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Decreasing your exposure to aerodynamic risk
1. Recent RA-Aus fatal accident history
Rev. 20 — page content was last revised 3 January 2014
Dr Rob Lee, the then Director of the Australian Bureau of Air Safety Investigation, wrote in 1998: "Over 40 years of investigation of general aviation accidents, by BASI and its predecessors, clearly shows that while the immediate circumstances of each accident may well be unique, the underlying [human] factors are always drawn from the same disturbingly familiar cluster — pre-flight preparation and planning, decision making, perception, judgement, fuel management and handling skills".
A preliminary study of the factors contributing to fatal general aviation accidents in Australia for the ten years up to 2000 showed that flight planning was a factor in 38% of the accidents, aircraft handling errors in 30% and fuel starvation or exhaustion in 10% and it appears that much the same proportions continued in 2001 to 2010. There is no reason to believe that the sport and recreational aviation experience differs markedly though the likelihood of engine mechanical or electrical failure is higher than in general aviation thus — though engine failure in itself shouldn't cause a serious accident — when combined with faulty judgement and decision making it also figures prominently amongst our causal factors.
We seem to have heard of more fatal accidents in recent years. Why are these accidents occurring? Are RA-Aus sport and recreational pilots and/or aircraft less safe than they were in the 1990s?Any person believing that fatalities are inevitable in sport and recreational aviation and examining the fatal accident statistics (an annual average of 3.6 p.a. during the five years 2008 through 2012) may conclude that the RA-Aus membership — being representative of powered, fixed-wing, sport and recreational aviation — has, perhaps, been achieving near-reasonable safety results, after taking into account the fading away of the older ultralight types and the continuing introduction of faster, heavier, more complex and less docile aircraft; together with a marked reduction in the average years of experience of the RA-Aus pilot base. The latter is because of the accelerated intake, and training, of new pilot members in recent years — although there is a very high turnover in newer members and RA-Aus has experienced a net reduction in total membership during both 2012 and 2013.
Such cold, bare statistics may be of some value to the 'inevitability' believers, but the statistics fail to reflect the heartache and economic difficulties within the families that result from serious and fatal accidents — and that ripple out into the wider community. What is perhaps even more distressing to all of us is that so many current and future accidents are, or will be, considered as so-called 'pilot error' or 'human error' and with 12 fatal accidents in 2013 the accidents have now increased to average 5.8 p.a. for the five years 2009 through 2013.
Generally, shortcomings in knowledge, awareness and task management plus misjudgement and/or unwise decision-making or poor planning, and perhaps neglect plus complacency ("we won't bother with doing the checks again, we'll be OK!) figure prominently as causal factors in those accidents. Accidents also happen when we attempt to operate in circumstances beyond our experience and/or ability. Quite often, just two or three misjudgements, possibly not that significant in themselves, combine to lead on to a heap of wreckage. And, of course, there are those few occasions where pilot incapacitation was thought to be the cause.
For those older members be aware that our abilities (including judgemental ability) and both the speed and appropriateness of our reactions does continue to deteriorate as we age, but some tend to deny it to themselves and to others. (Speaking as an octogenerian who has been able to observe the ageing process on myself and acquaintances for quite a number of years). One acquaintance of similar age told me 'I am still licensed but don't fly pilot-in-command any more – found myself making too many small mistakes and figured I'd better quit before I made the big one'.
We — the entire sport and recreational pilot community — must do all we can to bring the number of all such accidents to zero. Fatalities are not inevitable, even an engine failure over heavily forested terrain is survivable and, possibly, some forms of pilot incapacitation accidents could be avoided if pilots follow the pre-flight safety and legality check procedures or appropriate aircraft maintenance in the case of carbon monoxide poisoning. Of course there are events that an individual pilot might have little control over such as a bird strike at a critical time or being struck by an overtaking aircraft on final approach, but again, there may be aspects of situational awareness involved.
