Ignorant Bliss

Unfamiliarity with surroundings and equipment is a prime reason pilots screw up


Human errors in aviation have potentially tragic results. Pilots tend to be perfectionists, always seeking to make another perfect landing and slightly aggravated at themselves if they bounce one in. Its even more embarrassing when you have a planeload of passengers along when you bounce one in.

In an effort to determine if there are better ways to prevent pilot error, researchers have looked at human learning and decision-making behaviors to see if there are common themes in accidents that lend themselves to effective preventive measures. One of the more interesting studies produced a list of conditions that tend to increase the chance of human error.

Unfamiliar With the Environment
The leading condition that increases the chance for human error is unfamiliarity with the task. Research shows you are 17 times more likely to make a mistake if you are unfamiliar with the task. For example, if you have never shot the missed approach out of Missoula, Mont., or Ketchikan, Alaska, you may not realize that it is necessary to begin that turn promptly to avoid hitting mountains that are very close to the runway. If you delay initiating the missed approach, you will become another accident statistic on that hillside.

Several air carriers operate daily into places like Missoula or Ketchikan. When their captains shoot the approach, they have been into this airport on numerous occasions as a copilot. If by chance they happened to miss that opportunity, they may need to have specific simulator training. Many air carriers have a slide or view show from the cockpit of a jet flying the approach in visual conditions so the crew can see the layout of the terrain and learn about nav aids and any other approach considerations prior to operating into these airports.

Airline pilots benefit from the experience of thousands of their predecessors operating into difficult airports, and programs are in place to help new crews become thoroughly familiar with the operating environment and procedural requirements prior to operating in that location.

For general aviation pilots, such resources generally are not available. Thankfully the Jepps approach plates now contain colored contours to indicate steep terrain immediately adjacent to the airport environment, and this serves to remind the pilot of the nature of the terrain. However, the pilot can still briefly look at the missed approach procedure and not correlate the steep mountains nearby to the need for precision during the missed approach.

If you find yourself flying into an area you arent familiar with, dont pass up the opportunity to get a thorough check out from someone who knows the local ropes. Your safety will greatly improve if you are familiar with the typical weather phenomena that affect the airport.

I once instructed at a very busy airport in the LA Basin that is perched on a slight plateau. The runway threshold was above an adjacent busy boulevard. The ocean breeze came right down the runway, but if you had never flown that approach before, you wouldnt know about a strong down draft that was nearly always present on short final. Its a real gotcha! that gets every pilot who isnt anticipating it.

If youre lucky, you may be lightly loaded and have quick enough reflexes that you can get out of trouble with a quick burst of the throttle. Maybe you have a little extra airspeed or altitude you can play off against the down draft. But one things for sure, come in slightly slow or low on approach and you can quickly find yourself looking up at the runway.

When operating in an unfamiliar area, it helps to know where the weather moves in from and the early warning signs. Know how the local and regional weather will affect your operations.

For example, if you are in a high density altitude location, you really need to see the effects of high density altitude. Its one thing to read about the effects, but quite another to see a 100 fpm climb with the Rocky Mountains filling your windscreen. Coastal fog, mountain winds, midwestern and southern thunderstorms -each of these will create special hazards to aircraft operations and require a place in your decision-making process.

Another advantage to being familiar with the airport is that you can anticipate the traffic clearances and the landmarks used in visual approaches. It really helps when you know the airspace, the local checkpoints ATC uses, and the frequencies. Learn about special activities, such as practice areas, soaring or parachuting. Familiarize yourself with the boundaries of controlled airspace, special use airspace, and military training routes.

If youre a transient pilot about to operate in unfamiliar circumstances call a local FBO or flight instructor and ask if there are any hazards to be aware of. Jepps also produces a briefing chart for many airports. In the narrative, it contains a description of the average weather and the influence of the local terrain.

This is very helpful because it also has pictures of the runway approaches from various angles, which helps you get a better mental picture of what youre getting into. It also has a description of the hazardous terrain, coupled with warnings.

Study the charts before the flight or take along a pilot friend who has been there before. Try to stack the odds in your favor by arriving in the daylight in good weather, or if the airspace is extremely busy, then on a clear night.

Have the charts and flight information organized on your kneeboard so it is easy to obtain and interpret. Being organized is very important, because if you arent well-organized you will quickly get behind the aircraft.

When working with ATC, have a pencil handy and be ready to copy an amended clearance at any time. If you dont know where an intersection is located, ask ATC for a radial and DME off of a major VOR. If you have a GPS, ask ATC to spell the intersections name and input that into the GPS.

When getting taxi instructions at a complex airport, have the airport diagram in front of you. If youre not instrument rated, you may not know that approach plates carry detailed airport diagrams. Get a set and learn how to interpret them.

Write down your ground clearances and read them back to ATC. Trace your taxi route on the chart and if you have any questions, then ask ATC for progressive taxi instructions. The resources in the tower are there for you to use, so when in doubt use them.

Unfamiliar Equipment
Unfamiliarity can also be a real headache when transitioning to a new aircraft. Many accidents occur when a pilot is transitioning to a new aircraft, especially one with performance that is markedly different from what theyre used to.

A friend of mine recently took a family member for a flight in a retractable gear aircraft. The family member had a private pilot license but had never flown a retractable gear aircraft. During climb-out, the family member remarked that the climb performance wasnt very good. Thats when the friend said, Well, gee, it will get better if you retract the gear.

But the differences are apparent in other cases as well. An airline pilot who has not flown a light plane in decades will have trouble adapting to the performance and reactions of a single engine prop plane. A pilot experienced in twins may have a handful in a taildragger. Its not the difficulty thats important, its the differences.

