise ...
  4. Is the thing that's inoperative required by 14 CFR 91.205 for the planned type of operation? If yes, the aircraft is grounded and corrective action is required. Otherwise ...
  5. Is the thing that's inoperative required by an Airworthiness Directive? If yes, the plane is grounded and corrective action is required. Otherwise ...
  6. Do you, as PIC, believe that safety of flight will be adversely affected by the thing that is inoperative? If yes, the aircraft is grounded (see Sam's blog for a great description of a PIC's real life safety-of-flight decision). Otherwise ...
  7. Deactivate or remove the thing that is inoperative, placard it as inoperative, make a maintenance log entry describing what you did, and you can now go flying.
An important thing to consider is "When did the thing that is inoperative actually quit working?" Often you'll discover something is broken during your preflight inspection, taxi check, or during the before takeoff checks. If you discover something is broken while in flight, you should tell someone and make a record of the discrepancy after you complete your flight. This discrepancy report (US pilots often call them squawks) should alert the pilot who is scheduled to fly the aircraft next, provided that information is recorded somewhere and communicated to maintenance personnel and the next pilot(s).

The FAA tries to incorporate these maintenance concepts in the various Practical Test Standards under the Emergency Operations and Postflight Procedures areas of operation. In my experience, few GA pilots actually complete a postflight inspection after flying. Heck, with some pilots you're lucy if they remember to tie the plane down, install the gust lock, and so on. Many designated pilot examiners will thoroughly quiz a candidate about required equipment and the handling inoperative equipment, but a lot of pilots seem to forget these procedures as soon as the ink is dry on their temporary airman's certificate. Even the very experienced airline transport pilot involved in the Cessna 310 crash seems to have overlooked the proper procedure for handling inoperative equipment.

A maintenance discrepancy log sheet recovered at the accident site, annotated during the previous day’s flight, described the weather radar display as going “blank” during cruise flight, accompanied by a “smell of electrical components burning. Turned off unit - pulled radar [circuit breaker] - smell went away.” No corrective action was annotated next to the discrepancy write-up, and no evidence was found to indicate that corrective action was taken prior to the mishap flight.

Post accident interviews with company personnel indicated that during a phone conversation the day prior to the accident, the ATP was made aware of the weather radar discrepancy item. A company aircraft mechanic confirmed that the ATP stated that he “didn’t care about the radar” during a telephone conversation on the morning of the accident.

None of the company personnel interviewed remembered seeing either member of the accident flight crew reviewing the airplane discrepancy log prior to departure, but one mechanic did recall that the ATP performed the preflight inspection of the airplane.

The pilots decided to take the plane without thoroughly investigating the squawk about the radar and it appears the circuit breaker that had been pulled was not "collared" by maintenance to prevent it being reset. Resetting the circuit breaker may have caused the Cessna 310's in-flight fire. Here's how.

Older style circuit breakers use a bimetallic, thermal design that responds to the heat generated when a specified electrical load is exceeded. A metal collar holds the circuit closed against the force of a spring contained inside the circuit breaker. Should the collar begin to heat up, it will expand, allowing the spring to open the circuit. This design generally works, but it has two problems.

Old circuit breakers may no longer perform as designed, especially if they have accumulated a coating of dirt, dust, or some sort of spilled contaminant like coffee or soft drinks.

Even if circuit breakers aren't contaminated, an arcing event between wires whose insulation has chaffed away may not generate enough heat at the breaker to cause it to open immediately. Significant arcing damage may occur and significant smoke can be generated before a conventional circuit breaker will trip. Arc-Fault Circuit Breakers are now available which can detect arcing events and immediately open the circuit before significant damage occurs, but you can bet that 70's, 80's or 90's vintage aircraft are probably not equipped with such devices.

According to AC 120-80, most hidden fires are the result of arcing between bundled wires. Uncontaminated wiring insulation is fire resistant, but an arc can easily provide a source of ignition for surrounding insulation materials or even wiring insulation if it has been contaminated with dust/dirt or stray corrosion inhibitors and lubricants. Once a circuit breaker trips, you may very well be confronted by an electrical system in an indeterminate state: The AFM's wiring diagram may no longer apply to your aircraft.

