2007 Fatalities: Not as safe as we think

Widow · Post by **Widow** » Fri Nov 02, 2007 5:26 pm

Just so we are clear. It wasn't "mucky" in Campbell River, to the west of Quadra where they took off. He had indicated that he would not be going north-east (first destination) because there was "muck" in that direction, but would likely head directly north (second destination) as it was clear there and in that direction.

BoostedNihilist · Post by **BoostedNihilist** » Fri Nov 02, 2007 5:30 pm

justplanecrazy · Post by **justplanecrazy** » Fri Nov 02, 2007 6:26 pm

If he had record of good work aside from this incident, I'd hire him in a heartbeat. Every mechanic and pilot will make at least one MAJOR mistake in his/her career. Even highly regarded pilots make really serious errors at times. Most of us will catch it or get lucky, this guy never. I would be willing to bet that he won't make the same mistake twice and will be more cognizant of what parts he is installing more than any other mechanic that hasn't been caught on a mistake. Now if there's a history of mistakes, then yes he is negligent and shouldn't be touching the equipment but to call him negligent or ignorant because he screwed up once and got burned on it big time, is telling everyone that you aren't human and you are incapable of human error.

I don't know how many highly regarded airline and other very experienced pilots paid the ultimate price for really obvious rudimentary errors. You obviously haven't been flying for very long if you think it's not possible for you to make the same lapse of judgement. I find it funny whenever there's a gear up landing posted, people take two stances. One is the understanding that it could happen to anyone and to take this as a reminder, and two is the thought that you are better than everyone and it could never happen to you and the guy it happend to is a negligent moron. You are obviously part of the second group, lets hope that your first error, that puts you in with the first group, doesn't kill you. I would fly with people from the first group over someone like yourself anyday.

BoostedNihilist · Post by **BoostedNihilist** » Fri Nov 02, 2007 7:37 pm

chubbee · Post by **chubbee** » Fri Nov 02, 2007 9:30 pm

What about a non human factors improvement to the situation?
Why not add a hardware safety system?
Why not have GPS encoded 406 ELT with a remote "on" switch in the cockpit as mandatory equipment in all commercial passenger aircraft?

When the engine got "sick" if the pilot flipped the switch SAR would have had the aircraft ID, GPS coordinates and that it was in distress.

xsbank · Post by **xsbank** » Fri Nov 02, 2007 11:17 pm

Why not indeed?

snoopy · Post by **snoopy** » Sat Nov 03, 2007 2:23 am

justplanecrazy,
If I may, correct a technicality:

"Unless things have changed, legal limits are 1sm flight visibility? and 0' on the ceiling???. You can fly legally over glassy water with clouds 20' above and 1sm vis???. Is it safe or smart? No. Would I expect to be blamed if I crashed, whether due to an engine failure or going IMC or controlled flight into terrain? Yes, in all cases."

I would suggest that your scenario would put yourself at serious odds with the regs, never mind safety:

VFR Flight Obstacle Clearance Requirements

703.27 Except when conducting a take-off or landing, no person shall operate an aircraft in VFR flight

(a) at night, at less than 1,000 feet above the highest obstacle located within a horizontal distance of three miles from the route to be flown; or

(b) where the aircraft is an aeroplane, during the day, at less than 300 feet AGL or at a horizontal distance of less than 300 feet from any obstacle.

VFR Flight Minimum Flight Visibility - Uncontrolled Airspace

703.28 (1) Where an aeroplane is operated in day VFR flight within uncontrolled airspace at less than 1,000 feet AGL, a person may, for the purposes of subparagraph 602.115(c)(i), operate the aeroplane when flight visibility is less than two miles if the person

(a) is authorized to do so in an air operator certificate; and

(b) complies with the Commercial Air Service Standards.

723.28 VFR Flight Minima - Uncontrolled Airspace

The standard for reduced VFR limits of one mile in uncontrolled airspace is as follows:

(1) Aircraft Equipment

The aeroplane shall be equipped with the following equipment:
(amended 1998/06/01; previous version)

(a) an artificial horizon;
(amended 1998/06/01; previous version)

(b) a directional gyro or gyro compass; and
(amended 1998/06/01; previous version)

(c) a Global Positioning System (GPS) navigation receiver.
(amended 1998/06/01; previous version)

(2) Pilot Experience

Before conducting operations at reduced visibility, pilots shall have achieved at least 500 hours of experience in Part VII or equivalent operations in the same category and class of aeroplane for which the authority is sought.
(amended 1998/06/01; previous version)

(3) Airspeed and Configuration for Operation in Reduced Visibility

Aeroplanes shall be operated at a speed such that obstacles can be seen and avoided. Aeroplane configuration for operations in reduced visibility shall conform to the Aircraft Flight Manual recommendations.

