Tag Archives: accident

Take the Blame for Your Own Mistakes

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Stop trying to pin the blame on others when you screw up.

I have to blog this because I’m pretty fired up about it.

This morning, I got an email message from a lawyer looking for an R44 “consultant”, someone who could

…educate us on the practical day to day operations of an R44. As a consultant, we would not reveal your name or association to anyone. We simply need someone to call when we have a question.

The email message provided enough information that I was able to track down the accident report for the accident the lawyer is working on. Although he didn’t say so, he made it pretty obvious that both Robinson Helicopter Company and the maker of the R44 Raven II’s “auxiliary” fuel pump could be targets of a legal action.

I read the accident report. Without going into details — in this instance, I want to protect the identifies of the parties involved — it was a pretty clear case of pilot errors in judgement and execution. As I summed it up in my email response:

The pilot elects to make an off-airport landing at very high density altitude to take a leak, starts to take off, then overreacts to a yellow caution light and tries to perform a run-on landing in rough terrain.

The helicopter rolled over and caught fire. The pilot and passenger were badly burned.

The details of the Full Narrative Probable Cause accident report paint a picture of a low-time private pilot who flies less than 100 hours a year making a very long cross-country flight in mountainous terrain. There’s evidence of poor flight planning and poor fuel management. But most evidence points to poor judgement on the part of the pilot. Nothing was wrong with the helicopter. It performed as expected in the situation it was put into. The pilot simply made a series of bad judgement calls.

How many times have I seen this in accident reports? Too many to count! The vast majority of aviation accidents are caused by pilot error. Period. This case is no different.

Yet there’s a lawyer involved and that means someone’s thinking about a lawsuit.

Sure, why not? Why not blame Robinson for not issuing [yet] another Safety Notice, specifically warning pilots about landing in mountain meadows at more than 10,000 feet density altitude? Why not blame them for allowing cockpit caution lights to illuminate when the pilot is operating close to rough terrain at maximum power? Why not blame them for not forcing pilots to tattoo emergency procedures on the back of their right hand so they can easily consult them during flight? And the pump manufacturer — why not blame them for making pumps that can have low pressure indications that trigger a caution light?

Why in the world would the pilot in command even consider taking the blame for the results of his own poor judgement?

Because it’s the right thing to do? Am I the only person who actually cares about silly things like that?

As I told the lawyer in my email response,

It sickens me that people can’t admit they made a mistake and get on with their lives. It sickens me that lawyers go after deep-pocket manufacturers to squeeze them for money when they are not at fault. Lawsuits like this are hurting our country, destroying small businesses like mine by jacking up expenses for insurance and equipment “improvements” we don’t really need.

Yes, it’s unfortunate that the helicopter crashed and the people inside it were burned. But it isn’t Robinson’s fault. And it isn’t the pump maker’s fault. The pilot needs to understand this and stop thinking about promises of big settlements. He needs to stop trying to blame others for his mistakes.

Do you think they’ll contact me again about being a consultant? Now that would be a bad judgement call indeed.

Note: If you plan to comment on this post, please limit your comments to the topic of inappropriate legal action. I will not approve any comments that attempt to discuss this particular accident or my summary of it. I assure you that my conclusions are fact-based; you can probably find the accident report if you try hard enough and judge for yourself. The last thing I need is for lawyers to start coming after me.

Dangerous Flying: Abrupt Control Inputs

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How sloppy flying could get you killed.

Recently, while flying with a 200-hour helicopter pilot, I was startled when he rather abruptly shifted the cyclic to make a turn. I didn’t say anything then because it wasn’t too abrupt (whatever that means). But when he did it again later in the flight with an even more abrupt movement, I spoke up and told him not to do it again.

Understand that we were flying a Robinson R44 Raven II, which has a rather unforgiving semi-rigid rotor system and very long rotor blades. We’re taught — or should be taught — during primary training to use smooth control inputs, especially when working with the cyclic.

I’m not a CFI and I don’t feel that I have the right to tell someone how to fly, but when a pilot does something I believe is dangerous, it’s my duty to speak up. So I did.

The trouble is, I’m not sure if he believes what I told him — that abrupt inputs are dangerous — or if he thinks I was just nitpicking his technique. (I let it go the first time partially because I didn’t want to be seen as a nitpicker.) Since so many pilots seem to read this blog to learn — or at least to get my opinions on things — I thought I’d discuss it here.

What Robinson Says

Section 10 of the R44 II Pilot’s Operating Handbook includes safety tips. Here’s the one that applies:

Avoid abrupt control inputs or accelerated maneuvers, particularly at high speed. These produce high fatigue loads in the dynamic components and could cause a premature and catastrophic failure of a critical component.