The problem is made worse by the fact that some aircraft designs put circuit breakers in very difficult-to-reach places. The Caravan has numerous rows of circuit breakers located on a panel adjacent to the pilot's left leg, leading some operators put color-coded plastic collars on important circuit breakers to help pilots figure out which circuit has opened. The Cirrus SR20 and SR22 have circuit breakers that are located near the pilots right foot in a location where parallax makes it virtually impossible to accurately read the labels while flying the aircraft. Piper Comanche and Twin Comanche aircraft have circuit breakers behind a trap door on the floor, another illustration of a fundamentally bad design decision.

Did the pilots of that Cessna 310 reset the circuit breaker for the radar equipment that had previously been pulled (but not collared) by the previous pilot? We may never know.
At 08:32:50, shortly after reaching a cruising altitude of 6,000 feet, the flight crew declared an emergency to the Orlando International approach air traffic controller (ATC). The crew advised that there was "smoke in the cockpit," and announced their intention to land at SFB. ATC cleared the airplane to fly directly to SFB and descend to 2,000 feet. Radar data indicated that the accident airplane turned toward SFB and commenced its descent. ATC then cleared the accident crewmembers to “to land any runway." The last radio transmission from the airplane occurred at 08:33:15. It was terminated in mid-sentence and appeared to include the phrase “shutoff all radios, elec.” The last radar return from the accident airplane was at 08:34:50, about 1/2-mile
east of the accident site.

GA pilots can learn a lot from this accident by following a procedure for fires and tripped circuit breakers that the airlines generally follow, as outlined in AC 120-80. First, be aware of the indications of hidden fires:
  • Odors of smoke or of hot electrical equipment
  • Un-commanded operation of an aircraft system may indicate a hidden fire
  • Circuit breakers tripping
  • Hot spots on the floor, or behind sidewalls and access panels
  • Smoke or visual signs of flames
Should a fire develop, be prepared to follow these steps:
  • Fight the fire immediately, be aggressive
  • Try to find the base or source of the fire
  • Do not reset circuit breakers unless the equipment is required for safe flight
  • Plan for an immediate descent and landing at the nearest suitable airport
  • Use personal breathing equipment (supplemental oxygen) if available
Be wary if a circuit breaker trips and try to apply all that systems knowledge you learned once you are safely on the ground. Knowing the signs of in-flight fires, how to properly handle inoperative equipment, leaving tripped circuit breakers alone, and being familiar with using fire extinguishers may save your life some day.

Tuesday, February 24, 2009

Internal Combustion

On July 10, 2007, about 0835 eastern daylight time, a Cessna Aircraft Company 310R, N501N, part of the fleet operated by the National Association for Stock Car Auto Racing (NASCAR) corporate aviation division, crashed while performing an emergency diversion to Orlando Sanford International Airport, Orlando, Florida. The two pilots on board the airplane (a commercial pilot and an airline transport pilot) and three people on the ground were killed. Four people on the ground received serious injuries. The airplane and two homes were destroyed by impact forces and a postcrash fire. The personal flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.


Few things in aviation are more frightening to contemplate than an in-flight cabin fire, which is what the pilots of this Cessna 310 were apparently attempting to deal with. Most GA pilots don't give much consideration to what parts of the aircraft might provide a source of ignition nor how they would handle an in-flight cabin fire. As with all things in life, forewarned is forearmed and there are some important things to consider regarding in-flight fires. Contemplating the ingredients required for an in-flight fire is a good place to start, followed by knowing if your aircraft is equipped with a fire extinguisher and what type it is, inspecting the fire extinguisher during your preflight, knowing how to remove and use the fire extinguisher, and an awareness of how much time the average GA pilot might have to successfully deal an in-flight fire. To be fair, other factors in the above mentioned accident appear to involve the improper handling of inoperative equipment and circuit breakers, which I'll cover in a future installment.

This just in: To have a fire you need a source of combustible material, an ignition source that will get that material to its kindling temperature, and oxygen. A lot of things inside an aircraft will burn with the most obvious being fuel, but insulation on wiring, circuit boards, and other electrical components will combust when given the right sort of push. Heat from an engine, open flames, bleed air, and electrical sparks and resistance are all possible sources of ignition. Oxygen is widely available at no charge. Once a material reaches its kindling temperature, the source of ignition will probably no longer be required to keep the party going. Even so, the first step in fighting an in-flight fire is to remove the source of ignition. Always follow the checklist procedures in your FAA-Approved Aircraft Flight Manual, but a safe first step is to de-energize the electrical system - Turn off the battery master, alternator and/or generator.

