Lessons Learned from Pilot Decision Making

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In every episode we identify safety iss ues and take the mystery out of accident investigations . So maybe pilots in their planes can have safer flights ahead Well, hello there Todge. Hello there, John. How are you doing today? Well, not bad at all. I'm fresh back from a visit to the IA Aviation twenty twenty six conference down in San Diego where I presented a paper on unidentified anomalous phenomena, which will be something we'll talk about that paper in a future episode, but we have a lot of other interesting things going on. What are you working on right now? Well, I've been digging through the through various sources looking for information for us to talk about , you know, and of course I always look for my favorite subject which is pre planning pre flights and after you get into the air paying attention . But I've got a number of things that I'm looking at in other areas . One is we've been talking about for a while , so I started digging into CESTA one hundred and seventy two accidents that happen with CFIs on board and just in general with students . So there's a lot of information there that some of it surprised me . And some of it's involving the pre and post pandemic events . And I've got the raw numbers, but we haven't really crunched it all yet on that. So we'll be talking about that again in the very near future . And I've also pulled out some maintenance accidents from those very same reports and some others too. So my favorite subject is to dig into what happens. You know, people forget pilots sometimes forget that they're the last line of defense on the airworthiness of their airplane, and that includes mechanical reliability . They really need to know what was done to their airplanes . And I love bringing it up. The fact that in one of the up pre flights, you found new hardware on airplane and you went to great lengths to figure out that was. And the short story there is the wing had been replaced on the aircraft, and I wasn't aware of it until after I'd done my flight that day . Had I been aware of fully beforehand, I would have said, you know what? Today I'm flying another airplane. No, it was an interesting one. And I'm also looking at the ASRS reports and the whole reason looking at that, it came and part of my digging and I don't know how I noticed this, but I did notice it that the number of reports from one hundred and twenty one carriers has been going down . You know, one would think that that should be going up with the number of new pilots they had, the number of problems we've had with just aircraft operations in general . So I haven't got to the bottom of that, but it seems like there's something going on there maybe it's nothing but it needs me some looking at because the numbers were substantially different. And we have the exact numbers here, because I went to the ISRS database and asked a very simple question, how many how many reports of my Part one hundred twenty one flight were in the database for the year before the pandemic, which is twenty nineteen, up to last year, twenty twenty five, the last full year for which they have dat a. And the bottom line is in twenty nineteen there are four thousand three hundred and four part one hundred twenty one reports , but in twenty twenty five , three thousand three hundred and sixty seven Roughly nine hundred or so, a little over nine hundred reports fewer than in twenty nineteen . Yes, from other reports , including the airline organizations, and we're going to get into the details with FAA specific details when I can find the right database . It looks like the number of flights that have occurred in twenty twenty five exceed what happened before the pandemic . So how can you have as many roughly flights as before the pandemic, yet roughly twenty percent fewer reports going on? Right, especially with the problems we've seen with air traffic control pilot pilots if they think they did something not proper, if they saw something not proper, they would file a report. They were always good with that . So we can need to touch that a little bit . It's inconclusive like the other three things that I mentioned. We're just picking up some what looks like trends and maybe there's something there, maybe there's nothing there, but we continue to look for it . And a brief return to the Part one hundred twenty one situation. I also compared that with the numbers coming from Part one hundred and thirty five operators, which are not going to be flying the same kinds of aircraft as Part one hundred twenty one , lower capacity. And a lot of the business jet and fractional ownership jet market would be part one twenty one thirty five operations . They had two hundred and ninety nine reports in twenty nineteen before the pandemic and up to three hundred and thirty in twenty twenty five after the pandemic, ten percent increase. Now it's harder to get the hard numbers on Part one thirty five , but I find it interesting that there are numbers ha ven't gone down . Yeah . Now, like I said, maybe something there, maybe nothing. We're going to look at it. Whether you're finding a one hundred and thirty five or one hundred twenty one, if you have a situation that you should write an ASRS report , please do so. You'll help the entire industry by doing so. And we've had a lot of people on other podcasts talking a lot about the G two hundred accident , and I've done a lot of work on that because that particular air frame has origins a piece of it coming from other sources. So it's going to be interesting to see what transpires, but there's been a lot of noise on other podcasts and YouTube channels. They've already got it figured out and there's been very, very little information out . I mean basically we know about the event. He took off, had an emergency, came back. It appears that he broke the airplane when he landed, drove the landing gear up . And of course, as soon as I saw that, I was started digging and looking for , you know what was his load? Was he carrying something? There was no passengers on board , but it appears that he may have been he may have had a full fuel tanks coming out. And so I started looking around and one of the things that I'd noticed was the price of fuel at that airport was considerably cheaper than any other airport in the area. So maybe that's why he filled his tanks up. I don't know. We'll have to wait and see what the