What Robinson is saying is that when you make abrupt control inputs you put stress on various aircraft components. They’re likely concerned about the rotor blades, mast, transmission, and control linkages most. This makes perfect sense.

Robinson Safety Notice SN-20, titled “Beware of Demonstration or Initial Training Flights,” includes these statements:

If a student begins to lose control of the aircraft, an experienced fight instructor can easily regain control provided the student does not make any large or abrupt control movements. If, however, the student becomes momentarily confused and makes a sudden large control input in the wrong direction, even the most experienced instructor may not be able to recover control.

And:

Before allowing someone to touch the controls of the aircraft, they must be thoroughly indoctrinated concerning the extreme sensitivity of the controls in a light helicopter. They must be firmly instructed to never make a large or sudden movement with the controls.

Of course, what worries Robinson here is that student pilots may make erroneous control inputs beyond what an instructor can fix to regain control of the aircraft.

What Worries Me More

January 31, 2012 note: Since writing this, a friend on the Rotorspace site has brought the topic of Mast Rocking to my attention. Apparently, some folks think that this accident may have been caused by Mast Rocking rather than an abrupt cyclic control input. I’m not convinced. Mast rocking supposedly does not cause the main rotor blades to diverge from their normal plane of rotation. How else could the tail be cut off in flight?

But what worries me more than putting stress on components is an accident report from 2006. I read this report on the NTSB Web site not long after the accident occurred. Back then, there was no known reason why an R44 helicopter with just two people on board for a long cross-country flight should fall out of the sky with its tail chopped off, but I had my suspicions. After my recent flight with the new pilot, I looked it up again. Here’s the probable cause (emphasis added):

The Canadian certificated commercial helicopter pilot was conducting a cross-country delivery flight with a non-rated passenger occupying the copilot seat. The passenger and pilot together had previously made delivery flights from the Robinson factory to Canada. Two witnesses saw the helicopter just before it impacted the ground and reported that the tail boom had separated from the fuselage. No witnesses were identified who saw the initial breakup sequence. Both main rotor blades were bent downward at significant angles, with one blade having penetrated the cabin on the right side with a downward slicing front to rear arc. The primary wreckage debris field was approximately 500 feet long on an easterly heading. The helicopter sustained damage consistent with a high-energy, fuselage level, vertical ground impact. Detailed post accident investigation of the engine, the airframe, and the control systems disclosed no evidence of any preimpact anomalies. The removable cyclic was installed on the left side copilot’s position, contrary to manufacturer’s recommendations when a non-rated passenger is seated in the left seat. The removable pedals and collective for the left side were not installed. The cyclic controls for both the pilot’s and copilot’s positions were broken from their respective mounting points. The copilot’s cyclic grip exhibited inward crushing. The Safety Board adopted a Special Investigation Report on April 2, 1996, following the investigation into R22 and R44 accidents involving loss of main rotor control and divergence of the main rotor disk, which included a finding that the cause of the loss of main rotor control in many of the accidents “most likely stems from a large, abrupt pilot control input to a helicopter that is highly responsive to cyclic control inputs.”

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
a loss of control and the divergence of the main rotor blade system from its normal rotational path for undetermined reasons.

(A full narrative is also available.)

This is pretty much what I’d imagined. The helicopter is cruising along at 110 knots in a very boring part of the California desert. For some reason, the pilot (or his passenger, who has access to a cyclic control), jerks the cyclic one way or the other. Maybe he was trying to dodge a bird. Maybe he was goofing off or pretending to be Airwolf. Who knows? The sudden input is enough to cause the blades to diverge from their normal path. One (or both) of them dip down and chop off the tail boom. The result: two dead bodies in a 500-foot long debris field.

And this is what was going on in the back of my mind when the pilot beside me made those sudden inputs.

Anyone who has flown a Robinson helicopter can tell you how responsive the cyclic control is. It wouldn’t take much effort to knock the blades out of their path. That’s why we’re taught — or should be taught — to use smooth control inputs.

Other accident reports like this one include: CHI05CA267 and MIA00FA102 (which is a “watch this” moment).

Other Concerns

Rotorcraft Flying HandbookThere are at least two other reasons to avoid abrupt cyclic movements. You can find all these in the Rotorcraft Flying Handbook, an FAA publication that’s a must-have in any helicopter pilot’s library.

Under the “Retreating Blade Stall” heading (page 11-6):

High weight, low rotor r.p.m., high density altitude, turbulence and/or steep, abrupt turns are all conducive to retreating blade stall at high forward airspeeds.

Personally, I don’t think retreating blade stall is an issue in Robinson helicopters, except, perhaps, at high density altitudes and high speeds. But in that case, you’d be exceeding Vne.

