Learn from what others are doing right... Issue 4/97

Electrical

FireThe Beech Baron pilot

was on a single-pilotcourier run betweenWinnipeg, Manitoba, andThunder Bay, Ontario. Hehad made two stops andwas inbound to ThunderBay when he advised airtraffic control that he had“a minor electrical prob-lem with smoke inthe cockpit.”

Three minutes later, heannounced that he wasexperiencing increasingsmoke in the cockpit.Radar contact was then lost as the aircraftdescended below the radar horizon.

The aircraft, found the next afternoon by a searchand rescue (SAR) aircraft, had been destroyed andthe pilot killed on impact.

Although the Transportation Safety Board inves-tigation has not yet been completed, it seems likelythat the pilot was overcome by the electrical smoke,fumes and/or fire and lost control of the aircraft. Thefact that he continued to communicate and his tran-sponder continued to function until radar contactwas lost would seem to indicate that he did not carryout the appropriate check for an electrical fire.

Most aircraft checklists are fairly generic when itcomes to electrical smoke or fire:• Immediately turn OFF the battery and generators

to eliminate the source. Even in instrument condi-tions, you can still fly the aircraft using theremaining air-driven instruments, as in the fol-lowing story about one pilot’s total electrical

Overcome by electrical fire.

failure at night over the cold grey North Atlantic.One big difference between the two occurrenceswas the availability of portable communications.If he had had he another means of communica-tion, the Baron pilot might not have been sohesitant to turn off all electrics.

• Go on oxygen and don a smoke mask if youhave one.

• Turn OFF all electrical switches. With the sourceeliminated, the smoke should disappear or the firego out.

• Essential electrics can then be brought back on-line one item at a time, while ensuring that thesmoke does not re-appear. The key word is“essential.” If you don’t absolutely need it, don’tturn it ON.Electrical smoke or fire is not a minor problem;

it is just as critical an emergency as an engine failureon takeoff is.

Total Electrical Failure . . . Using Your Resources

Some-time afterdepartingIceland, shenoticed thatthe rightalternatorhad failed,but sheelected tocontinue toSt. John’s.

About160 mi.from desti-nation, stillover thecold greyNorthAtlantic,she had acomplete

The ferry pilot was making anight transit from Reykjavik,Iceland, to Florida via St. John’s,Newfoundland, in a Britten-Norman Islander.

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electrical failure, leaving herwithout light, radios or naviga-tion aids. However, she was notwithout resources: using aportable global positioning

system and a flashlight, she wasable to continue to St. John’s,where, with the aid of a portableradio, she re-established commu-nications.

The weather was 300 ft. over-cast with 2 mi. visibility and,without electrical power, shewas unable to fly an instrumentapproach. Undaunted, air trafficcontrol provided the pilot withvectors for a successful emer-gency surveillance approach.

As the aircraft touched down,one engine quit. The pilot shutdown the other engine after thelanding roll.

After the aircraft was towedto the ramp, she called the towercontroller to thank her for herassistance during the approach.

That’s keeping cool and usingall of your resources.

Maintenance found that theright generator had failed owingto an electrical fault, the leftgenerator was hanging by onebolt, and the battery wascompletely drained.

Slippery-Runway Technique

The Canadair Regional Jet(RJ) operating manual containsthe following caution about land-ing on a slippery runway with acrosswind:

When changing from reversethrust to forward idle, pause atidle reverse to allow the enginesto unspool before selecting for-ward idle. If reversers arestowed while the engines arestill spooled up, there will be anoticeable decrease in decelera-tion or a forward surge of theaircraft.

It also advises that thrustlevels be reduced symmetrically,if necessary, if control difficultiesare experienced.

Further advice is provided: “Ifdirectional control difficulties areexperienced, release the brakes.”This is because main-gear tirecornering forces available tocounteract drift will be at a mini-mum when the anti-skid is oper-ating at maximum effectivenessfor the existing conditions.

