Category Archives: Decision making

Blowing a Valve Over the Post Office

I was chatting with a fellow on twitter today who had a gear down problem, and made mention of the fact that sharing his experience could be a great learning tool for others. This got me thinking a bit, and I thought, wow, I should probably do the same… and with almost 30 years of flying I have quite a number of them, so here goes. (this is from 1985)

I knew the engine was slightly over TBO, but the compression figures were still looking good. We’d done a top overhaul about 350 hours previously, and were hoping to eek out another 200 or so, before tearing it done for a major overhaul in the fall. A student had come back in from a solo flight, and was crabbing about poor climb performance. Since the density altitude and humidity was pretty high that day, it would have been easy to leave it at that, but we decided it best to check things out before sending out the next student.

As such, I did a ground run up, and checked max rpm, and it was right on the money as far as history goes and such. There were no unusual noises, nor was there any roughness noticed at all. A pre-takeoff checklist also indicated no problems whatsoever.

I then proceeded to taxi out, and did a second pre-takeoff check at the pad, where everything checked out just fine. Tower clears me for immediate takeoff… there is a DC9 in position and hold on the intersecting runway. During the takeoff roll, everything seemed normal… acceleration was typical, as was the climb to about 100ft, and then things started to go south. My first thought was carb ice, being it was a humid day, and I’d often run into such before with this particular aircraft. Of course, by that time, I’d run out of runway, and was right on top of the post office… and upon hitting the carb heat, it was pretty obvious icing was not the problem this time.

Directly in front of me is a residential neighborhood with wires everywhere. To my left and somewhat behind is the remainder of the intersecting runway… too bad, the DC9 had already been cleared for takeoff, and no way was I going to risk a midair, to say nothing of wake turbulence. To my right and slightly behind, is a long street, with a fair amount of traffic, but no wires. Fortunately, since about day 2 of training, I could hear my primary instructor hollering in my ear, “you just lost your engine, where are you going to land”, so I at least knew before takeoff what my options were.

On a positive note, since the engine is still producing some power, I am still able to climb albeit exceedingly slowly. In addition, I’m also making a very shallow bank towards that road. I dont know when or if the engine is going to quit but I figure each foot of altitude gained is a positive. I also knew of a second option, namely that when the long road ended, if I continued the bank another 30 degrees, there was a second road without wires I could use.

As I rolled out of the bank over the road, at now an amazing 200 feet, I called up tower, and said I had engine trouble and needed to land asap. They saw I was in trouble, and cleared me to land any runway… sure, I’d like to use a runway too, but a road will do, turf would do even better, as long as its long and flat enough… but houses or wires would really suck. I also run through the emergency flow at this time to rule out any other problems.

Fortunately, I’m still climbing, and now I’ve changed my plan to the diagonal road without wires. It was looking to be a lot better choice than having to try and land between cars… and if I kept climbing, I might well be able to make it back to an intersecting runway. Then again, a road at a 30 degree angle, puts said intersecting runway at a near 120 degree turn… and no, I’d rather risk a near zero traffic road without wires, than a 120 degree steep turn at low altitude.

Decision time is now coming up again… the engine is still producing power, I’m at roughly 300 feet, and my ability to land on the road will be questionable shortly as it takes an abrupt right turn. On the other hand, at this point, even if the engine quits I can make the airport boundary, and put the plane down on turf even though it will make for an interesting crosswind landing.

Knowing that the airport boundary and turf is assured, I now start a shallow bank to line up with one of the runways. I leave the power setting alone, and continue to try and climb. In fact, I kept power on until I was assured of making the runway. The landing was uneventful, as was the taxi back to the hanger.

ImageI got in, and after shut down, including a shut down mag check, I pulled the prop through to confirm my suspicions. One cylinder had no compression… and based upon the air rushing through the exhaust system, I figured an exhaust value was toast. After pulling the heads off, it turned out the valve itself wasnt massacred like the one in this photo, but the poor valve seat was a goner in a huge way. It was interesting, when we did the major… short of mandatory replacements, and the heads, the rest of the components were well within spec. Its even more interesting that the top overhaul failed at a mere 350 hours, when it should have lasted close to twice that long.

