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Fuji Abound
29th May 2010, 10:47
There is an interesting article in Flying this month.

The article examines the safety record of private pilots in the US.

In spite of the various initiatives of the FAA (and doubtless other regulatory authorities which have followed a similiar path) there has been little improvement in the flight safety of private pilots whereas there has been a marked improvement in CAT flight safety.

We might all assume that advanced training, experience, perhaps an instrument rating etc all contribute to making us a safer pilot. Certainly there is some evidence that the safety record in the Cirrus has improved as a result of insurance companies insisting on more training in the States.

The largest insurance company in the States (which only insurers private pilots and the lighter end of the market) would seem to have found otherwise.

It would seem in terms of avoiding fatal accidents (and the most serious) attitude is the most important factor; having the right attitude does not seem to stem (at least directly) from training, experience, etc.

It would seem that some of us are just very good at handling "emergencies". We are able to prioritise, ignore distractions, and make informed decisions. Others, in spite of 1,000 of hours, are not.

Interestingly "showing off" would also seem to be a significant contributor to accidents - more happen when there are passengers aboard, than when there are not.

Further on in the same edition there is a good analysis of the Colgan 3407 tragedy - which interestingly may illustrate some of these features where even a commercial pilot has failed to react "well" in an emergency situation.

YouTube - Colgan Flight 3407 NTSB Animation of Buffalo Accident Q400 (http://www.youtube.com/watch?v=lxywEE1kK6I)

In this instance the pilot was flying a coupled approach; because there was a very small amount of ice build the autopilot had been triggered to disengage at a slightly higher speed than normal. The autopilot duly disengaged, took the pilot unexpectedly, who then reacted to the stick shaker by pulling the nose up. Sadly the aircraft stalled. The accident would seem to be entirely attributable to a mis handled stall not occasioned by any mechanical defect. Depsite the commanders considerable flight hours there was evidence that he was not all that good at reacting under the pressure of an unexpected sequence of events.

Maybe a interesting debate will follow for the bank holiday. :)

Redbird72
29th May 2010, 12:14
That would certainly be in line with current thinking in the commercial flying world.

I recently attended an aviation safety conference aimed primarily at CAT and Aerial work, which was looking at what needed to be done to further improve safety.

Professionalism in the cockpit was the catchphrase, and was set out by many speakers as; if you always aim to fly as well as you possibly can, your skills remain sharp for that one time you really, really need them to be. If you fly sloppily because 'it doesn't really matter' on a routine flight, then your finer skills atrophy and aren't there to call upon when it really counts.

Although this was aimed commercial flying, I have taken this to heart for my own leisure flying, as it not only makes sense but also mirrors what my instructor always tried to drum into us.

Mike744
29th May 2010, 12:16
Corrected link:
YouTube - Colgan Flight 3407 NTSB Animation of Buffalo Accident Q400 (http://www.youtube.com/watch?v=lxywEE1kK6I)

IO540
29th May 2010, 12:42
I am sure this is true. Once a cowboy - always a cowboy. People don't change - except temporarily to make a good impression on somebody.

But the training is also lacking. Private pilot training doesn't deal with the broader "management" issues. You sit the exams, you fly the hours, and anybody who doesn't kill the instructor will eventually get a PPL. They say "a license is a license to learn, young man, now go away, I have a new customer waiting" :)

Short of getting clued-up by a lot of internet activity, and meeting up with other pilots (some of whom will be good and some will also be cowboys), one has little opportunity to drag oneself beyond the PPL sausage machine.

Edit: just found that article. It basically says that a study found that pilots were in two distinct groups, grouped by some fairly basic psychology. Also their ratings and total time did not make much difference to their chances of getting killed, though experience did make a difference to their chances of having minor prangs.

However I suspect that as always with these things the overall picture is hiding stuff like a higher rated pilot flying more complex mission profiles, etc.

Pull what
30th May 2010, 11:15
The lack of interest in this thread goes someway to highlighting the problem!

gasax
30th May 2010, 18:55
In what way?

State the blindingly obvious and what do you want - applause?

Are we all supposed to coo in admiration?

Check out posters from world war one, remember the 'old bold pilots' stuff. Anyone of any maturity will understand that people's attitiude is key to their performance in many ways.

Think of many of the so-called 'heroes' where there is a considerable undercurrent of negative comment in terms of their inability to relate to authority, colleagues, publicity etc...

Leopeards do not change their spots. Equally risk taking is unlikely to be compensated by raw skill. Read up on Bud Holland in the USAF, none of this is in any way new.

Pilot DAR
31st May 2010, 13:16
Two thoughts have rolled around my mind while I thought about this:

"You start out your career in aviation with a full bag of luck, and an empty bag of experience. The trick is to fill the bag of experience, before you empty the bag of luck".

The other is the subject which comes up in discussion about our kids; what's the balance between "nurture and nature"?

I any life pursuit, there are people who are "naturals" at it, and those who struggle, and are eventually adequate. In the course of objective, and non-predjudiced evaluation, the naturals and the adequate will look virtually the same in their performance. Only a deeper examination of their skills may show the differences, and for many reasons, that deeper evaluation may never occurr.

So even the "adequate" may find themselves comfortable in their skills, not thinking to continue to grow their abilities. This can be made worse by company training which is so focused, that the pilot learns only what they are being taught, to the apparent exclusion of their basic training.

Stalls come to mind. I have occasion to stall all kinds of planes, as a part of required evaluation of modifications. Often I fly alone, but for aircraft types which are new to me, or for which I am not type rated or insured, I will be accompanied by a "qualified" pilot. My challenge is that they are usually a "line pilot" whose job and training is to simply not stall that aircraft. But that's what we're there to do! Even after a briefing, I will find that he's pushing on the controls, while I'm pulling. "Am I feeling the plane, or you?" "Oh that's the plane, not me" as I see the while of skin between his thumb and forefinger.

So that pilot's attitude is generally right: Do as trained, do not stall planes. But, sometimes planes are to be stalled, so attitude should include, fly the test safely and properly. His experience is that stalling planes is bad, so avoid and prevent. The problem is that his experience should be good enough to comfortably stall and recover, when it is planned and expected, but he does not have that confidence. The antithisis of this, is the occasional pilot, who happily lets me do what I'm there to do, and then says "can I try that for practice while we're up here?". My answer is always "yes".