It pays to review those proce-dures frequently — perhaps aspart of the crew’s approach brief-ing when anticipating a cross-wind landing on a contaminatedrunway.

With that in mind, here’s anoccurrence from last winter:

Runway excursion.

The RJ was inbound from thesunny south. Destinationweather was 800 ft. obscured,visibility was 0.75 mi. in lightsnow, and the wind was 90° tothe runway at 10 kt. No JamesBrake Index readings were avail-able because snow clearing wasin progress and the runway wascontaminated with snow andslush, but the runway-conditionreport passed to the crew a fewminutes before landing was :

100-ft. centreline, 60 per centbare and wet, 20 per cent lightslush and 20 per cent lightsnow; outside the centreline1 in. of slush and snow mixed.These conditions did not

exceed the recommended runwaysurface conditions for the aircrafttype. Nor did the crosswind com-ponent of 10 kt. exceed the opera-tor’s 15kt. maximum for wet orslippery runways. However, thecrew reported after the eventthat the runway was 100 per centsnow-covered.

The aircraft approach andtouchdown speeds were normaland the spoilers deployed attouchdown. Thrust reverserswere deployed and rudder andaileron inputs were applied tocounteract the left crosswind.

So far, so good. Then, as the

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aircraft slowed to about 40 kt., ityawed into wind. To counteractthe yaw, the pilot maintainedfull right rudder and continuedbraking. He reduced reversethrust to idle and then quicklystowed the reversers. However,his quick actions did not allowthe engines to spool down and

they transitioned to forwardthrust at a setting higher thanthe idle-thrust setting. He thenreselected first the left-engineand then the right-enginereverser, with the left engineunintentionally slightly aboveidle power.

left, departed the runway at lowspeedand, as it came to a stop,its nose gear sank into the softground.

There were no injuries or air-craft damage, only a long busride to the terminal.

The aircraft continued to the

Let’s Take the SAR...out of “garbage”!

Have you removed the batteries?

"What’s that?” you say.“There’s no SAR ‘in garbage’,regardless of what languageyou’re spelling.” That may betrue, but a month or so ago,there were numerous SAR techsand other SAR-related peoplerummaging around in aCanadian garbage dump, muchto the consternation of the resi-dent Jonathan Live-it-up sea-gulls, who are not accustomed tofighting with SAR techs for theirshare of the — ahem — spoils.

What on earth brought themthere? Initially, it was some-thing above the earth. COSPAS-SARSAT to be exact. These alertsentries detected an ELT signal.Using suitable linkage, the SARsystem came up with a fairlylarge circle in which the ELTcould be located. A SAR aircraftinitially aimed at the circle,then, as it flew closer to the site,

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homed to the beacon. The spot-ters squinted through their vari-ous windows, looking for thescattered remains of an aircraft.

Despite their squintiest gazes,there was no sign of an aircraft,but there was lots of aerial activ-ity. Flocks of seagulls, buzzardsand pterodactyls wheeled,soared and swung in the air cur-rents wafting heavenward fromthe local garbage dump.

Could the aircraft have gonein like a dart and been coveredup with garbage? Perhaps, butthere were no reports of missingaircraft in the local area.Besides, as garbage dumps go,this one was reasonable tidy. Itdid not look as though it hadrecently been rearranged toaccommodate a crashed aircraft.

But there was no doubt aboutit. The ELT signal was comingfrom the garbage dump. What todo? Find it. Thus it was that a

flock of folks went rummagingthrough a garbage dump lookingfor a transmitting ELT.

Eventually, they found it.Down at about the 3-ft. level,searchers came upon a perfectlyserviceable ELT, squawking itslittle electronic heart out.Someone had discarded it withthe batteries still inside, and thefunction switch in the ONposition. When the bulldozeroperator came along to spreadout fresh treats for the gulls, theblade evidently gave the ELT asharp enough rap to set itsinging.

