Aircraft Disasters

[swampyankee]

Not a pilot myself but ex military and it's far easier to blame the man rather than machine.
Can you imagine the RAF blaming themselves? For anything? Dead men can't defend themselves and I have followed aircraft investigation for many years and there does seem a blame game and usually the pilot is at fault even if he isn't.

The agencies have gotten much better at avoiding the "pilot error" as first and often only choice for any accident. Even if the pilot is directly at fault, the current philosophy is to try to find why the pilot erred.

 

[DerAdlerIstGelandet]

I actually do aircraft investigations for my company. You stick to the facts, and leave your personal feelings at the door.

 

[MIflyer]

Well, if you study aircraft mishaps, as I have, you soon find out that while "pilot error" is the largest single cause, there is a substantial variation of how you define it.
For example, say an engine fails due to a mechanical problem, not related to anything the pilot did. Not pilot error, right? But what if he is right over an airport and should have been able to easily land the airplane but crashes it?
A fatal Cirrus crash here in FL shows how much pilot error can occur. The pilot flew from the east coast to the west coast of FL, landed, and checked the oil level. He did not tighten the oil cap. On the way back he saw the oil pressure was down; oil was going overboard due to the loose cap. He had an opportunity to land at an airport only 20 miles away but did not. He diverted around thunderstorms and then decided to land at another airport since the oil pressure was getting very low. He did not make it; the engine quit and he crashed in an open field near the airport, killing himself and his wife, both in the front seats; the rear seat passenger survived. He could have diverted to another airport when he saw the problem but did not. He could have just landed it in the open field but did not. He could even have popped the parachute but did not. Now what was the cause? The loose oil cap was the real cause but he had multiple ways to recover from that problem.
By the way, on the Cirrus, look up the specs. If you pop the chute at below 1000 ft AGL it probably will not open in time, and that is even worse if you are in a spin.

 

[DerAdlerIstGelandet]

Well, if you study aircraft mishaps, as I have, you soon find out that while "pilot error" is the largest single cause, there is a substantial variation of how you define it.
For example, say an engine fails due to a mechanical problem, not related to anything the pilot did. Not pilot error, right? But what if he is right over an airport and should have been able to easily land the airplane but crashes it?
A fatal Cirrus crash here in FL shows how much pilot error can occur. The pilot flew from the east coast to the west coast of FL, landed, and checked the oil level. He did not tighten the oil cap. On the way back he saw the oil pressure was down; oil was going overboard due to the loose cap. He had an opportunity to land at an airport only 20 miles away but did not. He diverted around thunderstorms and then decided to land at another airport since the oil pressure was getting very low. He did not make it; the engine quit and he crashed in an open field near the airport, killing himself and his wife, both in the front seats; the rear seat passenger survived. He could have diverted to another airport when he saw the problem but did not. He could have just landed it in the open field but did not. He could even have popped the parachute but did not. Now what was the cause? The loose oil cap was the real cause but he had multiple ways to recover from that problem.
By the way, on the Cirrus, look up the specs. If you pop the chute at below 1000 ft AGL it probably will not open in time, and that is even worse if you are in a spin.

Again, as someone who does aircraft mishap investigations, there are so many variables.

Being over an airport, and still not successfully being able to land the aircraft safely is hardly an indication of pilot error. Still so many variables involved.

 

[pbehn]

Investigations by large organisations have to cover a lot of possibilities. Asking what someone had for breakfast may well serve to establish how much they can remember leading up to the accident, concussion and trauma can wipe peoples memory and substitute false ones. I had an accident which I don't really remember at all, what I put in a police statement was actually what I dreamed while unconscious and under anaesthetic.

 

[XBe02Drvr]

the current philosophy is to try to find why the pilot erred.

Which is why we are (finally!) seeing the incorporation of such things as cognitive psychology, ergonomic factors, and circadian sleep science into accident investigation.
Cheers,
Wes

 

[XBe02Drvr]

Being over an airport, and still not successfully being able to land the aircraft safely is hardly an indication of pilot error.

Not pilot error, just inexcusable pilot ineptitude. Not too unusual in the private pilot world. If it looks like error, sounds like error, and stinks like error it might as well be error, at least in the professional world.
Cheers,
Wes

 

[XBe02Drvr]

They call it paying your dues..

I call it "proprietary servitude", otherwise known as slavery.
Cheers,
Wes

 

[XBe02Drvr]

it has seemed to me in the USAF aircraft mishaps I have worked on, the Mishap Board is run by pilots

One thing the military does do right!
Cheers,
Wes

 

[XBe02Drvr]

Ultimately the fault was that a couple of civilians at OC-ALC had decided that it was too much trouble to change out the auxilliary tank pressure regulator on a time compliance basis and just wait until it failed.

Once again economics triumphs over safety!
Cheers,
Wes

 

[DerAdlerIstGelandet]

I call it "proprietary servitude", otherwise known as slavery.
Cheers,
Wes

And think that guy making $16 an hour has to get you safely on the ground in an emergency.

 

[DerAdlerIstGelandet]

Not pilot error, just inexcusable pilot ineptitude. Not too unusual in the private pilot world. If it looks like error, sounds like error, and stinks like error it might as well be error, at least in the professional world.
Cheers,
Wes

I don't agree it is always pilot error.

Don't take me wrong though, pilot error is the majority of mishaps.