The next step is to extinguish the fire and many, but not all GA aircraft are equipped with at least one hand-held fire extinguisher. If you own the aircraft, you probably know whether or not there's an extinguisher on board. If you are renting an unfamiliar aircraft, take the time to determine if a fire extinguisher is installed. Fire extinguishers are often located between the two front seats, but in some aircraft they are squirreled away in a weird location. Even though AC 20-42C recommends that fire extinguishers be mounted where they are readily accessible, I've seen extinguishers mounted underneath the pilot's seat and in locations that are not only inconvenient, they could be downright dangerous in an emergency when every second counts. And if you aren't following a preflight checklist that includes the fire extinguisher and you can't actually see the fire extinguisher, you're likely to forget about it. Out of sight, out of mind.

Once you've found the extinguisher, make sure it is securely held in its mounting bracket. If you are unsure how to remove the extinguisher, the preflight inspection is a good time to get familiar the process rather than during an in-flight fire. If the extinguisher is mounted in a hard-to-reach location, you may decide to remove the extinguisher to complete the next steps.

Check to see what type of extinguisher you have. Halon (halogenated hydrocarbon, a liquified gas) is the most common type for use in aircraft because it can be used on most types of fires, except when the combustible agent is a metal, such as magnesium or titanium. Halon comes in two basic varieties: 1211 and 1301. If you're interested, the four digits represent (in order from left to right) the number of carbon, fluorine, chlorine, and bromine molecules contained in the product. 1211 is a liquid streaming agent that can be projected over a distance and directed at the source of the fire while 1301 is a flooding agent that is designed to smother hard to reach fires. Some extinguishers contain a mixture of these two agents. The main advantage of Halon is that it can reach fires that you might not be able to see, like behind an instrument panel. Halon will also minimize residue left on electronic components, but fire extinguisher damage to a radio stack may be the least of your worries when the cockpit fills with smoke.

If you're worried about the in-flight effects of Halon on you, AC 120-80 advises that Halon discharged in confined spaces may result in dizziness, impaired coordination, and reduced mental sharpness. Since a fire requires a source of ignition, a source of combustible fuel, and oxygen, the goal is to remove the source of ignition, extinguish the fire and then ventilate the cabin. The effects of Halon, if any, should be short-lived if the fire is extinguished quickly and besides, you don't really have many other options.

One issue with Halon is that halogenated hydrocarbons harm the earth's ozone layer and the production or importing of Halon in the US has been prohibited since the Clean Air act went into effect in 1994 (as part of the Montreal Protocol). Though production of Halon is banned, possessing or discharging Halon is not prohibited nor is it against the law to sell a new unit or recharge an existing Halon fire extinguisher. In case you're wondering, discharging a Halon extinguisher just to test it is a really dumb idea: It's bad for the environment and it's expensive, too. In spite of the manufacturing ban, Halon continues to be available because it is recycled from used extinguisher systems. It's been estimated that about 40% of the remaining supply of Halon exists in the US, though the limited supply has certainly driven up the cost. Replacements for Halon will have to be identified eventually.

Virtually all hand-held extinguishers have a safety pin to prevent accidental discharge. Locate the pin and verify that it is in place. The safety pins will usually be held in place by a thin plastic tie that must be broken before the pin can be removed.

If the extinguisher has a pressure gauge, it should be reading in the green. Not all extinguishers have a pressure gauge in spite of the fact that this is the primary way to know if the extinguisher is operable, short of actually pulling the pin and discharging it. If the extinguisher has a service tag, check when it was last serviced and when it is next due for service. If you have removed the fire extinguisher from its bracket, you can also try this test: Note the position of the pressure indication, then turn the extinguisher upside down and right side up five times, then verify that the needle is in the same position. If the needle has moved, have the fire extinguisher serviced.

The standard method for using a fire extinguisher is often summed up with the acronym PASS: Pull the safety pin, Aim the fire extinguisher nozzle or hose at the base of the fire, Squeeze the handle, and Sweep the extinguisher's stream back and forth. This sequence may sound simplistic, but if you start squeezing the handle as you're trying to remove the safety pin, the pin may not come out freely if at all. An in-flight fire behind the instrument panel will make it impossible to accurately aim the extinguisher's stream. Some extinguishers don't have a hose, they just have a nozzle. Many fire extinguishers are marked with instructions saying that you should hold the fire extinguisher upright while discharging or you may reduce the effectiveness.