As in so many things in life, it is a balance. All attitude is going to get you killed for sure, 'cause you just can't get it right for lack of experience. Fortunately, you can't get a lot of experience, without getting some attitude along the way - both good and bad. Hopefully, training and mentoring will teach which is the attitude to retain, and which to never repeat!

Now, are the trainers up to the task?

During a flight test of a suspectedly non-conforming 172, I was required to take an instructor (club rules). "Ok, here's what I'm going to do.... you're welcomed to the ride, I won't really need any help with this, but feel free to ask, if there is something you would like clarified, or something you want to see." After determining that the plane was quite worthy, and having put it through all of it's paces, it was occurring to me that my crisp shirt, epaulette wearing guardian was actually still catching up to where we were in the sky at any given point. So after a brief straight and level, I delared the plane just fine, and asked would he like to see anything before we go back?

A roll please, this plane will roll, won't it?

"Um, No! Yes, this plane will roll perfectly well, but I'm not going to roll it, particualrly with you in it!

The poor fellow looked totaly dejected. I realized at that moment that he was a highly inexperienced pilot, who thought he saw, for a brief moment, an opportunity he would otherwise never have, to experience a roll, and would not get that experience. Is attitude problem, was that of even opening the door for me to do that, lest I try it! Worse, I demonstrate one, then off he goes to do more on his own, with too much attitude, and 'way to little experience!

I later learned that amoung the 20 or so instructors at that school, he was not only one of the seniors, but the school's safety officer!

Attitiude!

Pace
31st May 2010, 13:49
Pilot Dar

This is a hard one so I would like to add another angle or call it a slight suspicion of mine ;)

I have flown with pilots who are extremely methodical and detailed but go at one mental speed and appear unable to pick up their game if events require that.

I have also flown with pilots who are equally detailed and methodical but can also pick up their game when required and to whatever level that is required and they tend to be the best.
They seem to have very fast visual brains and are natural multi taskers.

In between that lot there are various combinations of the above.

I read an interesting article on how our brains worked and how we all have different talents and abilities.
Most of us are fine when all is running ok but it is when something starts to go wrong that the flaws appear.
It was explained like this. Imagine a computer which holds banks of memory.
Now think of the graphics card which also holds its own memory.
As we gain experience a lot of stuff is stowed away in the computer memory banks while the graphics card memory deals with all the instant and visual stuff.

Some of us have small amounts of memory on the graphics card and rely on our main memory in the computer.

Flash to much information too fast and the poor graphics card stutters and then freezes.

The guy lucky enough to have top of the range high memory cards and large onboard memory can deal with everything that is thrown at it without stuttering and freezing.

So yes training, attitude etc are all important and make for a safe pilot 99% of the time but there is more to it than that.

It is interesting in the safe confines of a simulator to throw more and more failures at a pilot until he goes into brain freeze where the brain can no longer deal with the information coming in and the level that that happens varies from person to person.

Pace

IO540
31st May 2010, 14:52
The catch in all this is that pilot training - all the way up to airline pilots - does not include any kind of character profiling and psychological testing such as might be implied in the above.

I'd think that austronauts were/are chosen with plenty of such testing, and I would be amazed if the RAF did not use psychological profiling for jet pilots, and anyway it is becoming pretty standard in big-company recruitment, but to become an airline pilot you only need to pass 14 exams and grind through endless training which is pretty well structured. To become a private pilot you need a lot less of that. But anybody with an IQ of more than 50 and with sufficient determination (and funding, perhaps) will make it eventually - despite the alleged establishment efforts to use the IR as a gatekeeper to stop undesirables from getting airline jobs :)

Back to private flying, it would be wrong to use psychological profiling as a basis for a PPL award, not because it would not improve safety (it would IMHO be the only way to improve safety) but because the State has no business in dictating individual attitude to risk. If one applied this to pilots, for every life safed one would save a 100 lives by applying it to car licenses.

Pace
31st May 2010, 15:32
10540

That sort of testing is done by Airline selection groups such as CTC But I totally agree with you that in Private flying we would not want anything like testing.

The reason for that is that the majority of Private Pilots fly for fun on days and weather that they select and as it is for fun they avoid conditions which would test them beyond their experience or capability levels.

But it is when such pilots go out of their comfort zones voluntarely or otherwise that any flaws, lack of training/ currency or natural abilities will rear its ugly head often with disasterous consequencies.

It has been argued that brain freeze accounts for the majority of crashes loss of control etc.

The only way to raise those brain freeze levels is by loading more and more info into the main computer memory ie by training, familiarity and experience meaning the graphics card memory has less to deal with especially in high overload situations ;)

Pace

Sir Niall Dementia
31st May 2010, 15:45
IO540;

Profiling is used during airline recruitment. You can get a CPL/ATPL without, but possibly not a job.

IO540
31st May 2010, 16:21
No suprise there.

Years ago, I went out with a (slightly mad) gurl who used to work for a business closely involved with airline travel. Her entire office of ~ 200 people had been recruited for the "cheerleader" character profile. Apparently, they all got on very well, all being equally empty headed, and most people in there were sh*agging somebody in the office :)

Just like the airlines, then :) (reading Air Babylon... must be true).

Fuji Abound
31st May 2010, 17:07
Check out posters from world war one, remember the 'old bold pilots' stuff. Anyone of any maturity will understand that people's attitiude is key to their performance in many ways.


I think you may have slightly missed the point.

If my understanding of the article is correct it goes deeper than that; the suggestion is the "right" attitude is innate as I think IO suggets in the thread above.

Is that not surprising or counter intuitive? It certainly isnt obvious, or if it is the FAA has missed the bl**ding obvious.

IO540
31st May 2010, 18:45
I doubt many doubt that pilot psychology affects the likelihood of unexpected death while flying.

What I am sure would suprise nearly everybody is that GA equipment modernisation has not improved the fatality rate.

It has definitely improved the airline crash rate - though together with this we have much more sophisticated training compared with the goode olde days of "hire all the ex Spitfire pilots".

So what does that leave, as factors affecting fatalities?

It leaves the pilot and his training!

The next level of analysis would try to separate the effect of pilot's attitude from his training.

Neither has changed since GA was invented ~ 100 years ago. The lack of PPL candidate psychological screening has not changed. The training has also not changed (in any significant manner) - it is still treated like training for a hobby e.g. how to grow cabbages... something you can drop out of when you get bored (which is exactly what the vast majority of people do, pretty quickly).

