Patterns Of Risk

Everything we do in an aircraft follows a pattern, but interruptions occur. Recognizing and responding to those interruptions are key.


I was in the right seat of a late-model A36 Bonanza with a student, fine-tuning his landing technique with some full-stop trips around the pattern in gusty winds. During one trip up the parallel taxiway we heard a Learjet on Unicom call that he was taxiing out behind us.

On our next downwind I noted the Lear taxiing toward the active runway, so my student made a point of radioing our turn onto base. The jet crew turned perpendicular to the end of the runway without another call, oblivious to my

Airplane Crash


students report of turning onto a short final. “We may have to go around,” I commented and, sure enough, the Learjet continued onto the runway in front of us without a pause, powering up and beginning its takeoff roll. “Go around, go around,” I commanded, and my client expertly applied power, established a climb attitude, retracted the landing gear and offset our path to the right of the runway as the Learjet blasted off and through our altitude.

We checked for other traffic and turned crosswind at mid-field, re-entering downwind. Here was an excellent teaching point. “We just had our routine interrupted by distraction and conflicting traffic, then quickly re-entered the pattern,” I told the Bonanza pilot. “This puts us at a historically very high risk of landing gear-up. Knowing we were distracted should remind us to be especially careful to extend the gear and confirm that its down.” My client settled back into his routine as if we never had to go around and made another smooth landing.

Its powerful to be able to recognize when the risk of mishap is extraordinarily high, so you can emphasize checklists and procedures to avoid that accident risk.

High Risk

The Air Line Pilots Association says, “The goal of accident investigation is not to solve accidents for its own sake, but to improve safety by preventing [future] accidents.”

As we all know, between 70 and 80 percent of all aviation mishaps result from human factors-“pilot error”-where a chain of decisions and actions (or indecisions or inactions) developed into the proximate cause. Delve deeply into the causes of accidents and a light suddenly shines…when you realize there are definite patterns of risk that accompany most crashes. Thus, as in the Air Line Pilots Associations investigative goal, something positive can come of this. Not only can we learn what has caused specific accidents in the past but-far more important-we can identify when were in situations where we are at high risk of a human error. Realizing were at a heightened danger of making a bad decision, we know to actively verify our actions (to prevent human error) while we take specific steps to reduce the risk.

So what are some common, high-risk situations?

Known Problem

The non-Instrument-rated pilot of a tip tank-equipped, high-performance single was en route between central Florida and Louisiana. The pilot and the airplanes

Anticipating Flight Interruptions


co-owner had been fighting a recurring problem with the airplanes modified fuel selector, which at times would not permit selecting the tip-tank fuel. They had not been able to fix the problem before the fateful flight.

It was night and fog was developing along the Gulf Coast. Nearing Pensacola, Fla., the pilot attempted to switch to the tip tanks-he could not make the nonstop trip without auxiliary fuel-but the engine sputtered. He quickly reset the selector to a main tank and may have tried the switch again, but he could not get fuel from the tip tanks to the engine. He decided he needed to get on the ground (although he still had a fair amount of accessible main-tank fuel) and asked to divert to Pensacola. Despite his lack of an Instrument rating the pilot accepted vectors for the ILS approach, but he was unable to get aligned with the approach and, after several wave-offs and re-intercept vectors from ATC, he lost control attempting to intercept the localizer. The pilot died in the resulting uncontrolled descent into terrain.

There were many decision points on this particular flight, but attempting the flight with a known fuel selector problem was a significant factor. The inability to switch to tip-tank fuel started a chain reaction of pilot decisions, including an attempt by the non-Instrument pilot to fly an ILS into low IFR at night. But he would not have been making that decision if the fuel selector worked.

Recognize that attempting flight with a known problem is setting you up for having to exercise judgment in an unusual situation. Why add the risk? Assuming you can legally fly with the balky equipment properly placarded and disabled, plan your flight expecting to have to do without, changing your plans only if things turn out better than expected-instead of hoping for the best and having to play catch-up if things go bad. If planning this flight on main-tank fuel only revealed the need for a night landing in marginal or worse weather, good risk management would tell you to delay the flight until conditions improve or you have completely repaired the inoperative item. You can actively manage risk by recognizing high-risk situations.

“Ive got to be there”

How many times have you heard of an aircraft accident on the way to a family event or holiday? How many mishaps occur when someones trying to get to work on time? The statement “Ive got to be there” should immediately raise a red flag. Its gratifying to fly yourself, but major life events that demand your presence are going to put substantial stress on you to “go” when threatening weather, maintenance issues or pilot health should make cancelling the smart move.

If you cant be flexible enough to fly there a day or two early if needed, and stay a day or two late if circumstances require, then its best you arrange some alternate means of transportation. You dont have to eliminate personal aviation as a choice, but make sure you have an alternative planned and make the go/no-go decision soon enough to implement your alternative and still get to Grandmas house on time.

Passengers often dont have the skills to recognize the need to cancel or delay a flight. Its up to you to educate them or else they will apply even more pressure on you to “go” despite your good judgment. Its all about managing expectations-remind your passengers that you want to ensure them a safe and enjoyable flight and that, in some cases, this means modifying the schedule or even spending an extra night away from home if conditions cant support their safety and enjoyment.