report says and I know you Todd you didn't particularly care about reports from the Dominican Republic . Well, the Dominican Republic and let's back it a little bit, the way it works when it comes to accident investigations , the country that the accident happens in in most, cases is the, country that does the investigation. Not the Dominican Republic. They've had accidents in the past, they've had reports in the past. But the amount of resources and expertise that can be brought to bear on an accident depends on what country you're talking about . So how much of an investigation will be done will depend on that authority . And the manufacturer which is Gulfstream, they might have a representative there or the engine manufacturer might have a representative there. We don't know. It's going to be run by the Dominican Republic . And as the country of registration, this aircraft was registered in the United States. The NTSB would be what's called a party to the investigation, meaning the NTSB represents the United States. So if there is a need for a subsystem manufacturer that's a U. S. manufacturer, they would work with the NTSB as part of the investigation. How long will the investig ation take ? Unclear . How open will the results be to the general public? Also unclear. But I will say this , unlike the NTSB where you very likely have not only an accident report, but a lot of background information, what's called the public docket. I don't believe the Vanican Republic has in the past had a public docket type system to go with their accident reports. Yeah, I don't remember, so I can't say one way or the other . But you open up a very good question here because I had one other accident , a Cessna one hundred and seventy two accident here in the United States . And I'd like to add that, you know just because it's a foreign entity doing a report doesn't mean it's going to be good, doesn't mean it's going to be bad . And just because we have we have the NTS being doing a report doesn't mean it's going to be good. It doesn't mean it's going to be bad. It used to mean it was going to be good , but in recent years , we've something to be desired . And I wanted to talk about an accident that occurred in twenty twenty three , ten twenty, twenty twenty three to be exact . And the accident report from the NTSB is pretty thin to say the least . And the reason why I chose this accident is because it fits into what I say at the end of every show . And I think I've said on this program multiple times before how painful it is for me when I go through accidents and come across both maintenance accidents, which this is not one , but also accidents that happen that shouldn't happen . Fortunately, this one had no f atalities . The outcome could have been different just a few minutes earlier , and we'll get into that in a second . But the NTSB in recent years has had a number of reports that leave a lot to be desired, and this is one of them . So having said all that, let's talk about this one hundred seventy two that was being flown by a twenty seven year old pilot who had two hundred and eighty eight point nine so two hundred and ninety hours at the time and he was out flying better part of the day . You know, four hours or so maybe a little more . If he picked the airplane up in the morning and he flew to another airport to pick up some friends flew with them for two hours and ten minutes. They landed someplace, they took on some fuel and then flew back to the air port where he picked up his friends from, dropped them off , and ten minutes later , he had to land because he ran it out of fuel basically Now before we go on, the description you just gave is much richer than what was in the actual accident report . You had to go into the public do cket and look at two different pieces of information, one a pilot statement, and one a statement from an FA investigator that really puts some meat on the bones that were on that report. It was a one page report, very short of probable cause and probable cause statement wasn't really backed up by information in the final report , but by reading the public docket information, the picture was clear. Let's read What was written. The last sentence of the analysis is the pilot noted that verification of total fuel on board before each departure and a more accurate usage of the airplane's performance charts could have prevented the accident. Okay s,ounds good. Now let's look at the probable cause. The NTSB determines the probable causes of this accident to be, the pilots inadequate pre flight inspection and fuel planning and improper in flight decision making, which resulted in a total loss of engine power due to fuel exhaustion . Now the improper decision making in flight there was no real explanation of that in the analysis section . But when you look at the public docket, among other things , he didn't measure the fuel fully before taking off at the beginning of the day, using a dipstick to verify what was on the fuel gauges. And as I've probably said at least a couple times during our many podcasts, in my experience flying this kind of aircraft, the SAS one hundred seventy two, the instrument that is least reliable, good, but not as reliable as let's say the compass is going to be the fuel gauge . And my going in assumption is , unless I know otherwise , if it says a quarter tank, I'm assuming it's just about empty, and I should either land or not take off depending on the situation In this case, it was a question of a few gallons difference. He thought it had a few more gallons in it, the airplane thought differently, and the airplane engine stopped running. Fortunately, like you said, he was able to walk away from this with a substantially damaged aircraft . But had it happened with his friends on board, it would have been a different story in my opinion. Hello aviation enthusiasts, safetyfess Proionals and curious minds, welcome to Flight Safety Detectives . We are thrilled that you drop by . Here we dive deep into the world of aviation safety from incident invest igations and technical analysis to lessons learned in what they mean for safer skies . As a member of our channel, you get exclusive member only perks , first access to new episodes , live stream discussions and Q and A sessions . We are a community of fellow safety detectives who love aviation as much as you do . If you're passionate about aviation or just curious about how things work , we'd love to have you on