So I am not sure where to go from here. Psychological screening is obviously not going to happen (nor should it). The equipment is not going to magically improve (the world is owned by Garmin). That leaves only the training, and I cannot see anything ever changing on that front - too many vested (business) interests.

We will see better capabilities e.g. precision GPS approaches to places previously without any approach (maybe not in the UK with its money-driven privatised ATC, but elsewhere). But these are prob99 not going to reduce fatalities because whereas currently almost nobody flies DIY approaches, everybody with the kit will be flying LPV approaches. It's like the SE v. ME argument: twins are no safer because people fly riskier mission profiles. This may be true with avionics also; a G1000 and a parachute is bound to reduce the perceived risk (wrongly with the G1000 but rightly with the chute).

Pace
31st May 2010, 19:00
10540

some of whom will be good and some will also be cowboys

That line of yours brings in another angle ;) different horses for different courses! Airline pilot profiles are for the team player almost accountant type profiles while the fast jet pilot is the loner the risk taker.

The Ferry pilot another animal ;)

Maybe the cowboy pilot suits a certain situation so we have to ask what is a good pilot and what is a bad pilot?

The litmus test was always would you trust your kids in their hands and probably that answers it!
Does the pilot instill in you the feeling that he will not loose the plot under any pressure, will make the right choices and will never get behind the aircraft? and knows his aircraft as if it was an extension of himself.

Any other opinions ;)

Pace

2hotwot
31st May 2010, 19:57
There is also an interesting aspect to this in terms of technology.
Do you encourage aeroplanes to be something which is easy to fly, has intergated safety systems and all the high-tech bells and whistles which will deliver high levels of safety to lower levels of skill and experience or do you regress to something simpler in terms of technology that requires a higher degree of 'pilot involvement' in the flying perhaps of the 'Cub' type of aircraft on the grounds that when something goes wrong the pilots hands on flying skills will get them back safely.
The arguement could be that without a panel full of instruments one is less likely to push on into deteriorating weather.

I would be interested in people's opinions of whether a Cirrus, for example, is safer than a microlight (or a Tiger Moth)!

Kerling-Approsh KG
31st May 2010, 20:04
There is hardly any correlation between experience and ability...

Good training, and ability, yes... Good common sense, backed up with sound fundamental knowledge, yes... Especially, good line experience, backed up by good training, in a good environment, yes...

But Hans-Jurgen Merton is proof (if it were needed) that there is no link between experience and ability.

Was it Napoleon who wanted 'lucky' generals, not experienced ones? I believe it was.

Fuji Abound
31st May 2010, 20:32
Perhaps more instructional time needs to be spent "loading pilots up".

We have all been in situations when events are in danger of over taking us. The article expounds that it is how the pilot reacts in these situations that can make the difference between life and death.

Of course this is relatively easy to do in the simulator, which is maybe one reason why the "professional" pilot is able to perform better. I spent three hours in one of the Airbus simulators recently; it was most impressive to see how many different scenarios could be presented, and I know I only scratched the surface of the scenarios the professionals experience.

Another reason could be that there is a SOP for most scenarios, so if the SOP is learnt and reproduced there is a good chance that the pilots will play out the best sequence of events to result in the best solution to the problem.

You may have seen the BBC's recent analysis of the Air France tragedy last year over the Atlantic. I found it interesting that despite it being a SOP how many pilots failed to advance the throttles quickly when presented with a failure of the ASI. The suggestion was the Air France pilot were so over loaded with mutliple failures that they may have failed to take the single action that could have saved the aircraft. Under pressure did they suffer from the same inability to prioritise that the article suggests is the single most significant contributor to accidents?

We in GA are not so lucky. It is difficult for instructors to "simulate" events in real life that could over load a pilot and see how the pilot reacts. Never the less some instructors are able to achieve this.

Maoraigh1
31st May 2010, 20:46
:) Has the fatal air accident which elicited the comment by Chuck Yeager "Scott was always a risk taker", any relevance to this discussion, bearing in mind how many years he flew before the accident?

IO540
31st May 2010, 21:22
I found it interesting that despite it being a SOP how many pilots failed to advance the throttles quickly when presented with a failure of the ASI.It's also possible that the turbulence was so bad the pilot(s) could not do anything.

In a GA plane, in severe turbulence, you really just need to hold the horizon the right way up, more or less, and if possible maintain the pitch attitude. In the Airbus context, setting 85% N1 (or whatever) and hand-flying the specified pitch angle, is probably very hard. Especially as the speed band between stall and overspeed, at FL350, is probably only about 30kt or so wide, so you have to get it reasonably right. Even reading the instruments might have been hard.

I suspect the reason so many pilots did not revert to manual mode is that they almost never have to do so for real.

cgg
31st May 2010, 21:38
I think this is a very interesting discussion and trancends all types of flying. The gliding world is no exeception. The number of pilots I know with thousands of hours yet seem to want to pick who does their check flying carefully because they are "old friends" who know them well. When I was a relatively new instructor, I frequently came up against the "cross-cockpit authority gradient" picking up basic faults/bad habits with people with infinately more experience than myself and trying to find the best way of pointing it out....

Gertrude the Wombat
31st May 2010, 21:49
a G1000 ... is bound to reduce the perceived risk
Not to me, although I have to admit that I haven't yet tried flying one.

What a G1000 says to me is "when that screen goes blank in cloud, what would I rather be flying, something with a blank screen or something with a full set of steam gauges?".

palou89
1st Jun 2010, 04:18
We in GA are not so lucky. It is difficult for instructors to "simulate" events in real life that could over load a pilot and see how the pilot reacts. Never the less some instructors are able to achieve this.A: "Hey little johnny, would you mind going under the hood for a moment?"
B: "sure, no problem"
A: "Ok, give me a climb at 65kts 300fpm, turn heading 215 while climbing. Tell me how much fuel is on board and how much time aloft we roughly have "
B: "we have 2 hours an-"
A: "Engine failure"

Done. :E

In order to become a private pilot here in Argentina you have to undergo a test (MSG I believe its called) that pretty much tests your ability to multitask and function under extreeme pressure.

On your first medical examination you will be tortured with the following test:
You'd have a mouse on your left hand that moves a cursor up and down, but its motion will be reversed. You have to follow an arrow which moves (erraticaly) up and down on the left side of a computer screen. You will hold another mouse on your right hand which will be controlling another cursor that you must keep inside a small circle that jitters and moves randomly across the screen. You will do this for 5 minutes non stop.