So, what did I learn…

  1. Expedited takeoffs while a nicety can serve to massively limit ones options should one run into trouble. I was in the habit of accepting them automatically.
  2. Its critical to know ones airfield, and have a number of game plans in the event of trouble. Granted, scoping out the area for wires and suitable roads is not always possible. In such an occurrence, it is often best to take the first reasonable choice, rather than making a turn only to find out the 2nd option is loads worse than the first.
  3. Being I knew the glide ratio of my a/c with the power off, and the prop windmilling, I had a reasonably decent idea of how far I could travel subject to my altitude. It should also be noted, that once one is in ground effect, if the surface is flat, the glide ratio often substantially increases. On the other hand, there were multiple embankments, and drainage ditches, expecting to use ground effect would be a bad deal in this instance.
  4. In the back of my mind, I knew I was likely causing more damage to the engine, but figured better it, than the airframe, or worse me. Valve guides are dirt cheap compared to an ER visit, even back then.

Approach-Avoidance Conflict and Flight Training

I was reading @SusanCain’s blog where she writes about approach-avoidance conflict in the public speaking arena, but also a bit more generally as concerns introverts. She presents a short quiz using the terms stop/go which can help folks understand themselves, and how such ties into their decision making process.

Taking this into the flight training arena, someone who scores high on both sections of the quiz looks to be an accident statistic in the making. Ie high scores within the go characteristic often lead to the FAA Hazardous Attitudes Scale factors of Anti-authority, Impulsiveness, Invulnerability, and Macho. High scores within the stop characterization, often lead to the factors of Resignation, and Worry/Anxiety.

In other words, high scores in both arenas would seemingly connect the links of an accident chain; get-home-itis, and impulsivity, often lead to trouble, only to be followed up by worry/anxiety/resignation which pretty much pounds a nail into ones coffin. Whats useful of course, is if a pilot is aware of such, they can be extra vigilant to keep one or more links out of the picture as part of their decision making process.

As we know, self evaluation of HAS factors is a tricky deal. Students don’t like the terms, and say, well gee, thats not how I am, and just blow it off as a bunch of FAA nonsense. The stop/go quiz, being so neutral, might help them think, hmmm, I could see myself slipping into that role/factor, rather than just merely self identifying.

One other statement in the public speaking post that I found of issue was the following:

5. Everyone has both a Stop System and a Go System. But many introverts seem to have extra-strength Stop systems that tend to act up as they contemplate doing scary things like speech-giving.

I’ve often noticed that folks who are more introverted often times have more of a challenge with stalls and or engine out practice, than the go-go-go types. The normal approach to such is to redirect their focus to the end goal, in some cases going so far as to go off syllabi for a bit to re-bolster motivation.

What I had not considered was how introversion / extroversion traits have the potential to link up with HAS. In part this is due to the fact that most hazardous attitude attributes usually don’t show up until much later in flight training. It’s also true, that as a CFI, I consider each and every student unique… One size fits all will invariably result in missing something critical, and one will get burned. On the other hand, bringing some of this to light early on, may well exercise the law of primacy, and get better, and more tailored decision making rolling from the get go, a very good thing indeed.

Pilot Decision Making Jet Blue 292

Aviation decision making and judgement are tough subjects to teach. There is a disconnect between academic knowledge, monday morning quarterbacking, and decisions made in real time. Scenario based training (FITS) is probably a good compromise, but it still lacks the real time psychological issues that dealing with an inflight problem present.

 Thus ASRS reports, and local reviews of accidents and incidents and Wings seminars do provide significant value. Otoh, they are filtered, partically do to time issues, and partially due to the need to be politically correct. Cockpit voice recordings otoh can be incredible tools for teaching, but it is rare for them to enter the public domain.

