Near the end of the accident chain – 4 lessons learned

The other day I learned a few things about flying after I blissfully found myself very near the end of an accident chain. Come fly along with me for a few minutes…

It was a beautiful summer morning with a light breeze out of the south. We took off from runway 21 of a small commercial airport with a control tower. The runway is 6,800 feet long and 150 feet wide and we used less than 20 percent of it before we were on our way to a nearby small, uncontrolled field to pick up a friend who is leaving his plane there for maintenance.

As we climbed out, enjoying the smooth air and beautiful view, we reviewed in our minds the airport information for our destination that we had studied the previous night. Forty-three hundred feet long, 75 feet wide, asphalt in good condition and, most important to remember, a right traffic pattern for runway 9.

Ten minutes later, we got the ATIS information for the destination and decided not to descend just yet. It was such a beautiful morning and we were early so we overflew the airport at a few thousand feet AGL and headed over to the large lake a few miles away and circled it a few times, enjoying the view.

Louisa County runway
When that runway is shorter and narrower than home, it can play tricks on your mind.

We descended to pattern altitude and entered a right downwind for runway 9. Everything looked and felt right and we felt content that, after 170 hours of flying experience, this was really cool – we knew how to do this! We glanced down at the runway and saw no traffic or anything else of concern and then watched for traffic in the pattern as we ran our final pre-landing checklist.

Time for the right turn to base, which we made smoothly while starting our final descent. As we leveled off from the turn, it immediately became apparent that we were pretty close to the runway centerline. Better start the turn to final, even though we were a little high.

As we started turning base to final, it was obvious that we were going to overshoot the centerline. “No problem,” we thought, “I can save this landing,” as we increased the bank angle and started thinking about how far down the runway we would touch down.

After a few seconds in the turn, we glanced down and noticed that the airspeed was good but the ball was not quite centered. Looking back out front, finally, our brain told us, “Time to go around.”

We leveled the wings, started the climb, reported on the CTAF and glanced down at the maintenance guy, standing outside his hangar, as we flew directly over him, and wondered what he must be thinking.

The next time around the pattern, with a little bit more focus and thoughtfulness than the last time around, the picture became more clear as to the mistakes that I had made and the steps in the potential accident chain. Did you catch them?

First was the runway environment. A shorter, narrower runway, a much smaller ramp area, fewer hangars and no control tower all conspired to cause me to set up my downwind much too close to the runway. Visually, it looked right to me – for my much bigger home airport. The second time around, I gave myself more space.

That light breeze out of the south? 180 degrees at 8 knots. Taking off runway 21, this was not even an afterthought. Landing on a much smaller runway 9, with a right pattern and a wind pushing me toward the runway, I should have paid more attention. That light breeze, coupled with being too close on the downwind, was another contributing factor. The impact of the wind, I am ashamed to admit, did not “click” for me until the second time around the pattern when I actually looked at – and paid attention to – the windsock.

I had at least three points during the short flight when the crosswind should have entered my consciousness. First, the wind at my departure was basically the same as the wind at my destination. I dismissed it because it was not a factor when taking off runway 21, even though I knew I would have to land on runway 9 or 27.

Windsock
Yes, the wind is blowing. But from which direction?

Second, when I listened to the ATIS and heard 8 knots, I am certain that my sub-conscious thought was, “8 knots…nothing to worry about there.” I didn’t process the fact that the 8 knots was at a right angle to the runway.

Finally, while enjoying that “perfect” setup on downwind and looking over the airport, I did not even look at the windsock which, while not sticking straight out, was obviously indicating a non-insignificant crosswind.

And the final step in the potential accident chain? Simple hubris. That thought of “I can save this landing” I am sure has killed many pilots. It is said that pilots with experience in the low hundreds of hours are the most dangerous and I gained some startling insight as to why this might be on this flight. I know that I am a rookie pilot with much to learn and I try to approach my flying that way. But I also am gaining confidence that I know what I am doing and feeling more relaxed while I am flying. This flight was a good reminder that there are many things that can go wrong and, often, even usually, there are clues along that the way that they will go wrong. No matter how much experience you have, you better listen to those clues.

