Critical Role of Situational Awareness in Accidents

[rookiepilot]

I believe this is an under appreciated aspect of accidents -- especially in the Single Pilot operations I'm familiar with.

Accident reports (often) attempt to pin down an accident to a single action, or omitted action on a checklist, for example.

I believe the true cause of many, many accidents is much more complex, and (loss of ) SA is underemphasized as a primary cause -- as are human factors, notably fatigue.

Completing one challenging IFR approach to minimums, for example, may well be perfectly safe for a rested, focused pilot, without distraction.

Completing the second or third attempt after going missed, for a pilot who is tired, come off a busy day with inadequate sleep, distracted by a balky instrument or nervous passengers , may well be a fatality in the making. Yet this factor isn't always given adequate primacy in a report.

ATC can lose SA as well. Task saturation is a critical risk factor, for ATC and pilots.

I had it happen to me, at an IMC approach to an unfamiliar airport in the Midwest. AS I recall it -- Airspace was saturated, ATC gave me a clearance to a fix -- but not a hold, just to fly towards the fix -- outside of, so not a part of, my expected ILS approach I'd loaded on my 430.

I then had to dump the approach I had loaded to enter the cleared fix. I reached the fix, and for some reason ATC momentarily forgot about me, and somehow I also lost SA.

I began flying away from the final approach course, and towards some hills to the south.

After 60 seconds, something felt very wrong, and I reached down to call ATC -- at that moment they called me, and gave me a new heading.


Another checklist, a longer checklist, isn't going to help, because situational awareness has been dangerously impaired. This can happen in any phase of flight.

The classic example is the airliner that descended into the everglades, distracted by -- a burnt out bulb. There are countless examples where the pilot lost SA on their position, descent rate, airspeed, flap position....the list is endless, which is the point.

It's my belief that at least in the single engine ops I'm familiar with, becoming comfortable with a flow for different phases of flight, so actions are ingrained and automatic, is not only more efficient, It's actually safer. Perhaps regarding complex fuel systems, they are necessary -- I have no experience with those.

In really busy situations, or an emergency, there may not be time to consult a checklist -- at least immediately.

Hence, I believe in airline training, critical items are memory items, If I'm not mistaken, and that's with 2 crew.

Situational awareness is a critical tool for pilots, to be reinforced from the first PPL lesson.

---------- ADS -----------

[pelmet]

Interesting post.

If I was sticking to one aircraft type, I could understand the memorized normal checklist/flow.

It reminds me of the Harvard for the downwind check. HUGBUMPF was the term we memorized and it worked well, although we were still expected to use a checklist on the ground.

I have a tendency not to memorize flows on small aircraft for normal procedures and use the checklist for start, run-up, and before takeoff. I do admit that I have a tendency to do a GUMP check for before landing as the rental school checklists can be quite long.

Why have I done this. Because I am flying so many different types. I was flying well over ten different types a couple of years ago although in the Covid era, it is down somewhat.

So when one flies a Mooney, Bonanza, several different LSA's, Diamond's etc, including a couple of twins and two taildraggers, all of which are quite different from each other, I don't want to memorize flows because there are just way too many. And some aircraft were only getting flown every few months.

I got checked out in a Sling LSA at one airport and the instructor had a flow for everything that he was saying I should do. I refused and insisted on the checklist. There are some really smart guys who don't seem to need a checklist for multiple types but they probably have a really good memory.

I consider myself a dumb guy who will inevitably forget something.

Same thing with a lot of airspeeds and engine limitations that are already marked on the aircraft instruments. If they are already there, why memorize dozens of more numbers.

[cncpc]

Good post. Valid points.

[pelmet]

Good post. Valid points.

Thanks,

There can definitely be a benefit to having some flows for normal ops when the overall result is a decrease in workload. But remember something. The original post said that critical items are memory items. But those critical items are subsequently followed up by a checklist.

For something like a Bonanza my personal preference is to have the critical emergency items memorized but if there is some sort of malfunction like a gear extension problem or a non-urgent electrical issue where there is no urgency, I just use the checklist even if I basically know what to do. Then you don't get into a situation where the handcrank is still extended and spinning around like crazy because I forgot to do the last item after I saw the green light illuminate.

[rigpiggy]

My first large airplane "748" the instructor insisted on "do the flow, then do the checklist" and had me either physically touch, or point and verify all points of the checklist. To many nowadays are read and doers, and there are some very slow readers.

[Zaibatsu]

My first large airplane "748" the instructor insisted on "do the flow, then do the checklist" and had me either physically touch, or point and verify all points of the checklist. To many nowadays are read and doers, and there are some very slow readers.