 While researching existing aviation podcasts this morning, I came across an excellent one from Fly with me . It includes the Jet Blue 292 nose gear incident from Sept 2005, and has actual recordings of the pilot discussion the problem with maintenance. Its an excellent demonstration of using available resources, and the decision making aspects of the pilot in command.

 The podcast is available at http://flywithme.podshow.com/?p=17

United 232 concepts applied to flight instruction part 1

Back when I lived in IA, I was able to meet breifly with Captain Al Haynes after a speaking engagement. He had recently reached mandatory retirement, and was going full bore on a lecture tour. I still believe he is on the speaking circuit, and hearing him in person is a great experience. I did locate an early transcript of his speech , and it is simliar to what I remember from those years back.

This is a multi part article, as he covered a lot of ground, but in the talk, and afterwords.

declaring an emergency
“I don’t know how many light airplane pilots you have here today, but I’ve talked to several groups of several pilots, and this one you can pass on Mary, they’re afraid to say anything, they don’t like to declare an emergency, they’re afraid their’ going to cause some problems or something like that.  And they said to me, well, you have all these resources of United Airlines at your disposal, and the center, and all this.  So do you  Three words: I’m declaring an emergency, and you’ve got it.  All the help you want.”

As flight instructors, we cover the FAR’s and the AIM, and the after effects of declaring an emergency to a T. One of the things it seems we fail to mention is that yes, all the help we need is available, if we ask. Sure, some folks will be ticked off due to delays, or an upset to their daily activities, especially if nothing happens. By the same token, those same people, even though ticked, are darn glad you made it down safely. One of the things Al impressed upon me as a CFI, was to beat it into my student’s heads to ask, and to lessen the emphasis on the after effects. A ton of paperwork, and a harried FAA inspector, is a lot easier to deal with, than a broken airplane, or human injury by either failing to declare an emergency, or not declaring one soon enough. Its obvious to us, it may not be so for a 70 hour private pilot.

post traumatic stress

“Now, I was never one to believe much in post-traumatic stress. had heard it a lot in WWII, from Korean, and Vietnam veterans, and Ithought, well, okay, if such a thing exists, I’ll let it go, because I don’t really believe it.  I believe it now.  And I’m asking you tobelieve it.  It may never happen to you–I’m fortunate enough not tohave suffered PTS–yet.”

Some of us, have experienced close calls, or actual accidents, or incidents that had the potential, or did seriously mess us up. I’m not talking about the student that does something stupid or we get caught off guard, but cases where a crash occured, or an inflight scenario of such a magnitiude, that causes long term significant mental anguish. Please note, this is quite different than the normal short term effects of emotional distress such as one might encounter in a car crash etc. As CFI’s, who have been through such scenarios, we may not talk about these very much. For some, its an issue where they don’t want inadvertantly regulatory oversight, for others, its embarrasement over doing something stupid, and for others, its being the tough guy.

One of the things Al Haynes mentioned was the importance of talking about these things, and doing so quickly, as a way of commencing healing and avoiding potential trouble later. I think this is critical in general aviation. We all know gung ho pilots, some with a 100 hours, some with a few thousand, who all of a sudden quit flying. My guess is, that in many cases, it wasn’t external factors, but something that happened in flight. My concern in this matter, is not loosing a good customer, but more so, someone may well be holding things in, and it could rear up and cause trouble in their life later on. We should encourage sharing of adverse situations, as an integral part of initial and recurrent flight training. An awareness of ways of coping, prior to an event, may be useful to a pilots mental health as well as the obvious impact such discussions can have in preventing future scenarios. Please note, neither Al Haynes in his talk, nor I suggest we grill someone for info, but that we lend a willing ear. I think it is reasonable to discuss this aspect of coping, in combination with ASRS procedures, and regulatory oversight. Despite the medical reporting issues that occur, seeking professional guidance after an event may not be such a bad idea. Remember, EMS, police, and firefighters are often required to do so. The lone pilot should not feel odd,  checking things out if need be, as a preventative measure.

Continue reading United 232 concepts applied to flight instruction part 1