Under the “Low G Conditions and Mast Bumping” heading (page 11-10):

For cyclic control, small helicopters depend primarily on tilting the main rotor thrust vector to produce control moments about the aircraft center of gravity (CG), causing the helicopter to roll or pitch in thedesired direction. Pushing the cyclic control forward abruptly from either straight-and-level flight or after a climb can put the helicopter into a low G (weightless) flight condition. In forward flight, when a push-over is performed, the angle of attack and thrust of the rotor is reduced, causing a low G or weightless flight condition.

You can find an account of this (with a lucky pilot and passenger) in this accident report from July 22, 2010. Indeed, the problem may have occurred during the right turn the pilot initiated — did he jerk the cyclic over as my companion had done?

Another accident report that suggests mast bumping is SEA03FA148 (which took the life of a pilot I knew).

I’m Not Just Nitpicking

The point of all this is that I’m really not just nitpicking a fellow pilot with limited flight time. He performed a maneuver which I consider dangerous and I have all this information to back me up. It’s important for him — and for others who might not know any better — to avoid abrupt control inputs.

Robinson helicopters aren’t capable of safely performing aerobatic maneuvers. Don’t fly them as if they are.

Update, March 17, 2012: Here’s another example of an accident likely caused by an abrupt control input. This one resulted in mast bumping.

Pilot Flying Fears?

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Education is the best way to deal with safety concerns — especially if you’re a pilot.

I recently took part in a forum discussion that revolved around safety issues. The person who started the discussion, a helicopter pilot training to be a CFI, was concerned about the possibility of flight schools emphasizing the fun part of flying without adequately addressing the dangers. It wasn’t a failure to teach emergency procedures that bothered him. It was the attitude of flight schools and CFIs. He worried that flight schools, in an attempt to keep enrollment high, were failing to make students understand just how dangerous flying helicopters can be.

While I’ll agree that flying helicopters is dangerous, I also agree that driving a car or or crossing the street is dangerous. In fact, you stand a far more likely chance of being injured or killed in a motor vehicle than in an aircraft. The pilot who started this discussion knows this, but he still wonders whether flight schools should be making student pilots more cognizant of the dangers, especially early on in training.

I understood his point of view, but I really don’t know firsthand how much his flight school is downplaying the dangers. The general feeling I came away from after reading his comments was that he had a fear of flying. (This turned out not to be the case.) While it’s always good for a pilot to be afraid of what could happen, there comes a point where the level of fear becomes unhealthy. Yes, it’s true that pilots need to be mentally prepared to react to an emergency within seconds. But no, we don’t need to spend every moment of every flight actively thinking about all the emergencies that could ruin our day — or end our life.

Experiences Teach

I flew with a 300-hour pilot a few years ago. He’d gone through training and was a CFI looking for a job. (I have flown with quite a few CFIs looking for jobs, but that’s another story.) We were on a cross-country, time-building flight in my R44. I would eventually fly a total of 20 hours with him.

Early on in our first flight, I learned that his CFI, who was the flight school’s Chief Flight Instructor, had been killed in a rather disturbing fiery crash. Although she had over 2,000 hours of flight time, she had only 24 hours in the helicopter make and model. On that fateful day, the NTSB concluded that the accident was caused by:

The pilot’s improper planning/decision in attempting a downwind takeoff under high density altitude conditions that resulted in a loss of control and impact with terrain. Contributing to the accident were the helicopter’s gross weight in excess of the maximum hover out of ground effect limit, a high density altitude, and the gusty tailwind.

(I don’t really want to discuss this accident here; I think deserves a discussion of its own elsewhere in this blog and hope to address it in the months to come.)

Near GormanIt soon became apparent to me that the pilot was unusually fearful of flying in the mountains. Our route required us to fly west from Wickenburg, AZ to the California coast near San Luis Obispo. He started fretting about the mountains ahead of us while we were still in the flat deserts of Southern California. The mountains he was worried about showed elevations of 5,000 to 8,000 feet on the chart; we’d be flying over a road that ran in a relatively straight and wide canyon. That part of the flight turned out to be uneventful and he seemed genuinely relieved when it was finished.

Monterey BayOddly, later in the flight, when the Monterey tower instructed us to cut across Monterey Bay at an altitude of only 700 feet, I was pretty freaked out. Here we were, in a single-engine helicopter flying far from gliding distance of land, without pop-out floats or personal floatation devices. My companion, on the other hand, was perfectly at ease. In fact, I think he thought me cowardly when I asked Monterey tower for clearance to fly closer to shore.