What’s the rush? Rushing is where accidents happen. Direct control of the aircraft you might have to rush, to avoid terrain or traffic. Doing anything else, you have lots of time. Hold in position, slow down, or go around.

That’s why other than the AFM memory items, most abnormal and emergency checklists are explicitly ‘read and do’ checklists rather than ‘flow and go’.

And the reason is simple. Emergencies aren’t practiced as often as normal items and the criticality of doing the items in that list, all of them and correctly, is far higher.

The same can be applied to a flight school checklist. Students are still learning flows and don’t have the muscle memory or the situational awareness yet to deal with even all normal operations.

There’s no instinctive starting point. There’s no instinctive end point. In the middle they are lost. Go through the list until you’ve done everything and try to ground fly or armchair fly until you’ve built a picture in your mind of how it works.

[cncpc]

Good post. Valid points.

Thanks,

There can definitely be a benefit to having some flows for normal ops when the overall result is a decrease in workload. But remember something. The original post said that critical items are memory items. But those critical items are subsequently followed up by a checklist.

For something like a Bonanza my personal preference is to have the critical emergency items memorized but if there is some sort of malfunction like a gear extension problem or a non-urgent electrical issue where there is no urgency, I just use the checklist even if I basically know what to do. Then you don't get into a situation where the handcrank is still extended and spinning around like crazy because I forgot to do the last item after I saw the green light illuminate.

Ha, ha. Intended for the original poster, but yes, the same applies to yours.

[Flightgame]

My first large airplane "748" the instructor insisted on "do the flow, then do the checklist" and had me either physically touch, or point and verify all points of the checklist. To many nowadays are read and doers, and there are some very slow readers.

I remember a retired investigator telling me the importance of knowing where every knob & button is with your eyes closed, so that if there was a smoke filled cockpit, you will have a slight edge.

[telex]

Accident reports (often) attempt to pin down an accident to a single action, or omitted action on a checklist, for example.

I disagree. An accident report is looking for root cause.

[rookiepilot]

Accident reports (often) attempt to pin down an accident to a single action, or omitted action on a checklist, for example.

I disagree. An accident report is looking for root cause.

I'm not trying to disparage the incredibly complex task of investigators.

I wonder though if the relevant human factors are given adequate attention.

[telex]

Accident reports (often) attempt to pin down an accident to a single action, or omitted action on a checklist, for example.

I disagree. An accident report is looking for root cause.

I'm not trying to disparage the incredibly complex task of investigators.

I wonder though if the relevant human factors are given adequate attention.

Pick an accident that has happened in the last twenty five years.

Focus on human factors and how the report addressed it.

We will discuss it.

[rookiepilot]

I disagree. An accident report is looking for root cause.

I'm not trying to disparage the incredibly complex task of investigators.

I wonder though if the relevant human factors are given adequate attention.

Pick an accident that has happened in the last twenty five years.

Focus on human factors and how the report addressed it.

We will discuss it.

I will as I have opportunity.

I think upon reflection the greater issue may not be the official TSB / NTSB report itself, but how an accident is sometimes poorly dissected and oversimplified on forums like these, and human factors not given the primary focus they deserve.

It is really hard to read about an accident with a highly experienced ATPL with what seems foolish behaviour, without human factors being a primary cause. Maybe I'm wrong.

I've flown with several 10,000 plus pilots. It's hard to believe one just took a stupid pill one day. I think the truth is far more nuanced.

[telex]

Yes, all correct.

Human factors is certainly not cut and dried.

[rookiepilot]

Yes, all correct.

Human factors is certainly not cut and dried.

Here is a well known example, as paraphrased on Kathryn's report: -- The Cirrus SR 20's Go-Around stall spin accident at Houston Hobby.

First, read the whole report:

http://www.kathrynsreport.com/2016/06/c ... n-llc.html

Unfortunately, too often the accurate report is too often dumbed down to the below single paragraph, which is extremely misleading, especially to inexperienced pilots.

To characterize most every accident as a simple omission of a checklist item -- raising the flaps at a safe airspeed is one of those -- dangerously ignores the reality that inexperience, fatigue, a new aircraft type, ATC, passenger distraction, wind / turbulence, multiple go-arounds, even an uncomfortably hot cockpit has on losing situational awareness.

The pilot's improper go-around procedure that did not ensure that the airplane was at a safe airspeed before raising the flaps, which resulted in exceedance of the critical angle of attack and resulted in an accelerated aerodynamic stall and spin into terrain.

The above doesn't begin to cover the cause of this accident.