SAR was in the seagull-herding business on theWest Coast, as well. Several air-craft, Vancouver ACC and thesatellites all reported an ELTclose to Vancouver Harbour.Again, there were no reports ofmissing aircraft, and the ATSpeople running the harbour traf-fic still had an equal number oftakeoffs and landings. Even ifthey hadn’t, any ELT that hadslipped below the waterswouldn’t be disturbing all thosefolks on the surface. A SARLabrador was summoned. Again,the spotters had their eyeballsspring-loaded to the pop-outposition. When they got close tothe “on-top” position they lookeddown and saw a ship. The signalceased before they could confirmits origin. They went home.

A few hours later, the CoastGuard reported hearing anintermittent ELT signal.Industry Canada was called in.After following the bouncing sig-nal around the Harbour, theywere led to the same ship whichhad attracted the Lab. Being acontainer ship, it was full of —

what else? — containers. Insideone of the containers was aneatly packaged helicopterheaded to an exotic foreign desti-nation.

Inside the helicopter was —you guessed it — an ELT withits function switch in theARMED position. Apparentlythe crane operator didn’t set thehelicopter container on the deckwith the same delicacy that apilot might have used. The ELTthought that it had crashed.Despite all the bits of ship thatwere in the way, the signal stillmade it out into the ether withsufficient strength to keep SARexcited for the best part of eighthours.

Not many people are discard-ing ELTs right now. The onesthat they have are adequate;they’ll do until the regulations

change, some time around theyear 2000. But as that timecomes closer, more people willbuy new ELTs and discard theirold ELTs. If they do it the waythat the garbage dumper did it,they could destroy the SARalerting system for a lengthyperiod.

Never, ever, throw away anELT with a battery in it. Never,ever, throw away an ELT withits function switch ARMED orON; battery or no battery. Thetransmission from anundamaged ELT in a garbagedump can mask a transmissionfrom a damaged ELT trying toalert SAR to an emergency.

Similarly, if you’re shippingan aircraft by ship, train, truckor air, ensure that the ELT func-tion switch is OFF. Ifpossible,remove the batteries. Placard the

aircraft when you do this, so thatthe pilot at the other end of thevoyage knows that the ELT-and the batteries-must bere-installed before flight.

The ELT-SARSAT-SAR-CASARA team works well toprovide SAR alerting, pinpoint-ing and rescue. Around theworld, the team has been instru-mental in locating and rescuing1624 aviators in 755 aviationdistresses since 1982.

Good as they are, they needyour help. You buy, use, main-tain and eventually discard thealerting part of the system.When doing so, please use thesame high standards of airman-ship that mark your other avia-tion activities.

Help keep SAR out of garbagedumps. It’ll help preventneurotic seagulls.

Tips on Mountain Flying - Part I by Pat Very

When the geography of theland is irregular, as it is in themountain and coastal areas, fly-ing can prove to be the most effi-cient and cost-effective way totravel. The spinoff to this is thefeeling that you get looking outover the spectacular beauty andawesome ruggedness of thepanorama below. It can be trulybreathtaking.

Here are a few tips that I’vepicked up over the years thatyou may find helpful when con-templating flight out West, inGod’s country.

Looking out for Number One...and Your Passengers

The key word when it comesto mountain flying has to be flex-ibility. You must gear your mindfor constant change and be readyand willing to adjust your plans.This is not to say that the triphas to be cancelled if you runinto weather, but ratherrethought. Maybe the primaryroute is not such a good idea on

that particular day. A goodmountain pilot will make thatssessment, adjust his or herrouting, notify the FSS as soonas possible and carry on. Be flex-ible: have a plan B or C or D...

You must plan to have asmany things going for you andyour passengers as you possiblycan. Filing a flight plan alongwith any amendments to your

route can enhance your chancesof survival in the event of amishap. What is on board willdetermine how comfortable yourstay will be. Always carry appro-priate survival gear and clothingfor you and your passengers,make sure that you dress for theterrain, and carry a good first-aid kit. Remember that being10 min. from home in the

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mountains can put you intocountry that could severelystrain your survival skills.Always let someone know whereyou’re going and when youexpect to return, even on shortflights. Make sure that yourELT is operational, regardless ofthe inspection or battery date.