After that they will add a set of yellow lights on each corner of the screen. Left mouse controls the lights on the left and right mouse the ones on the right. Inner clicks will turn off the lower lights and the outer mouse button will turn off the upper lights. The lights will come on and off randomly and you have to click the correct mouse button to turn it off. Keep doing this for another 5 minutes

At the end they will throw at you simple math calculations for another 5 more minutes. In order to submit the answer you have to release one of the mouses to type the 1-numerical-character answer on the numpad and continue will all the previous tasks. If you took too long to key in the answer another calculation would be given to you.

After that test I actually felt kind of dizzy and sick, never been so stressed in my whole life and I really mean it. It was incredible to see how many times you would brainfreeze under the extreme pressure of the test because you knew your medical depended on the outcome of that test (I dont know if they can actually denny your medical on those grounds, but you surely didnt be the first to find out).

great training device :yuk:

Fuji Abound
1st Jun 2010, 08:00
Especially as the speed band between stall and overspeed, at FL350, is probably only about 30kt or so wide, so you have to get it reasonably right. Even reading the instruments might have been hard.


IO

You may not have seen the program - the theory goes something along the lines on the bus that you set 85% power and one stage of flaps and without further ado the aircraft will maintain a 5% nose up and a speed above the stall - or something like that. There is almost no need to fly attitude or adjust the throttles. The point was made that because the auto throttles on the bus do not physically adjust the position of the throttles in the quadrant a glance at the throttles tells you nothing. The suggestion is that the first thing the crew should have done when the autopilot dropped out was to adjust the power - whether they did we dont know, but on numerous other occasions when the ASI failed the crew took too long to make this adjustment. You are of course correct extreme turbulence could have made doing anything in the cockpit tuff.

Palou89

Interesting.

I think it is suggested the key is not so much being good at multi tasking but almost the opposite - the ability to prioritise and to focus on the key task that makes the difference between life and death. Very simply put the pilot is flying glass, not instrument rated and finds the weather closing in around him. He is asking air traffic for a change in direction when the screen fails and his girl friend pukes. We all know that at that moment he should simply ignore the radio call and the girlfriend, fly the aircraft and "deal" with the "emergency". In fact he feels pressurised into finishing his call with AT or sorting out a bag for the girlfriend.

IO540
1st Jun 2010, 08:18
I did see the BBC2 prog. AIUI, to achieve a given speed, you need a) a specific engine power and b) a specific pitch attitude. Just setting the flaps won't do. That's true for any aircraft.

How you set the pitch attitude on an Airbus, I don't know. Any decent autopilot should have a mode for that (mine has) but in "fully manual", I suppose one has to use the yoke/stick.

chrisN
1st Jun 2010, 10:22
IO540 wrote: "So what does that leave, as factors affecting fatalities?

It leaves the pilot and his training!

The next level of analysis would try to separate the effect of pilot's attitude from his training.

Neither has changed since GA was invented . . ." [snip]

Not entirely, or at least not everywhere. Recent experience in Sweden has halved or better their GA accident record, as I understand it.

In 1998 (or thereabouts), the Swedish CAA teamed up with the flying clubs' umbrella organisation to start a ten year program with a very ambitious goal: to reduce the accident rate, in particular fatal accidents, with 50% within those ten years. The program, called H50P, ended in 2008 with an astonishing result: success!

See Privatflygarens drifthandbok - Transportstyrelsen (http://www.transportstyrelsen.se/sv/Luftfart/Tillbud-och-olyckor/H50P-projektet/Privatflygarens-drifthandbok/)

and at:

H50P (http://www.h50p.se/)

Chris N

mad_jock
1st Jun 2010, 10:38
Chris any chance you could summarise what the key actions were to get that cracking reduction in fatalities.

Sorry my Swedish is limited to 4 words and two of them arn't used in polite company.

Pull what
1st Jun 2010, 11:44
In what way?

State the blindingly obvious and what do you want - applause?

Are we all supposed to coo in admiration?

No, but thanks for an insight into your attitude!

Fuji Abound
1st Jun 2010, 11:47
I did see the BBC2 prog. AIUI, to achieve a given speed, you need a) a specific engine power and b) a specific pitch attitude. Just setting the flaps won't do. That's true for any aircraft.

Yep, I think that is what I said. :)

Pull what
1st Jun 2010, 11:50
I think this is a very interesting discussion and trancends all types of flying. The gliding world is no exeception. The number of pilots I know with thousands of hours yet seem to want to pick who does their check flying carefully because they are "old friends" who know them well. When I was a relatively new instructor, I frequently came up against the "cross-cockpit authority gradient" picking up basic faults/bad habits with people with infinately more experience than myself and trying to find the best way of pointing it out....The problem is that the pilot's with the worst attitudes are always the ones who feel they are superior to all others and need no further training or knowledge.

-as you will find out when you have been on here a little longer

Fuji Abound
1st Jun 2010, 12:44
Pull what

- again I think this isnt quite the message you imagine.

It is not the pilot's attitude in its simplistic terms that matters but his ability to prioritise when the chips are down.

A gungho attitude may well get you into the sh*t in the first place but it is the ability to prioritise that may get you out of it. That, at any rate, is the message I think.

chrisN
1st Jun 2010, 13:06
I can't remember where I've seen it, but I found a brief description of the Swedish program to reduce GA accidents. As well as the Swedish civil aviation authority producing a series of educational materials, I believe there was a movement to establish one or two people in each flying club or at each aerodrome whose job was to champion safety. I don't know exactly what they did, and efforts are being made to try and get some translation from Swedish.

Chris N

MichaelJP59
1st Jun 2010, 13:26
It's a debating point which pilot is the safer..

(a) The very careful vfr-only guy who only ever flies on nice days and goes to airfields that he's thoroughly researched and have nice long tarmac runways. Doesn't matter so much about his sky-god emergency handling because he'll be very unlucky to be put to the test.

(b) The one who flies far more hours, pushes the envelope and gets into many situations that challenge his skill. He is much more likely to be able to cope with an emergency than (a) but then is much more likely to get into that situation in the first place.

I guess we all make our choices about this, interesting talking point though.

Pace
1st Jun 2010, 20:02
MichaelJP

I could not agree with you more especially regarding private flying where you can choose your day and weather!

Its the pilot who knows his limitations and keeps within those that are safe.

It is often said that an accident is not one mistake but an accumulation which results in loss of control.