In the airline world, it may take months of initial training to learn the systems on the jet. Pitch and power settings, flows, procedures and profiles are memorized before the pilots step foot into the simulator. They can quickly do a blind cockpit check and know the exact location of every switch, the power source of every switch, and what that switch and gauge indicates. Then simulator training can take another month or two.

In the general aviation world, you dont get the benefit of such in-depth training. The manuals arent as good, there are seldom profiles given to help you know the approximate pitch and power settings, and you dont get the benefit of much simulator training by highly qualified instructors. Ive had local checkouts that involved going up and doing slow flight, a few stalls, some hood work and then some landings, but have left me wondering afterward how to do an emergency gear extension or how to operate that particular GPS.

Some pilots tend to think they know what theyre doing well enough that they can fly anything with wings. I once watched a relatively inexperienced pilot buy himself a sleek racing sailplane that had retractable gear. I was inside the hangar cleaning the canopy of a sailplane when I heard him land – gear up. The pilot flatly refused to accept a checkout prior to flying the aircraft, even though he was unfamiliar with it.

There is no substitute for familiarity. You should know the systems thoroughly. Know the normal settings, the power sources for all instruments and indicators, what happens if the power source of an instrument dies, how will the system fail, and what the indicators will say if the power source dies. This is seldom covered in transition training.

Know the strengths and weaknesses of the design. For example, Mooneys have relatively little prop clearance. This should be thoroughly discussed so that you know to lower the nosewheel gently and avoid rough surfaces or surfaces with contamination.

Know the handling characteristics. For instance, low-wing aircraft, especially those with short landing gear, tend to float more in ground effect than a high-wing Cessna. Knowing this will affect your flight procedures.

Some aircraft have a pronounced pitch-up or pitch-down when the flaps are extended in the pattern. Know about this and anticipate it so that you dont lose or gain excessive airspeed while in the traffic pattern.

As you step up in aircraft complexity, the chances are that better simulator training will be available for that aircraft, especially as you move into the bigger twins and turbine aircraft. Type-specific simulators are so realistic that you can practice every conceivable emergency in the relative safety of the simulator.

If you have the option to attend type-specific simulator training, do it. Its one thing to receive training in the actual aircraft, but usually the simulator training centers tend to be more thorough, the instructors tend to know the aircraft systems intimately, and the training centers tend to be standardized.

A government agency that flies Twin Otters conducted its own in-house training since it acquired the aircraft. The accepted procedure for an engine failure on takeoff was to bring the operative engine to full power and climb at blue line speed.

After an accident nearly destroyed one of the aircraft, the check airmen and instructors of the unit attended simulator training operated by a private company. During their first attempts at simulated engine failures on takeoff, the check airmen and instructors of the unit used their procedure and crashed every time.

Finally the simulator instructors pointed out the proper procedure for handling engine failure just after liftoff, which was to retard both throttles and land straight ahead. The check airmen and instructors in the unit also had problems with crew coordination and procedures in other portions of the simulator experience.

In-house training is common at many Part 135 operators and suffers from some of the same problems as FBOs at local fields. In situations where flight instructors and pilots are rapidly moving upward in the job market, the flight instructor available for a checkout at the local airport may have rather limited experience and a lack of in-depth knowledge of the aircraft and procedures.

He was taught by someone with an equally shallow understanding and experience, who in turn was taught by someone with less credentials and experience. Its a vicious cycle.

The end result is that the check-out can often be too shallow because the instructor just doesnt have the time, training and experience. In-house training can suffer from too much inbreeding, wherein the same mistakes and wrong procedures are taught within the department. Those factors all combine to make an excellent argument for using a good type-specific training center.

For the turbine aircraft Ive flown for the last 10 years, I have attended type-specific simulator training at least once a year. Generally the first year overwhelms you with details to remember. I try to stay in the books throughout the year by occasionally reviewing a system, learning the procedures and emergency procedures associated with that system.

When recurrent training comes along the next time, the systems make even more sense. Periodic review is important. It also enhances long-term learning of the material. But it is just as important to sit down with the real experts and have them point out the strengths and weaknesses of the systems and procedures.

This year going through upgrade training I had the opportunity to have a simulator session with a captain who has been a training instructor on the 727 for nearly 20 years. Its no exaggeration when I say that captain has forgotten more about the 727 than Ill ever be able to learn.

In one session, he was able to take my knowledge of the systems, which I understand fairly well, and build a failure of this system that would cascade later in the flight. It showed me how it would affect my flight planning and other procedures. Find an instructor like that and try to soak as much as you can from them. They are golden.

What You Dont Know
An old saw about inexperience is that you dont know what you dont know. When flying IFR approaches into difficult airports, you just dont realize how difficult those procedures are until you have fallen into the pitfall, survived and hopefully learned your lesson. Experience can be a terribly unforgiving teacher, however, and many pilots are not given a second try.

Unfamiliarity is one of the leading root causes of human error. You wont see it listed as a common cause of accidents because the NTSB uses other terms. However, one of the more important acts you can undertake to reduce the potential for error is to reduce your unfamiliarity with the environment, equipment and procedures.

Know your equipment thoroughly through in-depth initial and recurrent training, and attend type-specific training if possible. When you operate in a new environment or equipment, take it in small steps if possible.

Just as you dont expect to go from a Cessna 152 to the Concorde in one step, neither can you rush the learning curve for instrument procedures or aircraft operations. Stack the odds in your favor by waiting for the right conditions before expanding your horizons.

Preparation, training, experience, and good judgment help stack the odds better in your favor. Reduce your unfamiliarity and your chances of a safe flight will dramatically increase.

-by Pat Veillette

Pat Veillette is an aviation safety researcher who flies Part 121 cargo jets in his spare time.


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