 

[MIflyer]

I recall one mishap at Torrance, CA. A Cessna 150 with an instructor and a student on board was inbound to the airport when the tower told them to switch from the west-heading runway to the east-heading end, due to a wind shift. The engine quit when they turned from what would have been a base leg onto a downwind. They had so little fuel that the extra distance, no doubt combined with the fuel slosh induced by the turn, caused the engine to die from fuel starvation. They made a nonfatal but messy landing in a Christmas tree lot. The pilot explained that the wind shift had caused the crash.
Yep, the wind did it - not trying to fly with maybe 2 gallons of gas left on board - not pilot error.

 

[The Basket]

A quote from a pilot.
We were the easy option—the cheap option if you wish. We made a mistake—we both made mistakes—but the question we would like answered is why we made those mistakes.
The pilot was from the Kegworth air crash. 1989 A 737 had a bad engine and the pilots turned off the wrong engine. This became public knowledge quite soon after and the pilots looked like prize clowns. So yes they turned off the good engine and people died. But why did they do that and why did the engine fail? Not a easy one to call

 

[pbehn]

A quote from a pilot.
We were the easy option—the cheap option if you wish. We made a mistake—we both made mistakes—but the question we would like answered is why we made those mistakes.
The pilot was from the Kegworth air crash. 1989 A 737 had a bad engine and the pilots turned off the wrong engine. This became public knowledge quite soon after and the pilots looked like prize clowns. So yes they turned off the good engine and people died. But why did they do that and why did the engine fail? Not a easy one to call

I remember that day because I was in the air when it happened, as you say it was described as a stupid error but I saw a later report that said the mistake was far too easy to make.

 

[XBe02Drvr]

I recall one mishap at Torrance, CA. A Cessna 150 with an instructor and a student on board was inbound to the airport when the tower told them to switch from the west-heading runway to the east-heading end, due to a wind shift. The engine quit when they turned from what would have been a base leg onto a downwind. They had so little fuel that the extra distance, no doubt combined with the fuel slosh induced by the turn, caused the engine to die from fuel starvation. They made a nonfatal but messy landing in a Christmas tree lot. The pilot explained that the wind shift had caused the crash.
Yep, the wind did it - not trying to fly with maybe 2 gallons of gas left on board - not pilot error.

Yank that CFI's ticket! And the flight school's too, if a poorly maintained fuel indicating system was a factor.
1. Bad judgement: Crowding the aircraft's fuel supply to the limit. No safety margin. The gauges would have been reading empty.
2. Bad example: Committing #1 in front of a student.
3. Bad flying: A properly coordinated turn would not have sloshed the fuel enough to make a difference.
Cheers,
Wes

 

[XBe02Drvr]

I remember that day because I was in the air when it happened, as you say it was described as a stupid error but I saw a later report that said the mistake was far too easy to make.

The mistake was so easy to make that an Airworthiness Directive later required that the offending switches be changed on all B737s.
Cheers,
Wes

 

[MIflyer]

The FAA says you have to have at least 30 min worth of fuel on board when you land and in a Cessna 150 that is about 3 gallons; I suspect they had less than that. And you'll still get some slosh even in coordinated turn. Now, the engine might come back on if there is enough fuel once things settle down.

I think the Cessna 150 belonged to the CFI, so he probably was trying to avoid buying gas until he has some more cash on hand.

I read where a P-51 pilot flying out of Italy over Yugoslavia was on his first mission with three old hands. They were using their drop tanks, and in order to keep AAA from drawing a bead on them they would make an abrupt turn every 3 to 5 min or so. Finally it got to the point that when they would make a turn his drop tanks would unport and the engine would quit momentarily and then restart. The new guy did not like that so he punched his tanks off; the other three guys kept theirs. As the mission went on he started getting concerned about fuel. The others used all the fuel in their drop tanks, not caring if the engine quit in a turn. He made it back to the base OKay but was sweating it.

 

[XBe02Drvr]

I think the Cessna 150 belonged to the CFI, so he probably was trying to avoid buying gas until he has some more cash on hand.

Hey, we've all "tankered" fuel from time to time to avoid buying it at expensive locations, but cutting into the FAR mandated fuel cushion is inexcusable. The smaller Cessnas aren't renowned for the precision of their fuel gauges, and I was never in the air with either tank indicating less than 1/4 full. That's about one hour's worth of fuel (if the gauges are accurate).
Cheers,
Wes

 

[XBe02Drvr]

So yes they turned off the good engine and people died. But why did they do that and why did the engine fail? Not a easy one to call

But the AAIB did a very thorough investigation and wrote a very thorough 152 page report. That accident was a screwed up mess. The engines had a fan failure mode that hadn't been detected in testing and one threw a blade. The engine vibration indicators had been made less conspicuous than in earlier aircraft. The air conditioning ducting had been changed from earlier 737s the crew were used to, so they misidentified the source of the smoke in the cockpit. Communications kept interrupting checklist procedures. The flight crew were not informed of engine flames seen by cabin crew. Fire warning on the burning engine did not activate until way too late. The only serious mistake the crew made was failing to carefully compare all parameters of both engines. Nothing in this crew's training prepared them for this set of confusing circumstances. Nevertheless, they were fired and grounded for life. "When it happens on your watch, it's your responsibility and your penalty to pay!"
Cheers,
Wes