board. Hit join , ring the bell to be notified and jump into the discussions in the comments . Strap in because together we're going to explore aviation safety like never before. Yeah, when he dropped off his friends , he had three gallons , three point seven gallons left in his tank roughly . So he never checked it in the morning . Maybe he thought the gauges were higher than what they were , but in any event he had , two , three , four , five opportunities where he could have checked his view on the ground , and obviously he didn't . He was doing the math in his head . You know, maybe he used pencil and paper, but he said whatever he started with the assumption of the fuel was on board wasn't adequate . So we added twenty eight gallons of fuel . In theory used twenty six of it roughly . So this burn may have been a little higher than what the published fuel consumption rates were or as flying style was a little bit using more fuel than the best economy . But in any event not checking your fuel, just adding with an assumption that you're going to have enough is that's the poor planning part . I'm reading between the lines a little bit of the what they call the NTSP piloted operator aircraft accident incident report where we have some details about the pilot's background . The pilot had a Class II medical certificate, which is one class above what you need to be just a private pilot. And he was listed as a private pil ot, and reading between the lines , a second class medical certificate is for someone who intends to do something beyond just flying for his or her own personal needs. What that is, I don't know . two hundred and eighty some hours, the amount to be had is not a small amount. It's on the order of forty to sixty hours before someone typically gets a license or well under a hundred hour s before one gets a license. So this person has had some experience. What kind of experience in the last ninety days where it was only I believe twenty hours? That remains to be seen. It would have been useful for us trying to learn from this accident if there's more information there. But this is again a situation where no one died, everyone walked away and perhaps there was not that impetus to get a detailed report out, but I will say this , he had a number of friends on board the aircraft on the previous leg An aircraft of that size that has several passengers in it, behaves differently than an airplane that has only a pilot or pilot and an instructor. And I'm willing to bet that although this pilot had a lot of practice of gliding the aircraft if a simulated engine out, etc and landing and taking the aircraft off routinely probably didn't do so a lot with people on board . So in a situation where the fuel is out, you're going through your checklist and you're setting up the aircraft for landing . He or she probably had quite a bit of experience flying the airplane lightly loaded , but not as much experience flying it full of passengers. In other words , the landing for an engine out situation that's close to being fully maxed out will be more challenging than landing with a relatively empty aircraft. You know, it's pre plan ning. I hop on it over and over and over . I mean so many accidents so many accidents with negative outcomes. This isn't bad. Yeah, he's going to get FA's going to punish him a little bit, slap him on the hands , but he's alright and nobody nobody got injured, nobody died . So it's a lesson that we all can learn from. You've got to treat an airplane like it's empty fuel tanks when you pick it up until you know otherwise . You got to make sure that everything is in place where it was, especially if it was left overnight someplace . Who knows what happened to it overnight . I mean, there's a reason why we look into all the openings on an airplane to see if some critters have crawled inside. It isn't just long term airplan that have that problem. Stuff can happen overnight. Sometimes happen even less than that . You've got to follow the rules, the procedures that are in place , right? They're not they weren't put together with all that detail in them from the very beginning. A lot of that detail was added after people that had problems and maybe even fatalities . You know, the age old saw that a lot of people use is the FAA's regulations are written in blood . Well, we most of us don't like to agree with that, but there is some truth to it . So please, if you're a pilot , pay attention to what you're doing . Man, don't take anything for granted . It just frustrates me. I can't even can't even say anymore . Well, that sounded a whole lot like the last word , which is I can't add to that, so I'll do the second and last word out of sequence. The second and last word is what if okay it's two words, but I'm looking at this pilot operator report and the what if that jumps out at me is they say here that the maximum grocery of the aircraft was twenty three hundred the weight at the time of the accident was eighteen hundred . Now by my mathematical calculations that's five hundred pounds. You say, Oh , no, that's a lot of leeway there. Well, let's assume you had a full tank of fuel. This holds around thirty five, forty gallons of fuel, and I'm doing math in my head here. That's one hundred fifty pounds right there, which means you have another three hundred fifty and pounds to max out the aircraft . And the report elsewhere, the inspector said he had friends on board . Did he have two friends or three friends? This is an airplane that seats four people. If they're two adver age size Americans , that would have been pretty much to grossing out the airplane, not grossing out. Max grossing the aircraft if everyone were on board and you had full fuel . Even with an empty fuel tank , again , it would have been a significant fraction of the maximum possible weight on board the aircraft if you had two or more people on board in addition to the pilot . So my last word the what if is it out? In this case, the what if didn't happen. What if we had more people on board? Probably would have ended differently. Thank goodness it didn't. How true All right, and please, please fly safely. I'm not going to say it all over again. Just please fly safely . Keep the head on a swivel . Pay attention Let me talk to the folks who have joined the flight safety detectives, our members . We thank you very much for doing so and we're hoping that you are enjoying your membership and the benefits that come with that, includ ing