This is a great example of how experience teaches. My companion was a “sea level pilot,” who did all of his training — and flying — in the watery areas around Seattle. He was comfortable with water and low-lying lands, but he was fearful of the conditions that had taken the life of someone he knew very well. I was a desert pilot with most of my experience flying over dry land, much it in high density altitude situations, including more than 350 hours flying tours over the Grand Canyon at 7500 feet or higher. I was comfortable flying over most kinds of terrain at just about any altitude but very fearful of flying over water.

(Nowadays, I wear a PFD when doing any extended flying over water and require my passengers to do the same.)

Learn from Other People’s Mistakes

Back in the forum, I began wondering if the pilot who had started the thread was concerned because he’d lost someone close to him in a crash — much like my cross-country companion had. (That turned out not to be the case.) I said:

If a person thinks too much about the danger of ANYTHING, they won’t be comfortable doing it. I admit that I don’t concern myself with it. I do everything I can to fly safely and maintain a safe aircraft. I’m confident in my abilities and never push the envelope of comfort more than I absolutely need to. I don’t fly around thinking that at any moment, something bad could happen. If I did, I’d hate flying and I’d likely be a horrible pilot.

Later, in the same post, I said:

You might also consider reading NTSB reports for helicopter accidents. What you’ll find is that most accidents are caused by pilot errors. REALLY. Reading those reports will help you learn what mistakes others have made so you’ll avoid them in the future.

He saw these two comments as conflicting and replied that I couldn’t really say that I wasn’t concerned with danger if I was reading accident reports.

My response was:

You need to understand that it’s BECAUSE I read the NTSB reports that I’m NOT overly concerned with the dangers of flying. The NTSB reports educate me about what can happen when you do something dumb: fly too heavy for your type of operation, perform maneuvers beyond the capabilities of your aircraft, fly into clouds or wires, etc. Each time I read a report and understand the chain of events that caused the accident, I file that info into my head and know to avoid the same situation.

I went on to say a lot more about what I’ve learned from NTSB reports. I read them for helicopter accidents at least once a month. Another pilot in the forum said he does the same thing — in fact, he even has a browser bookmark that’ll pull up the reports by month! I cannot say enough about the usefulness of these accident reports for training and awareness.

Unanswered Questions Can Fuel Fear

As I look back now on the flights I took with that mountain-fearful CFI — with the forum discussion in mind — I’m wondering whether the flight school had properly debriefed its students after the loss of the Chief Flight Instructor.

What had the flight school told him and the other pilots? Had they told him what caused the crash? I know that back then, before the NTSB report was issued, the flight school was in denial about the aircraft being overweight for the operation. Had they told their students anything at all? Were my companion and the other pilots and student pilots at that flight school left to wonder how such a great, experienced pilot could have been involved in a crash in the mountains?

Were his unanswered questions fueling his fear?

Another thing I suggested in the forum is that flight schools might want to conduct monthly seminars that students are required to attend as part of ground school training. Get all the students and CFIs into a classroom or meeting room with a few knowledgable, experienced pilots at the front of the room. Pick 3 to 5 recent helicopter accidents for which the cause is known. Talk them out. Explain what went wrong and what could have prevented the accident. Don’t point fingers; present facts.

Why don’t flight schools do this? Could it be because of what this forum pilot originally said: flight schools don’t want to scare off students by discussing dangers? If so, they’re doing their students — and the rest of the aviation community — a serious disservice.

Education and Experience are the Answers

Nowadays, if you want a job as a pilot carrying passengers for hire, you’ll need at least 1,000 hours of experience as a pilot in command. (Yes, I know some companies will take less, but those are few and far between.) There’s a reason for this: they want pilots who have experience flying. Experience leads to skills, knowledge, and confidence.

Some people think 1,000 hours is an arbitrary number and frankly, I have to agree. My first 500 hours were very different from the average CFI’s first 500 hours — in some respects, my experiences are “better,” while in other respects, a CFI’s experiences are “better.” But I also can’t see any other easy way to gauge a job applicant’s level of experience.

But it isn’t just experience that makes a pilot a good pilot. It’s also knowledge and attitude. Both of these things could be the end product of a flight school’s training program.

Many flight schools seem satisfied getting students and putting them through a “program” with just enough skills and knowledge to pass a check ride. Many students, who don’t know any better, are more interested in the cheapest way to get their ratings than the quality of the training.

I believe that with better quality training and better quality experience, less hours of experience should be necessary to have and prove good piloting skills. I also believe that pilots with better quality training and experience will have a better, safer attitude toward their responsibilities as a pilot.

It’s not a matter of teaching new pilots to be fearful of what could happen by stressing the dangers of flying. It’s a matter of educating about dangers — and how to avoid them.

What do you think?