Know your aircraft’s per-formance, especially how muchroom it takes to turn it around.Practise and become proficientin minimum-radius turns.Turning is part of learning to flyin the mountains.

Schedule frequent stops whenflying unfamiliar mountainroutes, Talk to local pilots; I’veusually found them to be friendly,helpful and very knowledgeable.Other benefits of stopovers areenjoying the local topographyand becoming familiar with theairport and local services, suchas courtesy cars, rentals andproximity to hotels. You neverknow — on a future trip, whenthe weather turns sour, youmight be spending the nightthere.

Assessing the ConditionsVisibility is essential when

mountain flying. What is mar-ginal on flat land might not beacceptable in the mountains. Ifyou encounter poor visibility enroute, slow down, and rememberthat the radius of the turn

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increases with speed. Be flexible:consult plan B.

Try to determine the winddirection and strength whenentering mountain valleys andpasses. Look for clues such asridge and peak plumes createdby compression, forming cloudson the downwind side. On thewater, whitecaps will form atabout 10 mph. Bear paws, thosedark patches on the water, arecaused by downbursts of wind,indicating gusty conditions,downdrafts and probably arough ride. Trees will bend andappear lighter on the upwindside. Cumulus and toweringcumulus will often slope down-wind at the top, becoming agreat wind indicator.

Always check both sides of val-leys when they are obscured bycloud. Stratus fractus, the raggedcloud often encountered in moistair masses, clings to the valleywalls. The view from one side cangive you a totally different per-spective than that from the other.

Cumulonimbus clouds are badnews in the mountains andshould be avoided like theplague. Visibility can drop tonear zero in no time, and down-drafts created by the storm cellcan rush out of the valleys andover the ridges with a vengeance,generating severe turbulence.They are also, by the way, thecause of many a forest fire in

those out-of-the-way valleys. Ifyou came across a fire en route,punch the position into your long-range navigation system(LORAN) or global positioningsystem (GPS) and pass it on tothe nearest FSS as soon as possible.

Outflow winds are a commonoccurrence at certain times ofthe year in this area and have todo with pressure differencesbetween the interior and thecoast. Air flows out from theinterior through valleys andfjords and, as it accelerates inventuri effect, it can reach veloc-ities as high as 70 and 80 mph.The mechanical turbulence gen-erated by these winds can beenough to ruin your day.Surprisingly enough, though,because of the nature of thesewinds, flying 2000 to 3000 ft.above the range usually puts youin smooth air. That said, youshould always be cautious andexpect turbulence when surfacewinds are high.

Next issue —Enroute & Mountain Strips

About the AuthorPat Very is a private pilot with

a commercial licence. He startedflying in 1970 on the East Coast,but since moving out West in1978, he has accumulated over4000 hrs of experience in andaround the Rocky Mountains.

When Hiring a Pilot

The Cessna 337 pilot was enroute on an IFR flight plan origi-nating from an uncontrolledaerodrome in Olds to PeaceRiver, Alberta. Thirteen minutesafter takeoff, he received his IFRclearance and was cleared tomaintain 8000 ft. Several min-utes later, he was observed at6600 ft. and the controllerqueried about the altitude. Thepilot responded that he wasbetween layers but would start aslow climb. Three minutes later,he was still at the same altitudeand was again queried about hisintentions. This time, heresponded that he had a rough-running engine but wouldcontinue the climb and make adecision on the engine when hegot to Rocky Mountain House.

Nineteen miles from RockyMountain House, the pilotrequested and received clearanceto the airport. Radar showed himheading to the nondirectionalbeacon.

Twelve minutes later, heasked for and received the latestweather from the UNICOMoperator: 500 ft. broken and1500 ft. overcast, with visibility0.5 mi. in light snow and fog. Hestated that he had the ground insight.