A Halon extinguisher is well-suited for situations where you can't see the source of the fire. When I used to fly freight, we had a single, large canister Halon extinguisher, equipped with a hose, and mounted between the pilot seats. Since there was no air-tight barrier between the cockpit and the freight area, the procedure for a fire in the freight hold was to 1) don the oxygen mask 2) pull the safety pin on the extinguisher 3) aim the hose back toward the freight area 4) discharge the entire contents of the extinguisher 5) declare an emergency and land as soon as possible. As always, if in doubt, follow the instruction in your aircraft's FAA-approved Flight Manual.

As for how long you have to control an in-flight fire and get on the ground in a GA aircraft, my research only uncovered survivability data for transport category aircraft. In these aircraft there was an average of 17 minutes from the first indication of a fire until the results became fatal. For smaller aircraft, one would assume that even less time would be available.

In the next installment I'll discuss recommendations for handling tripped circuit breakers and the importance of properly dealing with inoperative equipment.

Friday, January 16, 2009

Simulated Flight



I spend more time instructing in simulators these days and am fortunate to have access to three very capable devices. Many pilots (myself included) complain that a simulator just doesn't fly like a real aircraft, but time spent in a simulator can save you money. First, there's no fuel bill. Simulators can also save you time because training scenarios can be set-up quickly and, here's the important part, you can pause the simulation, discuss the desired responses, and practice the scenario repeatedly to learn and ingrain the desired responses. And time is money, after all.

Time in an approved simulator with an instructor can be recorded in your logbook and in about an hour, you can knock out six approaches and a holding pattern to keep you instrument current. Depending on the type of simulator, you may log the time toward most any certificate from private to ATP as long as you are receiving instruction from an authorized instructor. The simulators I use are even qualified to be used to complete an instrument proficiency check.

Before you sit down at the controls, you and your instructor need a clear idea of what you wish to accomplish in the simulator. As with any instructional flight, there should be a plan and a pre-flight discussion of that plan. Without a plan, your simulator time will tend to be haphazard, the effectiveness of your training may fall short of your expectations, and you won't get your money's worth. At the completion of your simulator session, there should be a debrief and an objective review of your performance.

Simulator time is a great way want to get acquainted with high-performance and complex aircraft as well as for learning high-altitude operations. In the US, regulations allow you to obtain a high-performance, complex, and high-altitude endorsement from an authorized instructor based on ground instruction and time spent in an approved simulator with a flight model that is representative of the type of endorsement you seek. For each of these endorsements, training will focus on learning the appropriate procedures for normal, abnormal, and emergency operations. 14 CFR Part 61 specifically defines the areas that must be covered for a high-altitude endorsement. Interestingly, you can't earn a tailwheel endorsement in a simulator and based on my time in conventional gear aircraft and the current state of simulation devices, this seems about right.

More and more pilots learn multi-engine operations in an approved simulator prior to training in a multi-engine aircraft and the savings can be significant. Instead of spending over $230 a hour and burning a lot of fuel, you can spend about 25% of that and learn the basics in a simulator. For multi-engine training, the Practical Test Standards (private, commercial, or ATP) will spell out the maneuvers, takeoffs, landings and emergency procedures you'll need to cover. You can experience multi-engine emergencies in a simulator, like engine failure on takeoff at Vmc, that may be too risky to simulate during training in a real aircraft. For many of the maneuvers, it's best to have a simulator with a 180 degree field of view.

For pilots seeking an instrument rating, having access to a simulator has become de rigeur. For practicing instrument procedures by yourself, most any simulator (including non-approved simulators) will do, though you won't be able to log the time. And just as when using an approved simulator, it helps to have a plan or you're likely to end up just messing around.

Learning instrument procedures in a simulator with an authorized instructor allows you to pause the simulation to discuss questions. Pausing the simulation can also give you a chance to catch your breath and regroup, which increases your capacity to learn. With just a few mouse clicks you can practice almost any approach most anywhere in the world. If you've never flown a Simplified Directional Facility (SDF) or Localizer-type Directional Aid (LDA) approach, you can do it easily in a simulator.

Giving quality instruction in a simulator requires the instructor to have a thorough knowledge of the limitations of the particular simulator you'll be using. Nothing is worse than having a pilot wait while you try to work out a simulator glitch, but this sort of thing can and does happen. If it's any consolation, I even experienced such delays during recurrent training in a level D simulator.

