75S A case study in what not to do and how not to do it!

[Killratio]

This one really hit home with me and I am not ashamed to say that I was a bit "shaky" by the time it finished.

Night VFR in a single would never be my "thing". Night IMC? Well...

I'm not an instrument pilot, so I won't comment greatly but the case does, in my opinion, highlight 2 very old, very important truisms in aviation:

"Time to spare, go by air"

and

"The only time you can have too much fuel is when you are on fire."

://www.youtube.com/watch?v=fLlWf-Fk_YM&t=2s

[DHenriques_]

This one really hit home with me and I am not ashamed to say that I was a bit "shaky" by the time it finished.

Night VFR in a single would never be my "thing". Night IMC? Well...

I'm not an instrument pilot, so I won't comment greatly but the case does, in my opinion, highlight 2 very old, very important truisms in aviation:

"Time to spare, go by air"

and

"The only time you can have too much fuel is when you are on fire."
://www.youtube.com/watch?v=fLlWf-Fk_YM&t=2s

This one happened right in my back yard. There were enough mistakes on this flight to fill a large book. Very sad.
DH

[Killratio]

I couldn't agree more Dudley!

The saddest part of the whole thing is that even though he put 5.5 hours of fuel in for a 3.7 hour flight, just another quart would have saved his life!


DH2

[DHenriques_]

I couldn't agree more Dudley!

The saddest part of the whole thing is that even though he put 5.5 hours of fuel in for a 3.7 hour flight, just another quart would have saved his life!


DH2

The problem with aircraft fatalities is that we don't make any new mistakes. We just keep making the same mistakes over and over again.
D

[Killratio]

The problem with aircraft fatalities is that we don't make any new mistakes. We just keep making the same mistakes over and over again.
D

So true!

[AKar]

In my opinion the lesson is that these mistakes are not only done as parts of chains of events leading into accidents, but daily and routinely. It does not turn a bad decision any better if one got away with it, as we all usually do with our daily bad decisions. All too often the best of case studies end up putting emphasis on the mistakes of the mishap crew instead of those who study the case being able to reflect the learnings on their own doing. These excellent re-enactments give a great opportunity to do just the latter.

-Esa

[DHenriques_]

In my opinion the lesson is that these mistakes are not only done as parts of chains of events leading into accidents, but daily and routinely. It does not turn a bad decision any better if one got away with it, as we all usually do with our daily bad decisions. All too often the best of case studies end up putting emphasis on the mistakes of the mishap crew instead of those who study the case being able to reflect the learnings on their own doing. These excellent re-enactments give a great opportunity to do just the latter.

-Esa

Aviation accidents in many cases are not the result of a single factor. Considering the human factor in many cases we are dealing with a normalization of deviance, where pilots early on in their active flying tenure slide into doing a thing in a certain way that is not safe then over time that trait slides even deeper and further toward the danger area until finally on a specific flight factors add and multitasking adds to produce a degrading of situational awareness to the point where all the factors present total into a short circuiting of the decision process.
This can spell "accident" in huge capital letters.
Back engineering accidents often leads us into the human factors element as mentioned above.
Of course going into aviation accident investigation we as well often run into the Dunning Kruger
factor.
On the very basic level, of course there is always the inevitable Occam's Razor explanation from the peanut gallery.

Dudley Henriques

[AKar]

In my opinion the lesson is that these mistakes are not only done as parts of chains of events leading into accidents, but daily and routinely. It does not turn a bad decision any better if one got away with it, as we all usually do with our daily bad decisions. All too often the best of case studies end up putting emphasis on the mistakes of the mishap crew instead of those who study the case being able to reflect the learnings on their own doing. These excellent re-enactments give a great opportunity to do just the latter.

-Esa

Aviation accidents in many cases are not the result of a single factor. Considering the human factor in many cases we are dealing with a normalization of deviance, where pilots early on in their active flying tenure slide into doing a thing in a certain way that is not safe then over time that trait slides even deeper and further toward the danger area until finally on a specific flight factors add and multitasking adds to produce a degrading of situational awareness to the point where all the factors present total into a short circuiting of the decision process.
This can spell "accident" in huge capital letters.
Back engineering accidents often leads us into the human factors element as mentioned above.
Of course going into aviation accident investigation we as well often run into the Dunning Kruger
factor.
On the very basic level, of course there is always the inevitable Occam's Razor explanation from the peanut gallery.

Dudley Henriques

Yeah, in what comes to the normalization of deviance, this is something that the organizational safety people (I changed the word!) all too often get wrong. The systems in place get pedant over knowingly overridden safety measures (which are most often reported accordingly, and are in the backs of minds of people taking such compromises, resulting, arguably, even in elevated levels of safety). All while remaining completely blind on routinely ignored ones.

It is almost always the latter that cause real accidents in operations with well-developed safety culture. This usually has to do with some procedural written-in stuff not making sense operationally, and hence getting routinely ignored. This process reduces back to individual flying in ways like that it is fine to be a bit under planned final fuel figures all the time in routine conditions, because that's what the 'overheads' are for. And suddenly, when having a bad day, your initial position to deal with the problem is already compromised.

-Esa

[DHenriques_]

In my opinion the lesson is that these mistakes are not only done as parts of chains of events leading into accidents, but daily and routinely. It does not turn a bad decision any better if one got away with it, as we all usually do with our daily bad decisions. All too often the best of case studies end up putting emphasis on the mistakes of the mishap crew instead of those who study the case being able to reflect the learnings on their own doing. These excellent re-enactments give a great opportunity to do just the latter.

-Esa

Aviation accidents in many cases are not the result of a single factor. Considering the human factor in many cases we are dealing with a normalization of deviance, where pilots early on in their active flying tenure slide into doing a thing in a certain way that is not safe then over time that trait slides even deeper and further toward the danger area until finally on a specific flight factors add and multitasking adds to produce a degrading of situational awareness to the point where all the factors present total into a short circuiting of the decision process.
This can spell "accident" in huge capital letters.
Back engineering accidents often leads us into the human factors element as mentioned above.
Of course going into aviation accident investigation we as well often run into the Dunning Kruger
factor.
On the very basic level, of course there is always the inevitable Occam's Razor explanation from the peanut gallery.

Dudley Henriques

Yeah, in what comes to the normalization of deviance, this is something that the organizational safety people (I changed the word!) all too often get wrong. The systems in place get pedant over knowingly overridden safety measures (which are most often reported accordingly, and are in the backs of minds of people taking such compromises, resulting, arguably, even in elevated levels of safety). All while remaining completely blind on routinely ignored ones.

It is almost always the latter that cause real accidents in operations with well-developed safety culture. This usually has to do with some procedural written-in stuff not making sense operationally, and hence getting routinely ignored. This process reduces back to individual flying in ways like that it is fine to be a bit under planned final fuel figures all the time in routine conditions, because that's what the 'overheads' are for. And suddenly, when having a bad day, your initial position to deal with the problem is already compromised.

-Esa

One need look no further than the new ACS (Airman Certification Standard) to see how the organizational standard is set. The entire program is mired deeply in T's that have to be crossed and I's that need to be dotted. It's regimentation taken to the extreme. There is no room allowed for deductive reasoning on the local level.
It's for this exact reason my mantra to the flight instructors I lecture to is always to,
"TEACH BEYOND THE TEST"!
Dudley Henriques