(4) Pilot Training

Pilots shall receive training as follows:
(amended 1998/06/01; previous version)

(a) initially and every three years thereafter, pilot decision making training which shall include the following topics:
(amended 2000/12/01; previous version)

(i) the decision making process, including modules on factors which affect good judgement;
(amended 2000/12/01; previous version)

(ii) human performance factors, including modules on physical, psychological and, physiological phenomena and limitations; and
(amended 2000/12/01; previous version)

(iii) human error countermeasures and good airmanship;
(amended 2000/12/01; previous version)

(b) one hour initial flight training and one hour annual recurrent flight training in basic instrument flying manoeuvres and flight at reduced airspeed; and

(c) initial training and annual recurrent training in the use of all equipment specified in subsection (1) above, and in all procedures specified in the Company Operations Manual for low visibility operations.

(5) Company Operations Manual

The Company Operations Manual shall contain the following information:
(amended 1998/06/01; previous version)

(a) a company-established minimum safe operational IAS and configuration for reduced visibility operations for each aeroplane type for which this authority is sought; and

(b) company low visibility operational procedures and considerations including, but not limited to:
(amended 1998/06/01; previous version)

(A) wind,

(B) gross weight and weather considerations,

(C) route/terrain knowledge and/or restrictions (availability of forced landing areas, potential for white-out, etc.),

(D) time of day restrictions (e.g., no low visibility operations at dawn or twilight), and

(E) communications.

Cheers,
Snoopy

justplanecrazy · Post by **justplanecrazy** » Sat Nov 03, 2007 8:25 am

Snoopy you're right, I was referring to the absolute worse conditions that one can fly in. Outside of controlled airspace its 2sm below 1,000' clear of cloud 300' AGL and 300' horizontal from obstacles. 2 sm above 1000' with 500' vertical and 2000' horizontal from cloud. So you can still depart Vancouver with 1sm and a 10' ceiling as long as there's a 305' ceiling and 2sm vis outside of the control zone for the enroute portion of the flight. As you pointed out, there is legislation that also allows 1sm for section 7 flights.

Chubbee, I think you're onto something. If a guy wanted to make a change, that would be an affordable improvement and could potentially save several lives, this would be one of them. If you're going to slag the industry you have to have an alternative to improve it and that's one of the few that I've heard. Widow, you should start a new topic where pilots can voice ideas like this one. Then take that to the government and the media as a solution rather than just tell everyone how dangerous flying is.

BoostedNihilist I don't have a lackadaisical attitude towards human error, I just have the understanding that it can never be 100% eliminated. Just look at the worst airplane accident in history. KLM's poster boy departed without receiving take off clearance at the same time that Pan Am took a different exit than instructed. Two very experienced pilots did two very stupid things arguably more obvious than installing a wrong part. As a result there were changes made to phraseology to try and limit mistakes. How many people have I told to taxi to position and watch as they round the corner and depart after reading back taxi to position only? Well, probably about 2+ a year ranging from cessna's to JS31's to citations. The only thing saving them was that there wasn't a jet on the runway.

Jeez no need to get all personal here. I can understand defending a tired argument is getting to you but no need to outright name call.

Yeah sure, fly with the guy who doesn't put the gear down, real bright idea... hope he checked his fuel or did another of the 15 items on his checklist.. or do we as pilots do those anymore? See, you will die or kill someone looking to prove a pattern whereas I would stop the pattern at the first instance... and that is how we keep safe and people don't get dead. There are a MILLION things that can happen up there... human error should be a situation where an error in REFLEX causes the action... not an error in recall or procedure.. Pilots should be qualified enough to land the plane gear down (if possible) 100% of the time... I guess our disconnect exists within our own personal standards. You can be happy with a lower standard, and I won't fly with you and we can both accept that outcome happily.

I'm not name calling. You posted this...

but no, I will NEVER cause my own gear up landing.

and I'm saying that you obviously don't have much experience or don't realize when you screw the pooch, to have that attitude. At some point in your career you're going to make a major mistake and lets hope it opens your eyes to the possiblity that you're not perfect. Like you said there are 15 items on a checklist to do and at some point in your career a distraction could easily cause you to eliminate one of them. Just like for whatever reason this mechanic did something that was blatantly wrong. If you don't acknowledge that reality, then chances are you are the person that will do it and not catch it. No its not acceptable to make these mistakes but to think that you are incapable of it is the ultimate ignorance. Because of that, I believe you're a liability and would never fly with you.