A good simulator instructor will know how to set up weather scenarios and equipment failures in a realistic way. And for instrument training to be truly productive, your simulator instructor needs to know how to act like a controller, giving you accurate instructions and approach clearances. There's often more responsibilities for an instructor in a simulator than in a real aircraft

Autopilots are becoming standard equipment in new GA aircraft and more pilots are learning to rely on them to manage their workload when flying single-pilot, especially in instrument conditions. Autopilot usage in an important part of simulator training because it gives you time to concentrate on procedures and emergencies. Some GA pilots still tend to think of autopilot use as cheating, but it's really just a different kind of flying. To be a well-rounded and proficient pilot, you need to regularly practice hand-flying as well as managing the aircraft with the autopilot. If you practice one style of flying and exclude the other, your overall level of safety and flying skill will suffer.

My simulator training for the part 135 flying I used to do always followed a familiar pattern. The first session concentrated mostly on normal VFR maneuvers, takeoffs and landings, and instrument procedures. Of course there was always some funny business. For turbine engines, the engine never started normally the first time: A hot start and a hung start always seemed to occur as did the need for external power starts. These sorts of problems are rarely encountered in real life, if ever, which makes the simulator the perfect place to experience them. In subsequent simulator sessions, you could count on excrement hitting the oscillating device at every turn. Engine failures, blown tires, asymmetric flap extension, icing encounters, runway incursions, thunderstorms, partial panel approaches, and a variety of arcane aircraft systems failures.

When giving simulator training to GA pilots, I like to follow a similar pattern, starting with normal procedures and working up to more the more challenging stuff. One of my favorite scenarios is to have a pilot fly an instrument approach to an airport, have to execute the missed approach, and then while holding over a VOR, experience an engine failure. I choose a VOR near or right on an airport and set the weather to give the pilot a fighting chance. In such a situation, an autopilot can provide valuable assistance in maintaining a power-off descent at the best-glide speed. Another valuable scenario is engine failures and other abnormalities during the takeoff roll or just after takeoff. Pilots often comment that these scenarios really get the blood pumping, even though it's just a simulator.

So grab your PTS and/or your approach charts, find a good simulator and simulator instructor, and take your training up a notch. It's go time!

Wednesday, December 24, 2008

Failure of Imagination

Pilots are trained to trust their instruments, follow accepted procedures, and maintain situational awareness, but these elements don't guarantee safe results. One model of risk analysis and management puts forth the "swiss cheese" model, originally proposed by British psychologist James Reason in the 1990s.

The idea behind the "swiss cheese" model is that safety barriers we use are not perfect. Holes exist in the equipment, procedures and techniques that we use. Rather than having a static position, it's useful to imagine the holes in each safety barrier as constantly shifting. Should a sequence of holes in each of our safety barriers align, our risk has just increased and here's the important part, we may not even be aware of it. When we pilots rely on multiple systems and procedures to mediate risk, we are assuming that multiple barriers will reduce the likelihood that risk will permeate all of the barriers and cause an accident.

With all this in mind, here is the third and final part of the video series on how disaster was adverted by an alert Air New Zealand flight crew.



For GA pilots in single-pilot operations, our first safety defense is a preflight briefing that includes weather information and NOTAMs (Notices to Airmen). The holes in this first barrier are many and may include a lack of surface weather observations at our intended destination or the simple fact that forecasts are imperfect. Another big hole is reading and digesting NOTAMs, which can be a complicated and error-prone process. Deciphering the abbreviations used in NOTAMs is a skill that can require time and practice. Yet if you skip the preflight briefing altogether or just "get the weather," you have effectively taken this barrier out of the picture and significantly increased the risks associated with your flight.

The second safety barrier is the go/no-go decision. Remember that light GA aircraft are much more vulnerable to hazardous weather due to their inherently low performance, slow speed, and lack of weather detection capability. If the preflight briefing suggests significantly nasty weather, stay on the ground. If you gloss over the go/no-go decision and commit yourself to flight, your life could become very complicated, very quickly. If you are loath to stay on the ground for fear that it will make you less of an aviator, get some serious couch time with a mental health professional.