I suggest overload/panic as the point that the plot is lost.

Going back to my Graphics card and computer memory theory some pilots have more ability than others and will handle more before that point is reached others will loose the plot very early.

Through training experience etc you are adding more and more to the computer banks meaning less Graphics card memory requirement.

If you naturally have a low ability or graphics card memory you can get around that by loading the main memory through training and experience.

I firmly believe if you do use an aircraft for private flying in bad conditions do a stint in a simulator and practice being overloaded so at least you know how you react and how to improve on that as well as where your natural limits really lie.

Pace

biscuit74
1st Jun 2010, 20:43
Attitude or Experience?

The CAA here in the UK hold GA Safety Evenings every year.

Until very recently it was the case that no light aircraft pilot who had ever attended such a meeting had been killed flying. They used to say half-jokingly that, almost by definition, they had the wrong audiences present!

I think that answers the question fairly well.

mary meagher
1st Jun 2010, 21:11
From my own experience, I don't think you can pidgeonhole people that precisely. After more than three thousand hours, the (few!) times I have come close to making a smoking hole in the ground were when I was showing off, to put it plainly. Being aware of an audience I wanted to impress. Being impatient because those dummies on the ground couldn't get their act together.

I hope I have learned from the frights then suffered that I can now recognise the trend in my own behavior and back off! Older and a little bit wiser.

Anyone else on this thread willing to admit it?

rmac
1st Jun 2010, 22:26
Almost at 1000hrs, have always tried new and challenging stuff, in the early days it was quite a bit of aero's, later longer distance flights like Brisbane to Singapore in a light twin etc etc..

Had a few emergencies and it is safe to say that although they all ended well, when looking retrospectively there were a number of things that could have gone better and subsequent revisions of POH and other material in slow time were able to give me answers which locked in the experience.

I think though that in every case, the primary thought in my head was "fly the aeroplane and when I have stable flight and time, think about everything else...", there might just be something in that....;)

funfly
1st Jun 2010, 22:49
Some of you are missing the point here with GA flying.
Unlike professional pilots, including RAF pilots, GA pilots start doing it as a hobby. It requires the incentive, the time and not least the money to learn to fly and to continue to fly. Hobbyists (of all sorts) do not consider that they require personality examinations in order for them to learn, a medical is considered enough.
So you get people who are older than they should be and you get people who are less able than they should be. Enthusiasm more than the pro's, abilities maybe less than the pro's. That's what amateur aviation and every other hobby is all about.
Having said that, and excluding the few mad sods that I have met, most GA pilots take in a lot of information about safe flying and good luck to them all.
The answer is the way we are all relicensed with maybe better ways of spotting those bad habits that we are all guilty of.

IO540
2nd Jun 2010, 06:19
no light aircraft pilot who had ever attended such a meeting had been killed flyingHaving been to 1 or 2 of those presentations in years past, I think there may be more than one reason for that ;)

Pace
2nd Jun 2010, 07:56
Some of you are missing the point here with GA flying.
Unlike professional pilots, including RAF pilots, GA pilots start doing it as a hobby. It requires the incentive, the time and not least the money to learn to fly and to continue to fly. Hobbyists (of all sorts) do not consider that they require personality examinations in order for them to learn, a medical is considered enough.
So you get people who are older than they should be and you get people who are less able than they should be. Enthusiasm more than the pro's, abilities maybe less than the pro's. That's what amateur aviation and every other hobby is all about.
Having said that, and excluding the few mad sods that I have met, most GA pilots take in a lot of information about safe flying and good luck to them all.
The answer is the way we are all relicensed with maybe better ways of spotting those bad habits that we are all guilty of.

FunFly

Totally agree with what you have said above. Safety evenings or anything else which encourages pilots to know their limits and to remain within those limits are one tool. It is a bit like teaching pilots to avoid a stall so they never have to deal with recovering from one. Then one day with all the avoidance a situation occurs where the pilot has to recover for real so he is trained not only to avoid but to recover too.

It is rarely one mistake which causes an accident but an accumulation of mistakes which lead to a crash.

I am not really talking about pilots flying in good weather within their limitations or being encouraged to fly within their limitations but more pilots who either through stupidity get home itis or whatever find themselves in a situation where events are quickly putting them in a situation where they cannot cope. Brain freeze is the final killer which causes those pilots to make innapropriate descisions or control inputs and knowing your own natural overload limits, how to improve them to avoid them is not only useful for professionals but any pilot hobby or otherwise.

Some time in a simulator or even in an aircraft with a suitable instructor who purposely loads you till you loose the plot can be an eye opener as making you realise where your limits lie and that does vary hugely from pilot to pilot.
Many of us think we are better more capable than what we are and such an experience can be very humbling which is far better than being humbled or worse for real and in a nasty real situation. We have all had brushes like Mary quotes above (I have had plenty) which are a wake up call and neatly get loaded into our computer memory banks as experience! that is if we are lucky enough to survive.

Pace

funfly
2nd Jun 2010, 08:25
I consider myself a 'safe' pilot certainly non adventurous. However in my flying life I have to admit that twice I have found myself in a situation where I realised that my own actions have placed me in a situation where I was at risk. I resolved each by staying cool but fully understand how easy it would be to let it all be too much.
I like to think that these incidents did me more good than harm as I will never allow myself to get in the same position again.
However times a mother tells her child not to stick his fingers in the fire he will only refrain after he has actually done it!
Because of this fact of life I tend to agree that simulator training for GA pilots would be a very good thing.

youngskywalker
2nd Jun 2010, 08:36
Biscuit74

I remember attending a CAA safety evening about ten years ago and a chap in the front row went in like a tent peg the week after. Apparently a classic CFIT in crap weather.

I also remember on one of my first ever CAA safety evenings and during a talk by the CAA's chief Medical examiner, one unlucky (or lucky?) pilot in the audience suffered some kind of seizure or fit, suffice to say his flying days were rsther curtailed.

biscuit74
2nd Jun 2010, 10:20
Skywalker -

Gosh. Ten years ago. How time flies. Oops. It may well have been nearly that long ago I was last at a CAA Safety Meeting. I usually forgot or didn't bother to take my logbook along anyway, so can't check.

Interesting you describe it as a 'tent peg'. We used to view that as the last aerobatic maneouvre, whereas stuffing yourself into the cumulo granitus was an error of an entirely different though equally dangerous kind!

IO540 - what other reasons, you intrigue me?