I used to work with a controller that stated quite regularly that he'd never have a sep loss. The day that he did, made him a much safer controller. After that, he began to question himself whenever he was unsure of something, realising that it was possible to screw up. He caught his errors a lot sooner from then on.

Dog · Post by **Dog** » Sat Nov 03, 2007 10:06 am

Just to clarify:
An Ops spec is available to allow VFR in one mile and clear of cloud outside controlled airspace.

BoostedNihilist · Post by **BoostedNihilist** » Sat Nov 03, 2007 11:14 am

justplanecrazy · Post by **justplanecrazy** » Sat Nov 03, 2007 12:04 pm

First off there's a quote button... use it

Second this is getting fu*#ing ridiculous.

Third I don't believe that people that haven't had a major mistake in their career are any less safe than those that have. The ones that believe that they are incapable of making a blatantly obvious mistake are.

"How many people have I told to taxi to position and watch as they round the corner and depart after reading back taxi to position only?"
Obviously they didn't hear you correctly and it is your responsibility to correct them. You are a 'controller' so control... or pass the buck whatever.

Fourth, obviously you are a complete moron and don't understand what to position only means and shouldn't be flying then. Correct them??? What should I say, JZA8043 you read back to position only I just want to make sure that you understand that you can't take-off, you can only go to position and have to wait there until I give you take-off clearance... oh wait I can't say take-off so what should I say then oh Obi-Wan? Should I tell them to taxi 100' ahead in a 90 degree turn and wait for further instructions? Yes I've resorted to name calling... it took 10 posts but I think I'm now fully qualified to label you as a moron for that last comment.

I can't count the number of times a pilot has screwed up his instructions... can it be stopped? It can be minimized by phraseology amendments etc. but just like someone that lands with the gear up or installs a wrong part, these things can never be eliminated completely unless you are inhumane and a God like yourself.

Talk to Cat or someone with a perfect and long record and ask them if they ever almost did something as stupid and simple as landing gear up. If they know you well enough they'll probably tell you about a major mistake early in their career that made them far more cautious and realistic for the rest of it. The pilot that feels he is better than everyone else and not susceptible to very basic error, is usually the first one to auger it in.

To answer your question I used to work as an auto mechanic and yes wrong parts being installed is not an uncommon occurance. The fact that the aviation department makes it one speaks volumes to their thoroughness and professionalism.

Cat Driver · Post by **Cat Driver** » Sat Nov 03, 2007 12:27 pm

Talk to Cat or someone with a perfect and long record and ask them if they ever almost did something as stupid and simple as landing gear up. If they know you well enough they'll probably tell you about a major mistake early in their career that made them far more cautious and realistic for the rest of it. The pilot that feels he is better than everyone else and not susceptible to very basic error, is usually the first one to auger it in.

If I were to relate all the mistakes I have made during my career I would have to write a book.

Like most from my generation I was exposed to the culture of risk taking such as no seats in bush planes and horrendous over loads.

I was more fortunate than most because a lot of experienced high time pilots took the time to explain to me that the rules were put there for a reason and very early in my career I refused to compromise and cut corners for any employer.

I voluntarily retired from flying for a living at the age of 70, not because I was concerned that I was not up to par physically or mentally but because I did not want to find myself somewhere down the road having fuc.ed up due to age having caught up with me.

For me it is the correct decision because I can look back and feel satisfied that I did the correct thing.

But it is very difficult to stay out of flying and I still do a bit of flying because it is in my DNA and I just can't quit completely.

Back to the rule breaking and how difficult it was for me every time I lost a job because I refused to fly in non compliance with the rules......

.....at first I was convinced that if I stood my ground and refused to break the rules and lost my job I could at least go to TC and ask them to defend my position.

Well for me it never happened because I soon learned that to go to TC for help was like loading a 357 magnum and putting it to my head and pulling the trigger......and I learned that in 1965...big time.....the fix was in between my employer and TC and I ended up with no job a young family and faced with the knowlege that to stay employed in aviation in Canada you need to be a rule breaker.....but I decided to stick to what I knew to be the safe way to fly and lost several more jobs for refusing to break the rules.

Maybe that and a lot of luck is why I flew 55 years without ever having banged one up?

BoostedNihilist · Post by **BoostedNihilist** » Sat Nov 03, 2007 1:12 pm

carholme · Post by **carholme** » Sat Nov 03, 2007 1:31 pm

The title of this thread is "Not As Safe As We Think".