The third safety barrier for GA pilots is a careful preflight inspection of the aircraft. The older the aircraft, the more holes you're likely to find in this safety barrier. I wouldn't be the first person to point out that there is a strong tension between keeping aviation affordable and maintaining safety. Maintenance is expensive and it's no secret that some owners skimp on maintenance. If you have doubts about the aircraft or a piece of installed equipment, especially if that equipment is critical to your flight, the choice is simple - Find a mechanic, find another plane, or stay on the ground.

The last safety barrier is the GA pilot himself or herself and all the intangible elements that each of us embodies. Are you current and proficient? When did you last fly the aircraft type you are about to fly? Are you familiar with the route and destination? Have you been there before? Did you get enough sleep last night? If the flight conditions will be challenging, are you up to the task? Are you prepared for moderate turbulence, heavy rain, a possible icing encounter, or a strong crosswind? Is another pilot going to be flying with you and can they take on some of the load? How about your passengers? If they get scared or airsick, can you handle the distraction? Do you have a plan B and a plan C?

Lack of familiarity with an aircraft's electronic navigation system can contribute to tragic results, as evidenced by the mid-air collision of a Boeing 737 and a Embraer Legacy jet over the Amazon in 2006. If you haven't already done so, I recommend reading William Langewiesche's Vanity Fair article which vividly describes the breech of several safety barriers - appropriate altitude for direction of flight, ATC conflict resolution, Traffic Collision Avoidance System, and crew situational awareness.

An increasingly popular way to handle the risk of complex avionics systems is standardized, recurrent training. This approach emphasizes eliminating errors, procedural violations and variations, or dangerous behavior on the part of pilots. Professor Reason refers to this as the person approach and the main goal is to eliminate variations in human behavior. At its best, standardized training creates another barrier of safety. At it's worst, this sort of training can emphasize heavy-handed, orthodox principals - "Never use the Direct-to button!" or "Always set the heading bug with your right hand!" are just two examples. I respect and appreciate standardized training, but standardized procedures can't cover every eventuality. That's where imagination comes in.

Imagination allows pilots to conceive of where they are in space, what they need to do next, and how certain choices or changes might affect the flight. At its worst, imagination can lead pilots to make incorrect assumptions to incorrectly explain something that doesn't seem quite right, as seen in the video above.

Flying in moderate or greater turbulence can be distracting, especially during an approach to landing. Assuming a pilot understands the effects and dangers of windshear, I encourage them to imagine how they'd fly the plane in smooth air and then do their best to make what is happening in real-time match up with their idealized flight. This use of imagination gives the pilot a specific outcome to strive for, rather than being at the mercy of the elements. Imagination can backfire, too. A few years back, I flew with a very intelligent pilot whose quick thinking and imagination sometimes led him to jump to incorrect conclusions and talk himself into all sorts of situations.

The G1000 provides an excellent example of a system intended to improve pilot safety through increased situational awareness and navigational accuracy. Used properly, the G1000 can provide exactly what it advertises. Yet the G1000 is it not particularly easy to use. It requires thorough initial training to gain proficiency and more than just occasional use to maintain that proficiency. In my experience, GA pilots who fly infrequently or on an irregular schedule are more apt to become confused or task saturated when using the G1000.

Hard to use systems, with numerous options, and several ways to accomplish the same function may seem flexible, but just as often the multitude of options simply increases a pilot's workload, effectively increases the number of holes in what is supposed to be a safety barrier. At critical phases of flight, poorly designed systems can lead to task saturation as the lone pilot tries to figure out "Why is it doing that?" or "How do I get it to do what I want?" Standardized training alone will not solve this problem.

This brings us back to imagination. A good pilot can imagine all sorts of possible problems that could scrub a flight or make a flight more difficult to complete. Imagination helps us consider a situation where we're behind the plane or where the GPS doesn't function properly. Imagination helps us realize that we might not be proficient, that we need some recurrent training. I'm all for optimism, but a pilot who always assumes everything will be just fine suffers from the worst possible lack of imaginiation - the kind of imagination that can keep all those holes in all those barriers from aligning.

Friday, December 19, 2008

Levels of Paranoia

All instrument approaches provide pilots with course guidance either to a runway or to a point near an airport or runway, but the ILS gives pilots left/right course guidance and descent guidance (glideslope). An instrument in front of the pilot or flight crew basically has two needles (the actual format varies), one vertical needle and one horizontal. The pilot or flight crew adjusts their heading to keep the vertical needle centered and the descent rate to keep the horizontal needle centered. Keep both needles centered, and the ILS takes you right to a runway.