Radio contact was lost and theaircraft failed to arrive. An air/ground search located the planethe following morning 2 mi. fromthe airport. It had struck a standof trees in a steeply banked out-of-control attitude and been con-sumed in a post-crash fire.Neither the company presidentnor his pilot had survived.

Several witnesses hadobserved the aircraft near theairport. All reported that thefront propeller was rotatingslowly. (Transportation SafetyBoard (TSB) investigators laterconfirmed that the front enginehad a cracked No. 4 cylinder,accounting for the reported

rough-runningengine. Thefront pro-peller was atthe low-pitchstop atimpact.However, thepilot had notcompleted theengine failurecheck to thepoint offeathering the propeller.) Onewitness familiar with the C337stated that the rear engine didnot sound as if it was at highpower and that the aircraftappeared to be wallowing at lowspeed in a nose-high attitude.These witnesses also reportedheavy snow showers in the area,with visibility as low as 0.25 mi.in snow and fog.

The pilot had received adetailed weather briefing byphone prior to the departurefrom Olds. The forecast predictedextensive low cloud persistingalong the foothills throughoutthe forecast period, creating ceil-ings 0 to 1000 ft. AGL, with visi-bilities of 0.5 to 4 mi. in snowand fog. Severe clear icing inlocal freezing drizzle wasincluded in the forecast. AnotherC337 pilot who flew into RockyMountain House 30 min. afterthe accident reported picking up0.5 to 0.75 in. of ice during theapproach. The accident aircraftwas not equipped for flight intoknown icing conditions.

Although the pilot held an air-line transport licence, his medi-cal category had expired and hislicence was valid for private pilotprivileges only. His instrumentrating had expired 10 monthsprior to the accident flight.During the two years before itexpired, his instrument ratinghad twice been suspended. Itwas first suspended when he

Loss of control.

attempted to take off into knownicing conditions with an aircraftthat was not properly equipped— during an instrument checkride. The second suspensioncame when he failed to follow hisair traffic control (ATC) clear-ance. He did both on the accidentflight.

He initiated this flight despitehis knowledge of the weatherand icing conditions and thecapabilities of the aircraft. Hemaintained an altitude of6600 ft., between layers, possiblyto avoid icing conditions, withoutinforming ATC of the deviationfrom the clearance to 8000 ft.that he had accepted.

When hiring a pilot, how care-fully do you check his or herpaperwork, capabilities, pastperformance and references?

The TSB accident report(A93W0026) concluded, in part,that:

It is possible that the aircraftwas unable to maintain flighton one engine because the frontpropeller was not feathered,and because the aircraft waslikely contaminated with iceduring the descent throughclouds.

Reduced performance andenvironmental conditions endedwith the loss of control at an alti-tude that did not leave room forrecovery.

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V1 Decision Revisited

Issue l/97 of the AviationSafety Letter featured a storyabout a runway overrun after arejected takeoff.

One reader rejected our con-tention that “a reject decision atV1 plus leaves no doubt — youare going off the end.” The state-ment was made in the context ofa balanced-field scenario.

Here are the reader’scomments:

To quote you: “But a reject deci-sion at V1 plus leaves no doubt —you are going off the end.”

This is not so, even thoughmany pilots agree with you.

Without complicating thepoint by discussing the differ-ences between critical-field andbalanced-field usage, or the mul-titude of calculations used todetermine whether a given run-way is acceptable for use for yourflight, let’s attempt to summarize:

Civil transport jets use abalanced-field concept.Oversimplified, this means thata reject/ abort around V1 willburn up about the same amountof runway as a “go” decision ifyou lose an engine near V1. Onheavy, long-haul operations, run-way-length requirements usuallycome damn close to the end ofthe longest runway available.However, in reality, the vastmajority of airline departures donot fall into this category. Excessrunway is usually available.Most operators use reducedthrust in this situation. Taking

off withminimumallowablereducedthrust isquite com-mon atlight take-off weightsoff longrunways.