So, the only statistic that sport and recreational aviation should be striving for is 'zero'; no fatal accidents and no crippling injuries. Operations Manual section 3.09.
The Australian Civil Aviation Safety Authority also decided that, from 1 July 2009, 'threat and error management' would be added to the existing human factor aeronautical knowledge examinations, within the day VFR syllabus. A Civil Aviation Advisory Publication CAAP 5.59-1(0) 'Teaching and Assessing Single-Pilot Human Factors and Threat and Error Management' was published in October 2008 and is recommended reading.
We were having terrible problems in the formative years of the 1980s (roughly one fatality per annum per 250 members): 90% of the fatal accidents then occurred in CAO 95.10 aircraft; the remainder in CAO 95.25 aircraft. There were 30 fatal accidents in the period 1985 to 1989 (six per year) while membership grew from 800 to 2200. The recommendations of the HORSCOTS 'Report on Sports Aviation Safety' began having effect in 1987.
During the 8-year period 1992 to 1999 AUF ordinary (i.e. voting) membership plateaued at around 3500; the membership turnover was low, pilot training — and the improved availability of choice in aircraft — started to take effect and the fatal accident numbers decreased steadily each year. CAO 95.10, CAO 95.25 and CAO 101.55 types each contributed about 25% of the accidents, with the remaining 25% split evenly between CAO 95.32 and CAO 101.28 aircraft. The factory-built types (95.25, 95.32 and 101.55) were involved in 62% of fatal accidents, and the home-builts in 38%.
However, in 1998 the advanced 544 kg 'AUF amateur-built (experimental) ultralight' (the 19-xxxx registrations) was introduced, which did much to provide the platform on which the rather astounding AUF/RA-Aus expansion was based. But this expansion also led to an alarming increase in the number of fatal accidents during the period 2001 through 2006. Amateur built aircraft figured in 47% of fatal accidents, other home-builts in 10% and factory-builts in 43%, reversing the home-built/factory-built distribution of the 1992 to 1999 period.
The graph below shows the 5-year running average of fatal accidents from 1989 to 2011. Using the 5-year running average has the effect of smoothing the data; the first 5-year period commences in 1985. HGFA and ASRA accidents are not included in any of the statistics.
However, 2008 recorded a great improvement. There was only one fatal accident in an RA-Aus registered aircraft during the year, but sadly both occupants died. There were two accidents where the pilots sustained severe injuries. Since the AUF/RA-Aus was established in 1983 there has been one other year (1996) where only one fatal accident occurred. The average number of aircraft on the register during 2008 was 2850, a 230% increase in aircraft since 1996 so, considering that, 2008 was our safest flying year ever. But the combined 2007 and 2008 total was still 9 fatal accidents in which 15 people died. The average annual number of fatal accidents for the five-year period 2004 to 2008 is 4.6 — slightly less than the 1999 to 2003 period.
The 2009 year started very well; there were no fatal accidents in the first seven months and it looked like the human factors training programs introduced in 2008 were starting to produce the required results. Then there were five fatal accidents between August and December. Three of the accidents involved trikes, one of which was an unregistered aircraft, and a passenger also died in one of the trike accidents. In addition, there was a sixth accident where an RA-Aus three-axis pilot died in a trike registered with HGFA. There were five accidents in which an occupant suffered severe injury. So, a year that started with a lot of promise ended very badly; in effect maintaining the historical average annual number of fatal accidents. The number of aircraft on the RA-Aus register at the end of 2009 was 2955 and there were 9186 ordinary members.
There were three RA-Aus fatal accidents in 2010 causing the deaths of three pilots and one passenger, while another passenger was severely injured. Four persons were severely injured in three other accidents.
The 2011 year started very badly with two fatal accidents in January and continued in that vein throughout the year to total six fatal accidents. The death toll was eight — five certificated pilots, one student pilot under instruction (i.e. an instructor was in command) and two passengers. It was another very bad year, but it could have been horrific — thankfully, there were no serious casualties when an RA-Aus aircraft, with two persons on board, flew into an operating fairground Ferris wheel. See the Australian Transport Safety Bureau preliminary report*.