Specialized versions of the ILS can be conducted by authorized flight crews in conditions of virtually no runway visibility, though a 200 foot ceiling and a half a mile of visibility are standard minima for us mere mortals. There used to be a few LDA (Localizer Direction Aid) approaches that provided a glideslope, but the only one I know of that still exists is the LDA RWY 6 approach into Roanoke, Virginia and it doesn't exactly take you right to the runway.

A lot RNAV approaches, many of them less than a few years old, provide vertical guidance in appropriately-equipped aircraft. RNP approaches exist for specially trained air crews that also get down pretty low. But when you need to get to the runway in really crummy weather, the good old ILS is still the gold standard for most pilots. But things can go wrong on an ILS and pilots need to be paying attention and prepared. I recommend you watch this two-part video. Together they are about 20 minutes long, quite thorough, and valuable, I think. If you're short on time, the second video makes the point on its own.





A question I frequently hear as an instrument instructor is "When can a pilot intercept the glideslope on an ILS approach?" My answer is always "When at all possible, from below, at glideslope intercept altitude." This is a good, though not completely infallible way to verify that things are as they should be on the approach. On FAA instrument approach charts, the point of glideslope intercept is depicted on the profile view as a lightning bolt style arrow. For many ILS approaches, the profile view looks something like this.



The glideslope intercept altitude for this particular approach is 1500 feet and the lightning bolt shows that glideslope intercept is slightly before the Maltese cross that represents the Final Approach Fix (FAF) and the altitude over the FAF (a VOR in this case) should be 1493 feet. Technically, the FAF on an ILS approach is where glideslope intercept occurs but I've always thought that to be just a bit of academic trivia. The Maltese cross is the FAF for the purposes of timing the segment between the FAF and the missed approach point. If you were flying just the localizer portion of the approach with the glideslope inoperative for some reason, the FAF is the Maltese cross. On some approaches the Maltese cross and the lightning bolt are the same point, but just as often they are not.



Some ILS approaches, like the ILS RWY 22L at Sacramento Mather, have step down fixes before the final approach fix and this is where pilots ask "If I can receive the glideslope before descending to the glideslope intercept altitude, can't I just start following the glideslope at that point?" Before trusting your life to an ILS glideslope, there are limitations to keep in mind. The gray feather shown on the profile view depicts where glideslope should be reliable. You may be able to receive the glideslope much further out, but I'd treat those indications with skepticism.

There is no preflight test for the aircraft's glideslope receiver that a pilot can perform. Several miles before the FAF, you should verify that the localizer display is not flagged. A few miles before the FAF, verify that the GS is not flagged, too. As you saw in the videos, this is not always a guarantee that all is well.

The videos point out that reception of a valid Morse code ID for the localizer does not mean that the glideslope portion is operational and functioning properly. ATC should know if the glideslope is inoperative and if so, your approach clearance should sound like:
Barnburner 123 is three miles from FIDO, fly heading 330, maintain 3000 until established, cleared Mooselips ILS 30 approach, glideslope inoperative.
Pay special attention to NOTAMs during your preflight briefing that mention any component of an approach (including DME) being unmonitored. "Unmonitored" means that for some reason, ATC will probably not be able to determine the health of that component in real time and warn you if it's misbehaving.

A recognized problem with intercepting the glideslope from above is the presence of false glideslopes. These false slopes are quite steep and should be easy to recognize as erroneous, but a coupled approaches in that situation could provide a pretty wild ride until you figured it out.

Though rare, false glideslopes below the normal slope can be caused by a coating of snow of the just the right thickness and moisture content on the ground off which part of the glideslope signal is reflected. There was an excellent article about this in IFR Magazine a few years back (a brief disclosure - I'm a semi-regular contributor to IFR Magazine). And you can read this accident report concerning a Piper Cheyenne that hit a power pole and crashed short of the runway with (according to the pilot) the glideslope and localizer needles centered.

On a check ride, the ATP and Instrument Rating Practical Test Standards contain the same criteria for the examiner's evaluating a precision approach:

"Establishes a predetermined rate of descent at the point where the electronic glide slope begins ..."

The "Instrument Flying Handbook" says:

"Pilots should pay particular attention to the following approach chart information: name and number of the approach, localizer frequency, inbound course, glide slope intercept altitude, DA/DM, ..."