Personally I've long felt that reading the AAIB Accident Reports is a good thing. Some salutary lessons, often of the 'there but for the grace....' style.
Learning from the errrors of others can be a great help & a lot less painful than doing them all yourself.

Fuji Abound
2nd Jun 2010, 10:54
I think the psychology of some accidents is fascinating.

Take the Colgan 3407 accident I referred to at the start of this thread.

The starting point would seem to have been an experienced crew working together in a multi crew commercial environment. It would also seem to include a fully serviceable aircraft operating in conditions which really couldn’t be described as anything other than benign (the risk of very light ice accretion on the approach with nothing to suggest this was any more than expected or had any direct impact on the aircraft). If that is all we knew (as would be the case had it been a light aircraft) the accident would have been a complete mystery and left us wondering how an experienced crew managed to stall in these circumstances. I guess we would have suspected some catastrophic mechanical failure.

In reality it would seem the explanation was much simpler. In fact the crew literally caused the aircraft to stall too close to the ground by pulling back hard on the yoke.

Now it would seem that there was at least one much earlier warning that there were some deficiencies in the commanders flying skills. Apparently while he had not failed any sim checks on three occasions in the recent past he had had issues and had required further review.

The aircraft was fully established on the glide slope and in IMC. The autopilot was flying the aircraft. The speed deteriorated to an unsafe level the autopilot tripped and the stick shaker and pusher activated. The commander pulled back on the stick exacerbating the stall.

So it leaves me wondering where things really went wrong. Put yourself in that cockpit and at that time. From the RT everything appeared totally normally immediately prior to the stall. Things therefore happened very quickly as the aircraft passed through (I think) 2,000 feet. The autopilot tripped and the shaker and warning horn triggered. All of our training you would have thought would kick in and we would unstall the aircraft, but the commander did the exact opposite and the first officer did not intervene.

So you have been to the CAA safety evenings, and you have an instrument rating and 5,000 hours under your belt, you are current and the aircraft is serviceable. Why do you think you wouldn’t make the same mistake? What makes you believe you have the “right stuff” or could we all make the same mistake in those circumstances?

Pace
2nd Jun 2010, 10:57
Safety: Does attitude count for more than experience?

This was the original question hence my comparing the human mind with the Graphics card memory and stored memory.

Put it another way the question above could be
Can a pilot work on a graphics card alone with very little in the stored memory.

The answer to that is YES if he is so careful, so selective, so safety concious that he never needs to work load the Graphic card he has.

If he is unlucky enough to have a bottom of the range low memory low ability card then he would have to be very very careful.

All of our training you would have thought would kick in and we would unstall the aircraft, but the commander did the exact opposite and the first officer did not intervene.

Fuji I deleted a piece I added on a post last night as reading it my post came over as arrogant but I will place it here.

I flew right seat with a Private pilot who was ultra scrupulous, very safety orientated, a big planner but he always went at one speed and that worried me somewhat. Try and speed him up and he complained.

We made an IMC approach and missed due to low cloud. We went around again and at minima I said forget it lets go to the alternative. The guy was sweating and overloaded! He purely pulled the nose up to climb but made no inputs to add power, raise the gear and clean up the aircraft.He was brain locked and had forgotten everything he had been taught in his IMCR. I dived in from the right and took control. Had the pilot been on his own he would have crashed. This happened some 10 years ago.

Your example sounds a little alike??? Maybe your pilot saw the aircraft had sunk below the glide and that became his frozen focus not the speed or stall?

Adendum

Just as an afterthought not all jets are recovered from a stall conventionally.
With the Citations you do NOT push the nose over but hold it level in a stall and power out.


Pace

mad_jock
2nd Jun 2010, 11:34
I don't think it has anything to do with either although both help to protect the clueless.

Common Sense you can't train it into someone but you can train to protect situations developing which would rely on common sense to get out of. Same with experence the more situations seen the more successful the out come mainly because monkey has seen it before had bum bitten and won't do it again.

New situations which is outside either experence or training is where common sense linked to applied knowledge will save the day.

Sorry to go again to use a multi crew example.

I was flying a week in a new airframe (which didn't have an autopilot) which had a, not normally there switch, bang smack in the middle of the avionics/ engine instruments. It had nothing round it to explain what it was for. It was sort of near the radios but also near the GPS. And next to the engine instruments. It was a big-un as well and looked as if it did something and wasn't just a dimmer switch. I saw it on the first day and asked an engineer what it was, as it wasn't in any of the pilot tech books, reply "f'd if I know". I then flew 3 days with a very good FO it was mentioned by him but neither of us was moved it to see what it did. It got left the way we found it.

On the thursday a different FO was working, we tottle off and everything is fine. Ten mins into the cruise at FL180 in IMC with me flying all I hear is "what does this do" while saying this the FO had reached over and flicked the switch. Instant sense of humour crisis on my part.

That second FO still doesn't get why the first FO got promoted to LHS and he was bypassed in both experence and time in the company.

Pace
2nd Jun 2010, 11:55
Mad Jock

Dont tell me it was a Scottish Malt whiskey dispenser and you both had a wie dram enroute ;)

Pace

S-Works
2nd Jun 2010, 11:59
all I hear is "what does this do"

Fired a halon extinguisher in to LH nacelle once doing that...... :O:O

Pace
2nd Jun 2010, 12:12
Fired a halon extinguisher in to LH nacelle once doing that......

Bose could have been even worse like an ejector seat button for the captain ;) I am sure many Co s would love one of those!!! I can think of one of mine who would :E

Pace

mad_jock
2nd Jun 2010, 12:14
I don't to this day have a clue what it did. Always meant to ask an avaionics type to have a look behined the panel to see what it was connected to.

Another feature of this aircraft type was after a certain failure mode of the test logic for the CAP panel. If you pressed the push to test to light the CAP up it would shut the LP fuel valves. They did a mod to stop this feature!!!

Gertrude the Wombat
2nd Jun 2010, 15:20
The aircraft was fully established on the glide slope and in IMC. The autopilot was flying the aircraft. The speed deteriorated to an unsafe level the autopilot tripped and the stick shaker and pusher activated. The commander pulled back on the stick exacerbating the stall.
I really don't get these accidents.

I know that they happen, because I read the reports.

I always thought that the pilots must have been trained, as I have been, to the point where "low-and-slow on approach means push forwards and add power" is completely instinctive.