*In a May 20, 2013 document titled 'Focusing our investigative resources' Martin Dolan, the Chief Commissioner and CEO of the Australian Transport Safety Bureau wrote:
There were three fatal accidents in the first half of 2012 but none during the remainder, two of the accidents involved trikes. The death toll was five — two pilots and a passenger in the trikes, an instructor and a pilot-under-instruction in a Piper Sport. The 5-year moving average accident rate is now 3.6 per annum, an improvement on the moving average 12 months ago when it stood at 4.6 per annum. The reason for the decrease in the 5-year moving average is that 2007 (which was then the worst year since 1986) dropped out of the series and 2008 (which was the best year ever) remained in the 5-year series. The 4-year (2009 through 2012) average is 4.2 fatal accidents per annum, so the 2009-2012 improvement was rather small. In addition there are usually 2-3 accidents reported each year where the pilot or passenger — sometimes both — were seriously injured.
2013 was a disastrous year, we have experienced a stunning tally of 12 RA-Aus pilot and 2 passenger fatalities, something we have never experienced before. The 12 fatal accidents equals the total accidents during all of 2010, 2011 and 2012.
The answer to the question — "Does it look like recreational aviators are now getting safer and that there is less chance of fatal accidents?" — is that they are most certainly not getting safer, despite the comparatively recent introduction of human factors training and, assuredly, we are not improving quickly enough.
Perhaps the adage 'The more things change, the more they stay the same' is appropriate?
HF training is part of airmanship development and is not designed to worsen the safety record, so there must be something wrong in the RA-Aus HF training syllabus — and/or lacking in its implementation by the flight schools and/or in the quality assurance assessment outcome — of both the association's HF training for student pilots and the 2010 HF 'examination' of the, then existing, certificated pilots.
In addition, there are concerns whether it is appropriate for the RA-Aus board to persist in its long standing opposition to the dissemination of information concerning the occurrence of a serious accident, and the later distribution of the RA-Aus accident investigator's report. The current situation is that the occurrences are never mentioned by the Board executive or RA-Aus management in the website news section or the monthly journal 'Sport Pilot'; not even when the member concerned is well known to, and well respected by, the broad membership. The unpublished policy is that it is left to the membership to learn of the event via the public media's uninformed reports and the internet forums' sometimes grossly speculative reporting, and thus the membership learn nothing of real value from the accident, except, when necessary — but very occasionally — an aircraft airworthiness directive might be issued as a result of the investigation. All they learn is that their elected representatives do not choose to provide factual information to the members they represent! Certainly, this negative attitude is doing absolutely nothing to improve safety outcomes and the governance of the Association is neglectful of member and passenger safety — including the safety of those members who need to be protected from their own wilful actions, possibly by grounding them.
There has been considerable tumult in the Board during the past 3 years and this seems to have contributed to an unusually high turnover in Board members and in the staff, reaching the point where concerns about an apparent lack of corporate knowledge are apparent.
The RA-Aus safety management system — if such exists — is ineffective. See page 12 of CASA's Sport Aviation Self-administration Handbook 2010 for the elements of a safety management system; also see the text of the 2012-2013 and 2013-2014 CASA/RA-Aus Deeds of Agreement in the members section of www.raa.asn.au.
Paragraph B.7 in the statement of purpose section of the RA-Aus constitution is a reminder to all ordinary members and all board members. It states: "To set promote and maintain standards of safety for recreational aircraft by the specification and dissemination of information concerning standards of airworthiness for aircraft, standards of workshops and standards of knowledge for pilots and in particular, to specify, impose and enforce standards of skill and competence reactive to all stages of flying operations and to require any Member to meet such standards to the satisfaction of the Association before authorising such Member to engage in flight operations or any stage or aspect thereof and to grant, issue authorise, modify, cancel, suspend or revoke under the rules of the Association for the time being in force certificates and authorisations relating to aircraft, aerodromes, flying instructing and flying schools and to the skill and qualifications of pilots, instructors, navigators, drivers, mechanics and all persons managing, flying, driving, constructing, repairing or otherwise engaged in connection with recreational aircraft or recreational activities and to do all things relating thereto as may be deemed expedient and to make reports and recommendations to any clubs, authorities or persons concerning the same."