In addition to being humbled – a lesson I will work to remember each and every time I fly – I learned a few other things from this experience:

Be a student of the game: No pilot can experience every possible situation or scenario in their own flying. When I talk to pilots with 10,000 hours, even they tell me that they see and learn something new every day. That is probably how they got to 10,000 hours. What stopped the accident chain in this case was all of the accident reports, articles and hangar flying that I have done over the years that talk about base-to-final turn loss of control.

Fortunately, even though I had not personally experienced the same situation before, something in my reptilian brain dredged up that knowledge at just the time that I needed it and overrode the “I can save this landing” thought with “time to go around.”

Conduct a debrief for each and every flight with yourself or, preferably, another pilot or flight instructor. The lessons that you can learn from your experience will stick better and someone else might learn something as well. This article started as a personal debrief and I decided to write it – and share it – so that other pilots might learn something from it.

Pay attention.   This may seem blatantly obvious but I think it was my most important lesson. Flying is a bit like a game of chess: the move, piece of information or observation that you make now will inform and influence the move that you are going to make in the future if you pay attention.

Airplane on final
Don’t try to save it – when in doubt, go around.

Before the flight, I had “become familiar with all available information concerning that flight” including the runway length (FAR 91.103), but I did not pay enough attention to what that information might mean other than confirming that I was comfortable landing on the length available. I did not think about how this information could inform what I would see when I got there, how it might be different from my normal airport environment, and how that might change my future “move” of where to set up on downwind.

I listened to the ATIS information twice, once on the ground before I departed, and once again enroute, and even wrote it down once. I paid attention to part of the information that it provided – 8 knots – but I did not pay enough attention to think several moves ahead about the potential impact of those 8 knots.

Finally, I didn’t pay attention to the windsock. A simple, useful tool put there for my benefit and I didn’t even look at it. I have no excuse for this one.

Going forward, I am going to endeavor to ask myself, “Why is this information important?” and “How might it impact a future move?” every time I make a move, collect a piece of information or make an observation. I doubt I will be able to foresee everything, and I am sure that I will not always have time to do this during many phases of flight, but, with practice and thoughtfulness, I suspect I will get better at it. I predict this will also make me a better, safer pilot as it will help me to see the links in the potential accident chain much sooner and avoid them altogether.

Have good pilot friends. I didn’t tell you the final chapter of the story. My second trip around the pattern was much better and the landing itself was excellent. I taxied to the ramp and shut down and spent a few minutes reflecting on the flight and what I had learned.

A few minutes later, my friend landed and, after shutting down, walked over to my plane. When I told him the story and the need for a go around, he didn’t say, “Ah, you could have made it” or “That happened to me a few weeks ago and I…” What he did say was the perfect thing to say to me as both a friend and a fellow-pilot and I will carry it forward with me as I continue to learn how to be a better pilot: “You made the right decision.” Thanks for that, Mike.

2 Comments

  • Alan,

    Great reminder of making the right decisions. My CFI brother pounded that making decisions is key to being a good pilot.

    I recall a similar flight I had several years ago after getting my private at age 62 (double your age). One of my first passengers was my younger brother. After taking him for a flight over his home and a few little other sites we returned to a local airport that was not my home airport. The runway and layout was familiar, so I can’t blame that for being out of sync, but nevertheless I turned final high and fast. Yanking full flaps and diving towards the runway I finally realized that no matter whether I got it on the runway I’d be near halfway down the runway before this Cherokee would decide to quit flying. Sooo, power up, flaps partial up, climb established, flaps up, and around we went again. Once on downwind again at proper altitude and speed, I made base and final on target, flared just before the numbers and made a near perfect landing just beyond. Little brother commented as we taxied about the go-around. I confirmed that the first attempt just didn’t look and feel right, and thus made the decision. I think I gained some respect from him that day. I think he realized that I had some brains and used them. All in all, flying with a non-pilot and having them enjoy their flight is one of the most rewarding things a pilot can do. Getting a “kudos” from another pilot is a confidence builder. Thanks for sharing.

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