V1, untilrecently,has been apublishedfixed speed

based on two parameters: air-craft weight and flap configura-tion. The runway length hasnothing to do with it, bearing inmind that the runway and flapconfiguration chosen has alreadybeen determined appropriate bythe process in para. 3. You’vedetermined that it’s long enough,but not how much extra youhave. This applies especially tothe case in which the runwaylength is less restrictive thanmaximum reduced thrust.

Assume that a DC-9 or 737light enough to depart fromVancouver InternationalAirport’s Runway 12 (7300 ft.)was given a runway change to26L (11,000 ft.), and chose tokeep the same flap/thrustconfiguration. The planes’respective V1 speeds wouldremain identical. In reality, bothaircraft would probably use lessflap on the longer runway with anincreased fixed V1, and morereduced thrust. However, in fewcases would their runway-lengthrequirements even come close to11,000 ft.

A reject at V1 + 20 offRunway 26L in bare and dryconditions, in this hypotheticalexample, would probably notresult in an overrun.

The latest safety evidencesuggests that pilots be “go”minded approaching V1. It’s goodadvice; however, it’s importantthat pilots, especially in thisexpansionary period, be armed

with knowledge of all of theiroptions and not just thosecurrently being hyped.

We referred the letter to theexperts in Commercial andBusiness Aviation, and theyagreed that a reject at V1 + 20probably would not result in anoverrun. However, consider whatthey said in detail:

We agree wholeheartedly withyour last paragraph. There is areason why the safety evidenceis biased towards the “go” case.That is because we have learnedthe hard way that high-speedrejects often fail to achieve theobjective, that being a safe recov-ery from an engine failure orother anomaly on takeoff.

Let’s start with a review ofwhat V1 is supposed to do foryou. A reject initiated at orbefore V1 should result in a fullstop within the confines of therunway and stopway. A "go”decision at V1 should result in asuccessful engine-out takeoff to35 ft. In both cases, we assumethat the runway is bare and dry.

Now let’s talk facts. High-speed (over 100 kt.) rejects areamong the top three causes ofaviation accidents and fatalities.V1 + 20 in a transport-categoryaeroplane certainly lies in thehigh-speed range. How manyaccidents result from “go” deci-sions made in the high-speedregime? The numbers are so lowas to be insignificant. An aircraftcertified to reach 35 ft. with anengine out will still complete asuccessful takeoff with a “go”decision made up to 5 kt. early. Astop decision made 5 kt. after V1doesn’t work out nearly so well.

What limited V1 for your air-plane today? Were you limitedby accelerate-stop, accelerate-goor improved climb-obstaclerequirements, or brake energy?Unless you have done the calcu-lations yourself, you don’t know.If you don’t know, you cannotdetermine your maximum safereject speed. A reject at V1 + 20may result in tire or brake

8 ASL 4/97

electrical impulses inducedin the aircraft wiring as aresult of the electromagneticfield created by a lightningstrike.

As you can see from the above,there should be no risk of theelectronics being fried. The air-craft may suffer minor surfacedamage from the lightning-strikeattachment or discharge points,and the carrier should conduct a

post-strike inspection of the exte-rior surface to determine theextent of any damage.

A few years ago, I was in aCanadian B-737 that was struckby lightning on approach toVancouver International Airport.After disembarking, I stood bythe window at the gate and waspleased to see a mechanic walk-ing around the aircraft, lookingcarefully at the radome and rear

lower fuselage, including anten-nas. Obviously, the flight crewhad reported the strike to theground crew. John Carr

Principal EngineerAvionics and Electrical

Systems EngineeringAircraft Certification Branch

Transport Canada

Updating Your Global Positioning System ?The following was taken from

a daily occurrence report:

In IFR conditions, a Saab 340with 20 people on board wascleared for the approach into anMF [mandatory frequency] aero-drome. It was on short finalwhen the FSS staff observed aRobinson RH22 inbound near theapproach path to the runway.