I leave it to the reader's own experience to judge whether the actions stipulated by paragraph B.7 are currently being carried out and, as B.7 contains the constitution's sole reference to 'safety' , does the constitution as drafted really express any concern with the need for an effective safety management system and the ongoing safety (and safety education) of all the membership and their so-called 'informed participant' passengers?
Five passengers died during 2011-2013 which raises the point of how is a passenger made aware of the potential risks inherent in sport and recreational aviation so he/she can make an informed decision about their participation? Various rather bland warning placards, not particularly addressed to the passenger, must be displayed in the aircraft cockpit, but that's hardly sufficient. As the association chooses not to report any information regarding persons fatally or severely injured — for the pilot to include in the pre-flight passenger briefing — how can any person, even the pilot, be regarded as well informed? Can a young passenger make an informed decision? The association doesn't even actively pursue the wearing of safety helmets in flight.
Why doesn't the constitution require dissemination to the membership, as one form of safety education, of RA-Aus serious accident events, investigation progress and the very valuable RA-Aus investigator reports that summarise the facts and the investigator's conclusions? Accident investigator's reports were last published in the AUF website in 2004. The following are previously published examples of AUF investigators reports, without the photographs.
The supply of material for self-education is most important. Martin Dolan, the Chief Commissioner and CEO of the Australian Transport Safety Bureau wrote (May 17, 2013 in answer to a query concerning boating accidents): 'In many cases they reflect what we see with smaller aircraft: the same accidents happening over and over. The best way to tackle these problems would seem to involve clear, targeted safety education [JB's emphasis] about how accidents can be avoided – as many of them are easily avoidable.' ATSB aviation occurrence statistics and BITRE general aviation activity reports; the latter include raw data supplied annually by RA-Aus administration. To compare like-with-like not all of general aviation aeroplane activity is included; charter, aerial work, agriculture, gliding and aerobatic are excluded — leaving GA private and business flying plus flight training.
RA-Aus, of course, presumes that the annual aircraft flying hours reported by the owners is reasonably accurate in the same way that CASA presumes the reported flying hours of VH registered aircraft are accurate.
The 2011 GA figures in the bar chart are estimated, as the number of fatal accidents is known but the BITRE report containing annual hours is still not yet available. The average number of fatalities in each of the GA accidents is two.
The pattern is interesting. Between 2002 and 2006 there was a continuing decline in the RA-Aus accident rate but in 2007, perhaps complacency was returning to the membership, and the accident rate shot up. Then 2008 was our best year ever — perhaps the membership was influenced by the shock results of 2007 — 2009 and 2010 averaged 2.1 then 2011 shot up, negating all the gains of the prior three years. A rough estimate of RA-Aus results for 2013 is 6.7 fatal accidents per 100k flight hours.
1.3 I'm a good pilot. I have my pilot certificate, my endorsements and 100s of hours. I feel I am competent enough and sensible enough to avoid an accident
The remarks of an instructor, following a very hazardous landing on icy grass, are pertinent: "I have been flying for 45 years and been an RA-Aus instructor for 12 years, but that flight taught me THERE IS ALWAYS MORE TO LEARN".
Airmanship is the cornerstone of pilot competency. It is the perception — founded on the acquired underpinning knowledge — of the state of that total environment and its potential risks that provides the basis for good airmanship and safe, efficient, error-free flight.