While my reading of this wording does not necessarily preclude intercepting the glideslope from above during a descent, I like to see pilots in light aircraft reach the glideslope intercept altitude a mile or so before the designated glideslope intercept. Several important tasks need to be accomplished just before the FAF and getting to the intercept altitude promptly gives you plenty of time to have the aircraft configured and stabilized.

Pilots who want to ride the glideslope down from an altitude above the GS intercept altitude usually do so, in my experience, because they are behind the aircraft. There, I said it! They are late appropriately configuring the aircraft or are behind ATC's game plan. When you are pressed for time in a single-pilot environment, you are less likely to be able to detect if something is wrong and staying ahead of the aircraft is critical.

Flying the ILS RWY 22L into Mather, here's how things would look beginning the descent to the step-down fix YOSHE. Note that we've set the #1 bearing pointer to display the GPS course, which will come in handy later. We've also engaged the autopilot to fly the GPS vertical track, which the G1000 provides until we get close to the FAF. More on that later, too.



Setting the #1 bearing pointer to the GPS lets you verify the localizer course is accurate and the bearing pointer's distance to the current waypoint (approach fix) can help you detect abnormalities in an otherwise normal looking glideslope.

As we begin the descent from YOSHE to GADBE, we'll need a fairly high rate of descent to arrive at glideslope intercept altitude a mile or so from the FAF (which also happens to be the point where glideslope intercept should occur). This is a good time to synchronize your heading bug with your current course and put the autopilot into heading mode. Many autopilots will disengage NAV or APR (approach) mode if the navigation source it is tracking is changed. With the G1000, you'll need to switch (or the G1000 will switch automatically) from the GPS to the localizer, so you can nip this in the bud by engaging heading mode. You can then program the autopilot to begin a rate descent.

Since your goal is to get below the glideslope, but not below the intercept altitude, the rate of descent will need to be higher than normal. The descent rate to stay on a 3 degree glideslope can be approximated by multiplying your groundspeed in knots by 5. So at 110 knots a descent rate of 550 feet per minute would keep us on the slope. To get to the intercept altitude and intercept the glideslope from below requires a higher rate of descent (try ground speed times 9 or 10) and this will result in a temporary indication of being below glideslope.



Leveling off at the glideslope intercept altitude requires the restoration of POWER and/or re-trimming the aircraft, something many pilots seem to forget. As the glideslope comes in from above, extending the landing gear should provide a stabilized descent with minimal power adjustment or trim input.

Here's what it would look like at glideslope intercept altitude, one half dot below the glideslope, at the point where gear extension and the Before Landing checklist would be performed. At this point we should again verify there are no flags, the glideslope altitude matches the altitude depicted on the approach chart, and that the GPS bearing pointer and the localizer course are coincident. Any of these being parameters being out of whack should result in a missed approach. If everything looks good, you can engage the autopilot in approach mode to capture the glideslope.



I recently worked with Hamish in an FAA-approved G1000 simulator and we decided to try the Roanoke LDA RWY 6 approach. In the process, we discovered something interesting: The G1000's GPS depiction of the approach course didn't match what the simulator had for the localizer. The #1 bearing pointer was set to the GPS, it gave a very clear indication that didn't agree with the localizer course, and Hamish caught it immediately at the FAF. Turns out this was a simulator bug, but it illustrates the value of using the GPS as a back-up to the localizer.

Descending on a standard 3 degree glideslope, check your position relative to the GPS missed approach point. At a mile or so to the runway threshold, you should be about 500' above the touchdown zone elevation for an ILS with standard 200' minima. Not all ILS are created equal and some have higher visibility and decision height requirements, so read the fine print carefully. Some approaches have interesting notes, like these below. HUD stands for Heads-Up Display and FD for Flight Director, by the way.



I'm often asked why an approach like the Monterey ILS RWY 10R would say that coupled approaches are not authorized. The answer is that the when the FAA flight check crews test flew the approach, they found variations that they thought some autopilots might not handle very well.



The keys to a safe ILS are to stay ahead the airplane (and the autopilot), intercept the glideslope at the appropriate altitude (preferably from below), cross check the localizer course against your GPS (even a hand-held GPS is better than nothing), perform a sanity check on your altitude at the FAF and a mile or so before touchdown, and carefully read the fine print on the approach chart.
Related Posts Plugin for WordPress, Blogger...