I can't imagine, for example, that series of ATC instructions given to an airline crew. They wouldn't stand for it. Yet this happens to GA once in a blue moon, for traffic flow reasons.

The technical cause of this accident may be correct -- raising the flaps.

But I speak from experience-- When ATC is (too) jammed up and telling you "keep (the turn) it in tight", "keep the speed up, there is a jet behind you" "Turn back on course (Into a storm cell)" -- there is a powerful tendency to "please ATC" and take their instructions as an "absolute and reliable authority here to keep me safe", because they are 99% of the time. It adds tremendous self - imposed pressure to the weekend GA flier, unless they have a personality that isn't shy about saying 'No".

In busy Airspace like Florida and the NYC area, controllers are going pretty non - stop, moving the metal. They don't have time for extras, even though they are great controllers. Assertiveness in bad weather or other circumstances is essential.

[telex]

Day VMC. Failure to maintain control of the aircraft. Yikes.

She put herself in a position she simply could not handle.

330 hours total time is just enough to give one some confidence.

The write up does come to a conclusion for the accident.

The inexperience and decision making brought her there.

[pelmet]

Day VMC. Failure to maintain control of the aircraft. Yikes.

She put herself in a position she simply could not handle.

330 hours total time is just enough to give one some confidence.

The write up does come to a conclusion for the accident.

The inexperience and decision making brought her there.

It is kind of like driving a car. It is best to avoid the super-highways until you have built up some experience over time. 330 hours is not a huge amount for a weekend warrior pilot to be flying a Cirrus but it certainly can be done depending on competence. Then head out to a super-busy place like Hobby where one has a high likelyhood of busy ATC and a situation like this is not unexpected. I remember spending many hours listening to ATC on my aircraft band radio to become familiar with ATC talk and procedures. One also needs to be able to give an honest analysis of their own personality and how it will affect their flying.

I believe that the quoted paragraph is from the NTSB.

One should be comfortable and reasonably competent in an aircraft before going somewhere that will be very, very busy. And ATC has no way of knowing your experience.

[rookiepilot]

Day VMC. Failure to maintain control of the aircraft. Yikes.

She put herself in a position she simply could not handle.

330 hours total time is just enough to give one some confidence.

The write up does come to a conclusion for the accident.

The inexperience and decision making brought her there.

Partially.

I have never heard such a brutal string of ATC instructions in my own flying -- in lots of places equally as busy as that airport. Why didn't they have her land on one of the 13's, with less of a crosswind component, and not be a factor for the jet traffic? Why didn't they hand her off to approach, resequence, slow things down?

And -- if she got in over her head -- which ATC recognized -- isn't it reasonable for ATC to slow things down, simplify instructions, give the pilot time to compose themselves?

Anyway, the point isn't who is at fault. The point is, its a hecka lot more complicated than missing a checklist item.

[telex]

"The pilot was attempting to land the airplane at a busy airport with high volume airline traffic."

Not the best environment for a weekend warrior.

However, she had a right to be there.

She was unfamiliar with the operating environment and unable to cope with the demands.

Expect ATC to give priority to airline traffic over GA traffic.

[rookiepilot]

"The pilot was attempting to land the airplane at a busy airport with high volume airline traffic."

Not the best environment for a weekend warrior.

However, she had a right to be there.

She was unfamiliar with the operating environment and unable to cope with the demands.

Expect ATC to give priority to airline traffic over GA traffic.

Respectfully disagree with this characterization, as does the NTSB

[pelmet]

"The pilot was attempting to land the airplane at a busy airport with high volume airline traffic."

Not the best environment for a weekend warrior.

However, she had a right to be there.

She was unfamiliar with the operating environment and unable to cope with the demands.

Expect ATC to give priority to airline traffic over GA traffic.

To be honest with you, there are some extremely busy airports that are uncontrolled. I have seen busy ones with skydiving operations mixed in with fast and slow aircraft on multiple runways. Others have gliders on an opposite side circuit landing on the same runway. In just the last few months I have been in a situation where I had to do maneuvering due to all the traffic and there can easily be an unexpected go-around for a variety of reasons including opposite direction traffic or just a botched landing.

Is there any reason to believe that this same result could easily have happened due to a go-around(or second go-around) at an uncontrolled airport. Make steady deliberate actions. Add power, start climbing or if necessary level off to accelerate, reduce high drag flap, continue(or start) the climb, when time and airspeed permit-retract the flaps. Practice it on a regular basis if you have not done it in a while. Rushing the procedure can lead to errors. One will likely be just fine leaving partial flaps for a while if they are busy.