Good airmanship is that indefinable something, perhaps just a state of mind, that separates the superior airman/airwoman from the average. It is not a measure of skill or technique or hours flown, nor is it just common sense (i.e. 'good sense and sound judgment in practical matters'); rather it is a measure of a person's awareness of the aircraft and the current flight environment, and of their own capabilities and behavioural characteristics, combined with sound judgement, wise decision-making, attention to detail and a high sense of self-discipline.
For example: "The aircraft, with instructor and student on board, was returning to the airfield when a pitch-down occurred; not known to them the elevator control horn assembly had failed. Control stick and trim inputs failed to correct the situation, but a reduction in power did have a correcting influence, although not enough to regain level flight. A satisfactory flight condition was achieved by the pilots pushing their bodies back as far as possible and hanging their arms rearward. A successful landing at the airfield was accomplished."
Insufficient perception, poor judgement (e.g.'I think I can make it!' or worse, 'I think I can make it this time!'), complacency (e.g. 'It'll be OK!') and insufficient self-discipline create a pilot very much at risk.
Most sport and recreational pilots, as with most general aviation recreational pilots, accumulate only a small number of hours each year. The average annual hours currently reported by RA-Aus Pilot Certificate holders, excluding instructors and students, is only 35 hours; which means that about 50% are flying less than 35 hours. Perhaps 30 to 40 annual flight hours is enough to maintain just those physical flying skills learned at the ab initio flight school — if the pilot has established a program for self-maintenance of that level of proficiency — but maybe not enough to maintain a high level of cognitive skills: for example situation awareness, judgement and action formulation. (It's perhaps similar to the person who only takes the car out for a couple of hours once a week.)
Note: the average annual hours flown by RA-Aus aircraft during the last 15 years — including the flight school machines — ranges from 44 to 60, but most years are between 50 and 55 hours, though, of course, some accumulate ten times that number.
The difficult decision for many recreational pilots lies in the situation that, for various reasons, they are only able to undertake those few flight hours. Should flying for enjoyment take a back-seat to the imperative for skill improvement and further training?
In addition, having completed flight theory studies sufficient to pass the basic aeronautical knowledge test and achieve the Pilot Certificate, it seems that many, perhaps most, pilots leave it at that, failing to expand their knowledge by further in-depth studies of flight dynamics — or even ultralight essentials like microscale meteorology. Possibly because it involves sometimes difficult detail rather than the broad-brush approach of the flight school manual, and perhaps assuming that such knowledge will be accumulated through subsequent flight experience — also hoping, I guess, that they will inherently know how to survive every learning experience.
For example, here is a learning experience that the trike instructor was lucky to escape from relatively unscathed, as was his paying passenger: "the pilot intended to conduct a trial instructional flight from a grass strip over 250 metres long. The strip was soft after rain but several solo take-offs had been carried out, each clearing the fence at the end of the strip by 75–100 feet. After some test runs with the passenger on board the pilot elected to take-off using a short field technique. The aircraft accelerated until the nose wheel lifted off the ground and then slowed — with the nose wheel sinking back onto the ground. Because he still believed he had sufficient speed in hand, the pilot tried to make it over the fence; but tripped over it. The aircraft was destroyed."
Like the 'Sunday driver', many pilots are just continually repeating the same flight experience — each year is much the same as the last — so all they accumulate is a repetition of one year's experience. They have no program of deliberately accumulating advanced knowledge or skills, nor have they really absorbed the safety basics that should have been instilled into them over the years: always maintain a safe airspeed near the ground; if the engine has been misbehaving never take off until the problem is identified and fixed; if the engine goes sick in flight, don't try to make it back to base — land as soon as feasible; don't continue flight into marginal conditions; and so on.
The bulk of recreational aviation is undertaken by 'amateur' pilots (using the original meaning of the term; i.e. a lover of a particular activity or pastime) with modest piloting skills. But such pilots, whether PPL or Pilot Certificate holders, must still approach aviation with the attitude of a professional.