Reading through the continual sniping at each other causes me to reflect back to the original rationale and development of the CRM program, which gathered three main components, Leadership. Interpersonal communications and Decision Making.

You don't neccessarily have to aspire to these components to be a better person but to effectively and together, run a better cockpit.

One can extrapolate, that to meet these components, that there has to be some understanding of where EGO fits into this scenario.

Maybe we should learn to practice CRM in a few other places as well.

carholme

justplanecrazy · Post by **justplanecrazy** » Sat Nov 03, 2007 2:00 pm

Carholme its funny that you bring up CRM because the point I'm trying to make to Boosted is actually straight out of that train of thought. It took me two minutes to google his complex as one of the main points in a CRM manual.

Human Factors covers the JAR PPL syllabus with an emphasis on up-to-date and relevant material, written for pilots, not doctors. The second part of the book, Flight Safety, breaks new ground in examining flight safety and airmanship issues from the PPL perspective: Why do pilots press on into deteriorating weather? What makes a pilot keep on flying until their aircraft runs out of fuel? Why are low-level aerobatics so dangerous? If you've ever read an accident report and thought, "That will never happen to me," you will find PPL5 essential reading. Pilots of every experience level will find food for thought in PPL5 Human Factors and Flight Safety and it looks set to repeat the success of the preceding volumes in the series.

Crew Resource Management – A Safety Tool

Crew Resource Management (CRM) became one of the two hot safety and flight training topics of the 90’s. As aircraft maintenance has reached new levels of reliability, aircrew errors have become the predominant factor in aircraft accidents. The US Air Force estimates that upwards of 80% of all mishaps are the result of human factors/errors.

BoostedNihilist · Post by **BoostedNihilist** » Sat Nov 03, 2007 2:27 pm

justplanecrazy · Post by **justplanecrazy** » Sat Nov 03, 2007 3:02 pm

Let me quote your posts so you don't have to go back and read your painful psychotic whirlwind of thoughts.

...but no, I will NEVER cause my own gear up landing.

the accident is 100% preventable

See the point of this all is that I REALIZE I am perfectly capable of making these mistakes, and that is precisely why I will not.

So yes, I am lumping you into the "That will never happen to me" group.

You would never install the wrong part, never land gear up with operable gear, never forget to switch the tanks, never depart without a clearance unless I tell you to taxi to position only as that is a very confusing instruction as you pointed out and should be clarified.

Seeing as the stat is taking out of a CRM manual, I don't think it is refering to shaving accidents.... just another intelligent comment to chock up to your brilliant posts.

Your brilliance astounds me. I take back my previous comments, you obviously will never fall into the 80% human error group.

carholme · Post by **carholme** » Sat Nov 03, 2007 3:17 pm

Boys;

The reference was to CRM, not "Tit for Tat".

carholme

xsbank · Post by **xsbank** » Sat Nov 03, 2007 3:28 pm

Did somebody mention..... oh, never mind.

BoostedNihilist · Post by **BoostedNihilist** » Tue Nov 06, 2007 2:05 pm

Cat Driver · Post by **Cat Driver** » Tue Nov 06, 2007 2:28 pm

Cat: How many gear up landings have you had?

I have landed with the gear up many thousands of times in an amphibian on the water.

I have never landed with the gear in the wrong position...ever.

If zero... how is this possible?

I have been flying amphibian aircraft since 1954 when I first flew a Sea Bee for several years.

I almost landed on a runway twice with the gear up......

Once in a PBY after a long day of water bombing and something distracted us from the pre landing check list.

And once in a Cessna 206 on Whipline Amphibs.....again something distracted me from my checks....

Both times I caught my mistake because when turning final in any aircraft I ask myself this question:

"" Where am I landing and where is my gear? ""

In both cases I had turned final to close in to allow for the gear extension so I did an over shoot and put the gear down.

I have done several hundreds of millions of landings and I owe the fact that I always had the gear in the right position by making sure my brain was in gear while I was flying.

Mistakes will and can happen, however we can stack the odds in our favour by self discipline and using cross checks for must do items.

justplanecrazy · Post by **justplanecrazy** » Tue Nov 06, 2007 7:33 pm

Boosted, I don't know if you're just fishing or if you really are that arrogant to put yourself above all of those that have messed up. I'm tired of trying to make sense of your posts so instead of trying to read it, I'll just summarize what I've been trying to explain to you over the last 5 pages and what is written in CRM manuals as well as documented fact by psycholigists and Safety experts across the globe.