So, is that just a PPL technique, and professional pilots are taught to forget that and do something else? I can understand the brain freezing up so completely that the pilot does nothing, but I can't get my head around why people go against instinct and training and pull rather than push.

And I would like to get my head round it, because if I don't understand it I don't know any reason why it isn't going to happen to me one day.

:confused: :confused: :confused:

RatherBeFlying
2nd Jun 2010, 15:49
Strange thing -- the more I fly, the more I find I (and others) can make mistakes.

My feeling about the standard training is that it gives us a methodology that, if followed, generally allows a newly licensed pilot to gain experience without killing himself. However that standard training does not cover all the ways pilots can screw up -- sadly I witnessed a fatal accident where the pilot put herself in a situation not covered in the syllabus and overreacted. Then there are the pilots who freeze up -- I saw one roll a Viscount simulator upside down at 16000' and sit there oblivious to my shouts to roll back the other way until we "hit" the ground.

Attending safety evenings and reading accident reports do go a ways in helping pilots learn how they commonly kill themselves.

People do not really learn about something until they start approaching the edge. The trick is of course to come up to it slowly in a controlled manner without sailing over the brink and losing it completely.

But flying requires more than simply learning the rudiments of a task. You also have to learn about yourself and how much you can manage at your current skill level. That skill level can go up and down with currency -- something I encounter with every new gliding season.

Fuji Abound
2nd Jun 2010, 16:25
Gertrude

And I would like to get my head round it, because if I don't understand it I don't know any reason why it isn't going to happen to me one day.

Very well put, and I think that is why I find these discussions so interesting.

I can understand the weather (IMC) related scenarios. I guess many of us have been there ourselves at some point in time. The temptation to have a look can be quite great and before you know it the weather has literally closed in around you.

On the other hand I find accidents like the one referred to above much more perplexing.

Pace
2nd Jun 2010, 16:27
RatherBeFlying

Well said!

With the aircraft locked on the Ils the obvious thing to monitor is the speed as the Captain would be coming back towards VREF Bringing in further stages of flap and drag, His gear would have probably already been down and locked.

The aircraft would up to the autopilot disengaging have been trying to maintain the glide and the localiser so I presume that something had destracted them from what the aircraft was up to to such an extent that the pilot on looking back to the instrument panel was faced with a whole host of incorrect indications.

One would probably have been that the aircraft had descended below the glide. If as stated the pilot had issues in simulator work it maybe that his scan ability was not the best. He may have locked onto being below the glidepath and pulled back oblivious to the more serious problems of lack of speed or thrust.

What could cause them to be so distracted? I have heard of pilots having a major row about something which has nothing to do with the job in hand while on autopilot even on approach crazy maybe but crazy things do happen.

But who apart from them knew???

Pace

mad_jock
2nd Jun 2010, 20:29
Wombat there is a nasty thing called tail stall which we can get in icing conditions. The recovery is to reselect the previous configuration and pull back to unstall the tail.

This became a huge feature of pish from the flight training offices after the dash accident in the US.

In my opinion most companys went over board and started in-graining tail stall recovery in the pilots heads in conditions that it was unlikely to occur. So pilots were seeing half an inch of ice on the wings and then planning to haul the controls back if they got a stall warning.

Completely missing the fact that a tail plane stall you have no warning at all, the nose pitches down when you select the next stage of flap and it gets a bit interesting. No stall warner occurs because either the wing warners haven't got the static point below them to lift the lever and if you have an AoA sensor the critical AoA hasn't been reached for your wings.

Stalling is done on a three year opc/lpc cycle, there are certain things you have to cover but other things are left up to the TRE and time. There are some terrible attempts at dealing with a normal clean stall by very knowledgable professional pilots in my experience.

Gertrude the Wombat
3rd Jun 2010, 20:47
Wombat there is a nasty thing called tail stall which we can get in icing conditions.
Ah, right, thanks. So there is a bit of PPL learning that I would have to un-learn to fly different aircraft in different conditions - the bit that went "the tail never stalls, because aircraft are always designed such that the wing stalls first".

IO540
3rd Jun 2010, 21:24
Tail stall is evidently possible (and like many I have seen the NASA video on the recovery procedure) but I bet that 99% of GA stalls are plain old conventional ones, caused by not knowing what the trim wheel really does (no instructor ever explained that to me during PPL training) and doing slow flight with the plane trimmed for an even slower flight (below Vs in the current config) and then getting distracted, or raising Vs by pulling too much G.

To get a tail stall you need a fair bit of ice, and I don't get a feeling that this happens often enough to be statistically significant in GA.

Fuji Abound
3rd Jun 2010, 21:35
Completely missing the fact that a tail plane stall you have no warning at all, the nose pitches down when you select the next stage of flap and it gets a bit interesting. No stall warner occurs because either the wing warners haven't got the static point below them to lift the lever and if you have an AoA sensor the critical AoA hasn't been reached for your wings.

Yes, but looking at the analysis and report there is no evidence that the pilots thought this was occurring.

mad_jock
3rd Jun 2010, 21:59
Intially some thought it was possibly a tail stall before the final report plus transcript came out.

Fuji Abound
3rd Jun 2010, 22:39
I dont dispute that, but it doesnt seem to be an explanation for why the pilots reacted as they did, unless they elected to ignore every indication to the contrary and were so overwhelmed by their training that they were hell bent on reacting to any stall as if it were a tail stall (which I guess is possible). Are you suggesting that is a possibility?

mad_jock
3rd Jun 2010, 23:38
I was replying to Wombats question about what would require a pull back on the stick instead of push forward.

http://ntsb.gov/Publictn/2010/AAR1001.pdf

He was awake at 03:10 and the accident happened at 22:16 and the previous 72 hours he seems to only have had 1 period in a bed. That night was the infamous first night on earlies which usually means that your not knackard enough to go to bed and sleep to give you 8 hours of kip. They don't go into what he had been working in the previous month but by the look of it he was constantly dealing with jet lag effect of shifting his sleeping patterns.

The accident happened on the third day of earlies which to be honest is the worst one for being knackard. The duty he did that day would not be allowed under the UK FTL's.

Personally I think it was a fatigue issue which caused a brain fart.

Pilot DAR
4th Jun 2010, 02:31
The more I fly, the more I find that my "little voice" is speaking to me. I guess it's the experience. Early on, though I never claimed it, I would have had the excuse that I was inexperienced. I no longer have that excuse available, so I work harder to not need it.