Too many pilots regard their biennial flight review as a bit of a nuisance, rather than demanding from the reviewer a professional in-depth audit of their competency. Beware your 'friend' the examiner who waives the flight check because he/she is satisfied, by 'discussion and observation', that you are competent. Pay to do the check in a two-seater if your own aircraft is single-seat.
For instance we have the 10 000 hour pilot who lost his life and that of his passenger near the top of the Great Dividing Range, possibly just because he believed "We can make it under the cloud base!" What may have contributed to that belief and may have led to that possible decision? We just don't know; the only certainty was the location of the wreckage.
Some accumulated beliefs may be dangerously false. For example, the long-time pilot who is convinced that a very light aircraft, caught in a strong lee-side downflow, will always be safe because it will 'go with the flow' when the downflow flattens out near the bottom of the slope.
The sound pilot must understand how the environment parts relate and interact with each other, and judge the likely consequences of any action, deliberate non-action or random event. A systematic approach to continuing improvement in airmanship, plus an ability for self-appraisal, is necessary to achieve that understanding. Don't expect that you can enrol for advanced flight training and somehow that training will reduce your risk exposure to minimum levels. Certainly it will help, but risk management/decision-making is very much in your own hands.
The Flight Manual or Pilot's Operating Handbook for the aircraft model being flown must be fully understood, and the content recollectable, when needed in an emergency. You must be totally familiar with the fuel and electrical systems. For an aircraft type that is regularly flown every switch, knob and lever position must be instantly locatable and identifiable without having to hunt for it. Do you know where the alternate static vent lever is? Every item in the pre-start and pre-take-off check-lists should be physically verified before opening the throttle — EVERY TIME. It's often the pilot who doesn't do the full checks — because he (usually a male) did them only an hour ago — that gets caught out. Every flight should be prepared and conducted correctly and precisely, using procedures appropriate to the airspace class and without taking shortcuts — even if just a circuit and landing or flight over to the neighbour's strip is contemplated.
Pilots should be aware that fatigue, anxiety, emotional state — or flying an aircraft that stretches their skill level, or just flying an aircraft they don't like — will affect perception, good judgement and wise decision-making. If you lack flight experience in a wide range of aircraft types you may find that you have insufficient skill to handle an aircraft that introduces new flight behaviour characteristics and which you are flying for the first time.
Most studies of aircraft accidents or incidents reveal not a single cause but a series of interrelated events, warnings or actions which, being allowed to progress without appropriate intervention, march on to a possibly catastrophic crash site. Sometimes the final trigger may be relatively innocuous, but sufficient in itself to totally remove a safety margin previously eroded by other events. A U.S. Navy pilot once wrote "In aviation you very rarely get your head bitten off by a tiger — you usually get nibbled to death by ducks." However U.S. Navy pilots are well-trained, well-informed, self-disciplined team players who do not expose themselves to those situations where the tiger concealed out there WILL leap out and bite your head off.
For example, take the young male pilot, deemed to have been above average at his flight school two years previously and thought likely to become a very capable aviator, who — in a fit of exuberant youthful bravado — succumbed to temptation and took his equally young female friend for a totally illegal low flying demonstration in a RANS Coyote and, when a wingtip hit a fence line, ended two lives before they had really begun, and deeply scarred the lives of the people who loved them.
Many years ago, the Australian gliding community demonstrated that there were two main cyclic periods (for them) where people were accident prone. This was about the 100-hour mark, where pilots were beginning to think they were immortal, and about 200-250 hours when they were sure they were; being survivors of the incidents of the first period. Other aviation organisations have indicated similar findings in the 50 to 350 hour period.
The next article is titled 'Don't fly real fast'
'Decreasing your exposure to risk' articles
| Introduction and contents | Recent RA-Aus accident history | Don't fly real fast | Don't stall and spin in from a turn |
| Don't land too fast in an emergency | Engine failure after take-off | The turn back: possible or impossible — or just unwise? |
| Wind shear and turbulence |
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