12 Classic
Accident Pitfalls
Nick Mayhew -
Mike Phillips -
Objectives
• Identify 12 classic accident
pitfalls.
• Define what is dangerous.
• Give real examples.
• How do we do it safely?
#1 Classic Pitfall
#1 Classic Pitfall
Responding to peer pressure.
G-CRST, A109, Central London 16 January 2013
Responding to Peer Pressure.
Responding
#1 Classic
Pitfall
to Peer Pressure
Responding to peer pressure.
This is poor decision making
based upon emotional responses
G-CRST, A109, Central London 16 January 201
to peers rather than evaluating a
situation objectively.
16 January 2013
Central London
En route for
passenger pick
up
G-CRST, A109, Central London 16 January 2013
#2 Classic Pitfall
Mental Expectancy.
Mental Expectancy
The inability to recognize and cope with
changes in a situation different than
that anticipated or planned. Visual
illusions and similar aural sounds
occurring at the “wrong” time often
lead to such miscues.
#1 Classic Pitfall
Responding to peer pressure.
Map
G-CRST, A109, Central London 16 January 2013
10 December 1993
Sightseeing Flight
14 NM SE of airport
Flagstaff, AZ
#3 Classic Pitfall
Get-there-it-is.
Get-There-It-Is
This “disease,” common among pilots,
clouds the vision and impairs judgment
by causing a fixation on the original
goal or destination combined with a
total disregard for any alternative
courses of action.
21 June 1985
Ship to Shore
Resupply Mission
Near Tayport, UK
#4 Classic Pitfall
Duck Under Syndrome.
Duck Under Syndrome
The tendency to “sneak a peek” by
descending below minimums during an
approach. Based on a belief that there
is always a built in “fudge factor” that
can be used or an unwillingness to
admit defeat and shoot a missed
approach.
27 September 2008
HEMS Patient Transfer
3.2 NM North of Andrews AFB
#5 Classic Pitfall
Scud Running.
Scud Running
Pushing the capabilities of the
pilot and the aircraft to the limits
by trying to maintain visual
contact with the terrain while
trying to avoid physical contact
with it.
26 December 2011
The aircraft departed Mayo Clinic
on a medical transport mission
and impacted terrain 17 minutes
later.
#6 Classic Pitfall
Continuing VFR into IMC.
Continuing VFR Into IMC
The all-to-often result of the practice of
scud running when this becomes the
only alternative to flying into the
ground. It is even more dangerous if
the pilot is not instrument qualified or is
unwilling to believe what the
instruments are indicating.
27 July 2013
Planned
Route of
Flight
Passenger Drop
Off Flight
Noxen, PA
#7 Classic Pitfall
Getting Behind The Aircraft.
Getting Behind The Aircraft
Allowing events or the situation to
control your actions rather than
the other way around. This is
characterized by a constant state
of surprise at what happens next.
#8 Classic Pitfall
Loss of Positional/Situational
Awareness.
Loss of Positional/Situational Awareness
Another case of “getting behind the
aircraft” which results in not knowing
where you are, and an inability to
recognize deteriorating circumstances
and/or the misjudgment of the rate of
deterioration.
28 May 2012
Platform ST67B
Gulf of Mexico
Passenger Pickup
#9 Classic Pitfall
Operating Without Sufficient Fuel
Reserves.
Operating Without Sufficient Fuel Reserves
Ignoring minimum fuel reserve
requirements under either Visual Flight
rules or Instrument Flight Rules. This is
generally the result overconfidence, a
lack of flight planning, or deliberately
ignoring the regulations.
6 August 2011
Planned Route
Of Flight
Mosby, MO
HEMS Patient
Transfer
#10 Classic Pitfall
Descent Below Minimum Enroute
Altitude.
Descent Below Minimum Enroute Altitude
The duck-under syndrome
(mentioned earlier) manifesting
itself during the en route portion
of an Instrument Flight Rules
operation.
22 April 1994
Planned Track
HEMS Patient Transfer
Bluefield WV
Actual Track
#11 Classic Pitfall
Flying Outside the Envelope.
Flying Outside the Envelope
Unjustified reliance on the (usually
mistaken) belief that the aircraft’s high
performance capabilities meet the
demands imposed by the pilot’s (usually
overestimated) high performance flying
skills.
4 May 2000
Blanding, UT
Seismic Survey
#12 Classic Pitfall
Neglect of Flt Planning, Checks,
Pre-Flights, Etc.
Neglect of Flt Planning, Checks, Pre-Flights, Etc.
Unjustified reliance on the pilot’s
(usually overestimated) short and
long term memory of regular
flying skills, of repetitive and
familiar routes, etc.
9 June 2009
Search and
Rescue Mission
near Santa Fe,
NM
12 Classic Pitfalls - Summary
• Responding to peer pressure.
• Mental expectancy.
• Get-there-it is.
• Duck Under Syndrome.
• Scud Running.
• Continuing VFR into IMC.
• Getting Behind The Aircraft.
• Loss of Positional/Situational Awareness.
• Operating Without Sufficient Fuel Reserves
• Descent Below Minimums En Route.
• Flying Outside The Envelope.
• Neglect of Flt Planning, Checks, Pre Flights etc.
Questions and Discussion
HELICOPTER FACTS
Contact: Tony Molinaro
[email protected] or (847) 294-7427
_____________________________________________________________________________________________
Twelve Operational Pitfalls for Helicopter Pilots
Pilots, particularly those with considerable experience, try to complete a flight as planned, please
passengers, meet schedules and generally demonstrate the "right stuff." This basic drive can
have an adverse effect on safety and can impose an unrealistic assessment of piloting skills under
stressful situations. Even worse, repetitive patterns of behavior based on unrealistic assessments
can produce piloting practices that are dangerous, often illegal, and will ultimately lead to
mishaps. Here are 12 of these possibly dangerous tendencies or behavior patterns:
Responding to Peer Pressure – This is poor decision-making based upon emotional responses
to peers rather than evaluating a situation objectively.
Mental Expectancy - The inability to recognize and cope with changes in a situation different
from those anticipated or planned. Visual illusions and similar aural sounds occurring at the
"wrong" time often lead to such miscues.
Get-There-Itis - This "disease", common among pilots, clouds the vision and impairs judgment
by causing a fixation on the original goal or destination combined with a total disregard for any
alternative courses of action.
Duck-Under Syndrome - The tendency to "sneak a peek" by descending below minimums
during an approach. Based on a belief that there is always a built in "fudge" factor that can be
used or on an unwillingness to admit defeat and shoot a missed approach.
Scud Running - Pushing the capabilities of the pilot and the aircraft to the limits by trying to
maintain visual contact with the terrain while trying to avoid physical contact with it.
Continuing Visual Flight Rules into Instrument Conditions - The all-too-often result of the
above mentioned practice of scud running when this becomes the only alternative to flying into
the ground. It is even more dangerous if the pilot is not instrument qualified or is unwilling to
believe what the gauges are indicating.
Getting Behind the Aircraft -- Allowing events or the situation to control your actions rather
than the other way around. This is characterized by a constant state of surprise at what happens
next.
Loss of Positional/Situational Awareness - Another case of “getting behind the aircraft” which
results in not knowing where you are, and an inability to recognize deteriorating circumstances
and/or the misjudgment of the rate of deterioration.
Operating Without Adequate Fuel Reserves - Ignoring minimum fuel reserve requirements
under either Visual Flight Rules or Instrument Flight Rules. This is generally the result of
overconfidence, a lack of flight planning, or deliberately ignoring the regulations.
Descent Below the Minimum En Route Altitude - The duck-under syndrome (mentioned
earlier) manifesting itself during the en route portion of an Instrument Flight Rules operation.
Flying Outside the Envelope - Unjustified reliance on the (usually mistaken) belief that the
aircraft’s high performance capabilities meet the demands imposed by the pilot's (usually
overestimated) high performance flying skills.
Neglect of Flight Planning, Preflight Inspections, Checklists, Etc. - Unjustified reliance on
the pilot's (usually overestimated) short- and long-term memory of regular flying skills, of
repetitive and familiar routes, etc.
All experienced pilots have fallen prey to, or have been tempted by, one or more of these 12
dangerous tendencies at some time in their flying careers. Hopefully, they are natural mistakes
that can be easily recognized for what they are and quickly avoided.
The International Helicopter Safety Team (IHST) promotes safety and works to reduce
accidents. The organization was formed in 2005 to lead a government and industry cooperative
effort to address factors that were affecting an unacceptable helicopter accident rate. The
group’s mission is to reduce the international civil helicopter accident rate by 80 percent by
2016.
More information about the IHST, its reports, its safety tools, and presentations from its 2011
safety symposium can be obtained at its web site at www.IHST.org and its Facebook page at
http://www.facebook.com/pages/International-Helicopter-Safety-Team-IHST/150529738351608
Training Fact Sheet – Emergency
Decision Making
Contact: Nick Mayhew
Phone: (321) 567 0386
______________________________________________________________________________________________
What happens when you lose a critical system?
You are sitting safely in an out of ground effect
hover at 1000 ft while the camera operator
focuses in on the traffic accident below in the
hope of getting a good story for tonight’s
news…….when out of the blue the hydraulics
give a kick and you feel a big jolt through the
controls, the attitude of the aircraft changes and
you quickly start to descend. What actions
should you take? What is most important?
What does the Rotorcraft Flight Manual (RFM)
say? What should you do first?
Recognize – what has happened? – do I know?
– maybe… but don’t guess or make a quick
assumption. Flying with passengers or other
crew? – warn them verbally with the symptom
NOT the diagnosis! “Control malfunction” or
“torque split” or “caution light” for example.
This fact sheet will try to address these
questions and offer some guidance and tips on
how to safely deal with loss of a critical system
or even the loss of a non critical system that can
distract and create a situation where you lose
another critical system.
Control – contain the situation. Move the
controls to keep the aircraft out of danger –
achieve a safe flight configuration (best IAS for
SE flight or fly below max hydraulic out IAS for
example).
The first tip is don’t rush into making a poor
decision where there may be a better one (even
with an engine failure you may have more time
than you think)! Let’s look at an acronym that
may help slow you down so you don’t make a
wrong choice and make the situation
worse….something that follows a logical order:




Diagnose – OK now that we have the aircraft
under control let’s see what went wrong? If you
have time and your aircraft has Flight Reference
Cards (FRCs) with an Emergencies section now
is the time to get them out. If not run through the
situation and determine what happened and
which systems failed and why. What are the
implications? Use your crew and keep your
passengers up to date.
R - Recognize
C - Control
D – Diagnose
I - Initiate
Some will have used RCDI to describe the Rate
of Climb and Descent Indicator – also known as
a VSI.
Initiate – what are we going to do about this?
Look for somewhere to land or start a diversion
to another location. Make a radio call – do I
need to make a distress call – Mayday or Pan?
Have I followed my instructor’s advice to Aviate,
Navigate and then Communicate (ANC)?
Initiate or continue the descent and pick a good
Let’s break this down a little.
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place to land. Let’s get this aircraft and its
contents safe.
better choices and keep the helicopter, its crew
and passengers safe.
What does the RFM say about landing? What
does Land Immediately mean? Each
manufacturer will define these actions in different
ways so you are best to follow their advice for
the aircraft that you fly but let’s look at some
generic definitions:
Remember that it is important to always follow
the advice and procedures laid down in your
aircraft OEM Manual or Handbook. Pilots will
improve their chances of making the right
decision if you regularly rehearse your actions to
unique situations from within the cockpit.
Land Immediately – continued flight may be
more hazardous than ditching or landing in
terrain normally considered unsuitable.
Summary
Land As Soon As Possible – Land at the
nearest site at which a safe landing can be
made.
Land As Soon As Practical – Extended flight is
not recommended. The landing site and
duration of flight are at the discretion of the
aircraft commander.
Rememb
er that if
you ever
need to
move
critical
controls,
especiall
y in an
emergen
cy situation, you should always take your time
making sure you are holding the right one! If you
are part of a crew make sure you use them to
confirm the switch or lever using this memory
aid:



D – Diagnose
D – Double-Check
D – Do

Don’t rush. Think RCDI.

Recognize the symptoms and Warn the
crew and passengers.

Control and contain the aircraft and get
into a safe flight configuration if
possible.

Diagnose. Use FRCs.

Aviate, Navigate and then
Communicate.

DDD. Identify and confirm all critical
controls and switches before taking
action.

Initiate. Tell somebody. Land safely
and appropriately as guided by the RFM.
References
Further reading on this subject can be found in
Ch 17 of the Helicopter Instructor Handbook
http://www.faa.gov/library/manuals/aviation/medi
a/FAA-H-8083-4.pdf and at the Heliprops site
www.bellhelicopter.com/MungoBlobs/432/954/he
liprops_22_2_en.pdf and in the
Risk Management Handbook
http://www.faa.gov/library/manuals/aviation/medi
a/FAA-H-8083-2.pdf.
More information about the IHST, its reports, its
safety tools, and presentations can also be
obtained at its web site www.IHST.org.
There have been many occasions where the
pilot has shut down the good engine or switched
out the working system. Stop, think, check and
make sure.
No matter how urgent you think the emergency
situation is you should always be able to follow
this simple RCDI sequence. Obviously some
situations will need you to process through the
sequence quicker than others but if you stick to
this routine you are far more likely to make the
2