Getting there is only half the fun. You need to plan alternatives for the return trip as well-there will be a strong temptation to challenge your better judgment if youve flown away from home and are on a deadline to get back home or to the office. “Get-home-itis” is probably responsible for the largest number of weather-related mishaps. Reduce stress and its effect on your judgment by pre-arranging alternatives for getting there and back on schedule any time you find yourself saying, “Ive got to be there.”

“Lets take a look”

Have you ever heard yourself say this? “Going airborne” to see what conditions look like is only a valid risk management technique if you have a clear shot at returning safely and the discipline to come back if conditions are not acceptable for you to continue. Use this option only if meticulous preflight planning shows its possible you can safely complete your planned flight.

Going up to “take a look” requires you first have a good idea of the current conditions, and the forecast, so you can compare “real” to “expected” and make an informed decision. Youve also got to have the minimums necessary to return safely to the ground if conditions indeed are worse than would provide safe passage-this is why most experienced pilots will not take off from an airport when the weather is bad enough they could not return and land. “Lets try it and see what happens” should be the result of a thorough evaluation of weather, the airplane and your current capabilities, not the first step in the information-gathering process.

Superior skill, hope or luck

Flying requires a high degree of self-confidence. Without it, who would dare launch into the blue (or even more, into the clouds) at the controls of a light airplane? But this mindset often convinces pilots they are better than they really are. In extreme cases, pilots will rationalize that the rules dont apply to them because they are better pilots than others. The reality is that most of us are “average” pilots, and many fall below average without recent experience and recurrent training. Accepting heightened risk because youre a superior pilot, or thinking the rules dont fit your situation because you know better, is a false security.

Some pilots rely on hope or luck to see them through. “I hope theres no ice in the clouds” or “Ive always been lucky enough that the crosswinds die down before I have to try to land” is to invite disaster when hope is lost or luck runs out.

Ive done it a hundred times

Its easy to fall into the trap that just because, “Ive done it a hundred times,” its safe, or that the outcome is assured every time. At one time I worked as a safety officer in a large construction company. Our insurance managers cited a study finding that, on average, experienced employees commit unsafe acts about 600 times for every time an accident occurs. When the accident does happen, its often a matter of circumstances (and luck) that determines the outcomes severity.

For instance, an equipment operator who jumps down off his tractor instead of climbing down the ladder probably wont get hurt most of the time. But if he lands wrong he may sprain an ankle. If the ground is uneven he may break a leg. If he lands on a small stone and falls over he might hit his head on a rock and die. It may not be possible to predict the outcome of the unsafe act until it happens-the only option is to avoid unsafe acts in the first place. Of those 600 times, you never know when youre flying “Flight #601” and your luck will run out.

The best way to avoid complacency is to follow standard operating procedures for all phases of flight, from preflight planning to securing the aircraft afterward. Disciplined use of checklists (printed, flow-check or mnemonic) will help you complete required actions, perform them in the proper sequence, and set your pace to avoid omissions. If you recognize youre doing something different than your usual way of doing things, then you need to realize youve artificially increased the risk.

“Everyone else is getting in”

From the NTSB: A single-engine airplane struck residential homes while executing an ILS approach. At departure, VFR conditions prevailed; however, the possibility of fog was forecast. The aircraft departed with approximately two hours of fuel. The trip should take 50 minutes. Upon arriving at the destination, fog prevailed throughout the area. The pilot made several VFR attempts to land.

At 2102:05, the pilot requested an IFR clearance to a nearby commercial airport. The pilot was asked and reported one person on board with one hour of fuel. He was then cleared for an ILS approach; subsequently, he missed the approach and was given missed approach instructions.

At 2118:20, the controller asked the pilot, “Can you execute this approach? Everybody else is getting in.” The pilot wanted to try the approach again and was given radar vectors for another attempt. At 2130:00, the controller observed the aircraft tracking northbound and asked the pilot if he was receiving the localizer. The pilot responded he was receiving the signal and was left of the localizer.

Subsequently the controller observed the aircraft was at 1000 feet msl and left of course. At 2131:16, the controller advised the pilot that the approach clearance was cancelled, issued climb instructions and noted the airplane was low and left of course. At 2131:28, the pilot advised that he was fuel critical. The controller asked, “How much fuel do you have?” The pilot responded, “About 25 minutes.” The controller advised he would vector the aircraft downwind for a five-mile turn to final. At 2135:35, he was given the final turn to intercept the localizer.

At 2136:27, the pilot transmitted, “Out of fuel.” The controller advised the pilot that the aircraft was eight miles from the airport.

Probably without realizing it, by saying, “Everybody else is getting in,” the controller issued a challenge to the pilot, even though hed missed the approach once and was getting low on fuel. The subconscious insult to the pilots abilities could have been a big motivator for him to try the approach again and again until fuel ran out. Hear those words and realize ego, not weather conditions, may be driving your decision to attempt the approach.

There are many more high-risk situations that run as common threads through the accident record. Recognizing when youre in a high-risk situation and taking active steps to verify your actions and reduce that risk are the keys to ensuring safety.

Tom Turner is a CFII-MEI who frequently writes and lectures on aviation safety.


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