That said, I have noticed moments during flying when I can start to see the holes in the "swiss cheese" lining up. That little voice not only speaks, but it asks me: "could that minor thing that just happened be the first thing in a string of events, which will lead to an accident? Will I be writing about that in the accident report I may have to write? The more I have read accident reports, the more I recall the mention of something seemingly innocent, but definately an element at the beginning of a chain of events. Now I'm trying to spot it all the time - the first hole in the swiss cheese, which if aligned with the rest, will allow me to drop through to the accident. Prevent, prevent, prevent. I cannot afford an accident, it would just be too hard to explain!

People have taken a few too many of the aircraft I have flown, and made a (or a few) poor decisions, which resulted in their loss of life. Though very much less importantly, but memorable none the less, I ended up writing a report for the investigators about the aircraft, and what it did when I flew it, or tested it. This is not a good feeling. thought I have learned that it is hardly ever the plane, which caused the accident.

In every case, the accident could be shown to have a less than adequate attitude toward safety, as a major contributing element. Mostly, little experience was also a factor. For the one where experience was ample, it seems complacency was too....

So it's a blend of attitude and experience. In the best world, they both improve together...

421C
5th Jun 2010, 11:42
Some thoughts to add to this interesting thread.

Firstly, I think a key point is that the risks in flying are multiple and "diffuse". It's not as simple as factors being ranked or dominant (eg. the 'is attitude more important than experience' question). I haven't read the article Fuji mentions, but I guess a theme is that experience is far from being a sufficient condition for safety. The attitude topic is not new, it's been a major element of FAA training for years. See http://www.sportpilot.info/sp/Factors_Affecting_Decision_Making.pdf (http://www.sportpilot.info/sp/Factors_Affecting_Decision_Making.pdf)

Secondly, I would question the "cowboy" point IO made in one respect. Yes, some pilots are consistently cowboyish, and yes, some accident reports do read as, basically, "the guy was a cowboy". But I think it would be a mistake for anyone to think attitude was a fixed, inherent (or even genetic) trait, the sort of thing that can be screened for, and that as long as you aren't the "wrong type", you're fine. Personally, I think that, 95% of the time, I am as attitudinally inclined towards safety as anyone; just the sort of sensible, risk-averse, somewhat nerdy bloke you'd expect to be posting on a thread about safety. I guess I'd pass any psychometric safety test with flying colours. The really difficult thing about safety attitude is that it is very situational. You can always have the very best intentions, but the "pressure of the moment" has an incredible distorting effect on judgement. The "moments" I experience are in the last 30mins before a flight, even more than in-flight. I find it easy for some unanticipated set of circumstances to arise where my judgement ends up being different from what it might have been outside of that "moment". It's not even a conscious decision, along the lines of "ok, I'd rather not, but I am under this specific pressure, so I'll take the risk". It's just a sort of dominoes-toppling thing where, with hindsight, you realise you did something you shouldn't have, despite all the inherent attitudinal best intentions.

Thirdly, I think there's a trait in how GA pilots discuss safety which might be misleading to some. Safety discussions have a tendency to drift into statistically irrelevant minutiae. We like discussing interesting stuff and not banal and boring stuff. One example is glass-cockpit failure modes. I'm a member of a US pilot forum where a debate raged for hundreds of posts about the G1000, potential failures and the merits of different kinds of back-up instruments for IFR safety. People post on those threads with well-reasoned arguments that are laudably safety-motivated. The thing that never gets said (perhaps because it's so obvious to everyone except me, but I think it's mainly because we avoid sounding patronising) is "this is all very interesting, but you do realise that, as GA pilots, we are not (statistically) going to crash and burn because of some deeply technical combination of factors and events? It's (statistically) going to be a really banal bit of bad judgement or a really banal lapse".

The discussion of airline safety is interesting because airline accidents are almost exclusively the result of deep and complex interactions of human and technical factors. The deep, complex factors are almost meaningless for us GA pilots, who, per hour, are hundreds of times more likely to have a fatal accident than a professional 2 crew operation. The key lesson from airline safety for a GA pilot is not in how airline accidents happen, but in how they don't happen. They don't happen for 99% of the "banal" reasons GA accidents happen. Let me restate that those "banal" reasons are things that 'pyschologically' safe and 'non-cowboy' GA pilots do. I don't think that the airline safety record is driven primarily by technology like TCAS and EGPWS. Those technologies improve airline accident rates from one in a million to much better than one in a million. But the key differences between airline and GA safety are little to do with the amazing features of modern jets. They are as "banal" and "boring" as 2 crew, regularly trained, highly current and (I think most importantly) absolutely, unwaveringly, sticking to "Standard Operating Procedures".

For me, a good airline SOP example is one I remember seeing at Bournemouth on a fantastic CAVOK day. A Ryanair 737 was on the ILS at 5 or 6 miles. For some traffic reason, ATC had to tweak their normal approach clearance slightly. I don't remember the details, but it was trivial and blindingly obvious the crew could safely land this 737 on Bournemouth's long runway in these perfect conditions. But the crew called back and said politely, with no hint of exasperation, "sorry, on that basis, SOPs mean we have to go around" and so they did. On the surface of it, utterly pointless; costing the airline thousands and wasting 10 minutes of everyones' time, but it did make me think afterwards about how powerful the benefits of SOPs are, and how it’s both very obvious and very subtle. The power and subtlety comes from the airline profession accepting the “nuisance” of SOPs which might bring no material benefit in 999,999 out of a million times the SOPs over-ride a crews’ judgement. The safety benefit comes from that one in a million occasion when the crews’ judgement would be wrong. I’m not exaggerating the statistics, I think it is fair to think of airline safety in the one-in-millions range.

For a GA pilot, the lesson is simple. Don’t worry about how psychological testing might trap the inappropriate pilot. Don’t worry about the N1 spool-up needed to recover an airliner stall. Don’t worry about most of the regulatory and technical things we debate on forums. If you want to be safe, train regularly, stay current and, perhaps most of all, try and put yourself in an SOP environment. It’s difficult, because 100% airline-style SOPs would impact the cost and utility of GA to an intolerable extent. But the SOPs that would avoid most GA accidents aren’t that difficult; and they might prevent the really banal judgement lapses that can and will happen to any of us.

PS. A good overview of this whole subject is available here:
http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/ccdd54376bfdf5fd862569d100733983/$FILE/Chap%201-3.pdf