The helo was not in radio con-tact with FSS and was not moni-toring the MF. The Saab pilotwas able to land safely and sawthe helicopter on short final,

FSS staff approached the pilotof the helicopter after it landed

and the pilot said [that] he hadbeen communicating on 118.0[MHz] (that frequency had beendecommissioned [three] yearspreviously). He said [that] thisfrequency was provided by hisGPS equipment, but, on [being]questioned, admitted that theGPS database had not beenupdated for “a couple of years.”He did not consult his copy of the[Canada] Flight Supplement,which was on the seat besidehim, because he was "too busy.”When FSS staff asked for hisname, the pilot declined to giveit, and said [that] “[he hoped]nothing would come of this.

Upon departure, the pilot didnot file a flight plan; rather, heflew on a company flight note.

Weather at the time of theincident was 700 ft. broken [and]2000 ft. overcast, [with] visibility5 mi. in light rain and fog.

Communicating on the rightfrequency in an MF is manda-tory. Having an up-to-dateCanada Flight Supplement andlooking at it or getting your GPSdatabase updated regularly maycost a few dollars, but a mid-aircollision could ruin the day for alot of people.

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Good Judgement Overruled cont. from page 12airports, it is likely that theweather was just as bad at hisuncontrolled departure airport,and there was no instrumentapproach.

He was given a vector for theILS localizer. He flew throughthe localizer and, when queriedby the controller, acknowledgedthat he was turning to intercept.The controller noted that he wasintercepting the on-course andthe pilot agreed. Less than aminute later, the pilot advisedthat he was having a gyro prob-lem. “It’s all mixed up,” he said.

The controller immediatelyresponded by telling the pilot toclimb to 3000 ft. The pilotacknowledged, but added, “I’mgoing to lose communicationpretty soon. My battery is prettybad.” The controller intended toprovide a surveillance no-gyroapproach and he began givingdirections to turn, stating whento start the turn and when tostop. The static-filled transmission“DG not working" was the lastfrom the aircraft. It crashed in aresidential area, killing the pilot.No one on the ground was hurt.

Including the time requiredfor engine start-up, the aircrafthad been operating at power forabout 30 min. when it crashed.

Investigators found no indica-tions that the gyro was not oper-

ating normally at impact. Evenwithout communications or navi-gation capability, the pilotshould have been able to fly theaircraft. However, it is possiblethat, in the high-stress situation,he started to overcontrol the air-craft to the point where hethought that the instrumentswere malfunctioning. When hestopped believing and scanninghis instruments, he apparentlybecame disoriented and lost control.

A 14-mi. trip in good VFR con-ditions would not likely havecaused any difficulties, even onquestionable battery power;however, the weather for theattempted flight was not “goodVFR.” It had beenreported at300 ft. overcast with visibility2 mi. most of the day. Waitinguntil the following morning toferry the aircraft to airport B toget the alternator replacedwould have cost the pilot a cou-ple of hours’ delay in the start ofhis Florida trip.

When forced by the weatherto fly a full instrument approachon a fading battery, the pilotknew that he had a serious emer-gency, and he should have declaredit. The controller knew about the

expected during the flight. Sincethe pilot did not declare theemergency, the flight wastreated in a routine manner.Had the controller known thatan emergency existed, he couldhave assisted by turning him inearly for the ILS approach orperhaps immediately giving vec-tors for the surveillanceapproach.

The accident should not havehappened. It happened becausethe pilot convinced himself thatit was acceptable to take a ques-tionable aircraft through poorweather to save a couple ofhours. His good judgement wasoverruled by the self-imposedpressure to get an early start thenext day.

Human factors experts wouldcall it an example of a mental“trap” known as a “framing bias.”

One of the things that contrib-ute to the poor judgment illus-trated in this accident is the waythat a problem is framed. In riskydecision making, there is a tend-ency to frame the problem as achoice between gains and losses.

With respect to losses, peopleare biased to chance the riskyloss, which they see as less prob-

aircraft’s mechanical conditions,but reasonably expected the pilotto have enough battery poweravailable to do what was

able, although more disastrous,than the certain loss.

Think about which way yourbias is!

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