Humans make mistakes. Some pilots/mechanics manage to catch theirs and others just get lucky without any catastrophic result. I would be very surprised if you're an experienced pilot. Even the most arrogant usually have a situation within their first 1,000 hours that makes them realise that they too can screw up.

Look at Cat, an experienced, talented, model pilot that knew when to say no and lived through a more fullfilling aviation career then 99.9% of us will have. He almost made the most basic error twice and caught it so close to touch down, that he had to overshoot. The reason he's not a human error statistic is because of his self discipline and I might add a little bit of luck. A flock of birds flying across in front of him short final could have also distracted him from his cross checks as easily as something distracted him in his original checks and he could have landed gear up.

We're human (with the exception of yourself) and we'll make mistakes. That can be minimized with talent and training but never 100% prevented.

The End

Cat Driver · Post by **Cat Driver** » Tue Nov 06, 2007 7:49 pm

We're human (with the exception of yourself) and we'll make mistakes. That can be minimized with talent and training but never 100% prevented.

Marriage one of societies most serious decisions is proof positive humans are prone to making mistakes......My talents are obviously in flying because they sure wern't eviddent in my marriage decision making skills...

BoostedNihilist · Post by **BoostedNihilist** » Tue Nov 06, 2007 8:21 pm

justplanecrazy · Post by **justplanecrazy** » Tue Nov 06, 2007 10:10 pm

hahhaha.... boosted, I just realised why my comment that if you don't understand that you will make mistakes, then you must not have many hours, pissed you off.

I figured you must be a very inexperienced pilot to have the attitude that you have and make the comments you did but I really wasn't sure. Then I realised what tipped me off, you refered to the gear down in a downwind checklist. Well you had me going for so long and seemed to take extreme offence when I suggested that you were a newby, so I decided to get a bit of background to see where you're coming from. Turns out you're not even a private pilot yet?????

hahahahaa... so thanks for the conversation but how about we wait about 10 years and then we can talk.

So just for shit's and giggles I thought I'd post some of your zingers now that I realise that they're being made by someone still learning how to flare and have a good laugh at them.

Do you fly planes or just control them? If you did fly you would know that if you are distracted and you miss your prelanding checks you can advance the throttle and go around and do it properly. This is the correct and prudent course of action. Certainly any 'experienced' pilot would know that when the ground is coming up the gear is going down.

And this coming from an 'experienced' pilot who's working on touch & go's in a C150???

That's alright though, at least there will be a bundle of sympathy out there for you after you @#$! your plane, or someone elses life up. You are not human either.. you are subhuman.

and you my friend will soon be subhuman or as some people call it, a pilot soon as well, welcome to the club.

This is the kind of attitude pilots need to avoid gear up landings and the like. Not your 'its okay, it happens to us all' bullshit logic. Man I seriously can't believe you are still alive.

uh... you've never lowered the gear in an airplane in your life...

Landing with the gear up is not something that is okay, or somthing so simply shrugged off... It is dangerous and potentially life threatening. If you put yourself, or worse human cargo, in that position shame on you and you should re-evaluate your suitability to pilot an aircraft.

uh... you've never lowered the gear in an airplane in your life...

Landing gear up with operable gear is inexcusable. It can't happen to the best of us because the best of us never do something so stupid.. it makes us NOT the best when we do things like this.

You're grouping yourself with the best pilots??? How about you wait until you finish that private flight test before you start calling yourself the best of the best.

I don't think you are fully qualified to do anything..

Well I don't know about that, I have a licence with over 6 ratings on it and you have your... uh... first solo??

Quantify this for me... exactly how much more obvious is installing the wrong part vs. taking off without clearance?
Have you ever turned a wrench on a machine.. do you understand what you are talking about?

Have you ever flown a plane without an instructor??

but no, I will NEVER cause my own gear up landing. As a pilot you should know that if you miss the gear you missed a bunch of other probably equally important stuff...

As a pilot who's never retracted the gear on an aircraft, you would definately know...

Boosted... find a new username and next time think before you post!!! Thanks for the laughs but this is a small industry and if you keep up this bullshit, people will get to know you and your career will be over before you get out of the booster seat. For the record, I've never had an accident, incident or major event in the 6 years that I've been airborn. I don't know if I'll be fortunate enough to have a record similar to Cat's when I retire but I do know that tomorrow I could do miss something a ruin the six year record that I've built for myself. I'll try my hardest to prevent that through crosschecks and proffesional flying but I'll never claim that it'll never happen to me... after all I'm only human.