Operational Pitfalls (Part One)

Operational pitfalls are traps that pilots fall into, avoidance of which is actually simple in nature. A pilot should always have an alternate flight plan for where to land in case of an emergency on every flight. For example, a pilot may decide to spend a morning flying the traffic pattern but does not top off the fuel tanks because he or she is only flying the traffic pattern. Make considerations for the unexpected. What if another aircraft blows a tire during landing and the runway is closed? What will the pilot in the traffic pattern do? Although the odds may be low for something of this nature to happen, every pilot should have an alternate plan that answers the question, “Where can I land?” and the follow-up question, “Do I have enough fuel?”

Weather is the largest single cause of aviation fatalities. Most of these accidents occur to a GA operator, usually flying a light single- or twin-engine aircraft, who encounters instrument meteorological conditions (IMC) conditions while operating under VFR. Over half the pilots involved in weather accidents did not receive an official weather briefing. Once the flight is under way, the number of pilots who receive a weather update from automated flight service station (AFSS) is dismal. An analysis done by FAA’s Aviation Safety Information Analysis System (ASIAS) found that during a recent five-year period, only 19 pilots out of 586 fatal accident flights received any information from flight watch or an AFSS, once en route. It is important to recognize weather presents a hazard, which in turn can become an unmanageable risk. GA aircraft travel slowly and must fly in the weather rather than above it. Since weather is unpredictable, it is highly likely that during a flight, a pilot will encounter weather conditions different from what he or she expected. These weather conditions are not necessarily severe, like ice or thunderstorms, and analysis has shown that most VFR encounters with IMC involved low clouds and restrictions to visibility.


Scud Running

Scud running, or continued VFR flight into instrument flight rules (IFR) conditions, pushes the pilot and aircraft capabilities to the limit when the pilot tries to make visual contact with the terrain. This is one of the most dangerous things a pilot can do and illustrates how poor ADM links directly to a human factor that leads to an accident. A number of instrument-rated pilots die scud running while operating VFR. Scud running is seldom successful, as can be seen in the following accident report.

A Cessna 172C, piloted by a commercial pilot, was substantially damaged when it struck several trees during a precautionary landing on a road. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The personal cross-country flight was being conducted without a flight plan.

The pilot had purchased the airplane in Arkansas and was ferrying it to his fixed base operation (FBO) in Utah. En route stops were made and prior to departing the last stop, the pilot, in a hurry and not wanting to walk back to the FBO to call flight service, discussed the weather with a friend who told the pilot that the weather was clear to the north. Poor weather conditions prevented him from landing at his original destination, so the pilot turned around and landed at a privately owned airport with no service facilities. Shortly thereafter, the pilot took off again and looped north toward his destination. The “weather got bad” and the pilot decided to make a precautionary landing on a snow-covered road. The road came to a “T” and the airplane slid off the end. The left wing and propeller struck the ground and the right wing struck a tree. The right wing had leading edge compression damage outboard of the root, and the left wing leading edge was crushed near the wing tip fairing. Both propeller blades were bent. As discussed throughout this handbook, this accident was the result of a chain of poor decisions. The pilot himself recalled what he should have done in this situation, “I should have picked a spot to do a precautionary landing sooner before the weather got bad. Second, I should have called flight service to get a weather briefing, instead of discussing it with a friend on the ramp.”



In get-there-itis, personal or external pressure clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for alternative course of action.

“I have to be in Houston by 7 o’clock.” In the previous case, the pilot was simply lazy.

Approximately 15 minutes after departure, the pilot of a Piper PA-34-200T twin-engine airplane encountered IMC. The non-instrument-rated private pilot lost control of the airplane and impacted snow-covered terrain. Prior to the cross-country flight, the pilot obtained three standard weather briefings, of which two were obtained on the previous day and one on the morning of the accident. The briefings included IFR conditions along the planned route of flight.

According to the briefing and a statement from a friend, the pilot intended to land the airplane prior to his destination if the weather conditions were not visual flight rules (VFR). The pilot would then “wait it out” until the weather conditions improved. According to radar data, the airplane departed from the airport and was traveling on a southeasterly heading. For the first 15 minutes of the flight, the airplane maintained a level altitude and a consistent heading. For the last minute of the flight, the airplane entered a descent of 2,500 feet per minute (fpm), a climb of 3,000 fpm, a 1,300 fpm descent, and the airplane’s heading varied in several degrees. The airplane impacted the terrain in a right wing low, nose-down attitude.

Looking beyond the summary, get-there-itis leads to a poor aeronautical decision because this pilot repeatedly sought weather briefings for a VFR flight from Pueblo, Colorado, to Tyler, Texas. During a 17-minute briefing at 0452, he was informed of weather conditions along his planned route of flight that included IFR conditions that were moving south, moderate icing conditions for the state of Colorado, and low ceilings of visibility along the planned route of flight. His next call took place at 0505, approximately 1½ hours prior to takeoff. The pilot responded to the reported weather conditions by saying “so I’ve got a, I’ve got a little tunnel there that looks decent right now…from what that will tell me I’ve got a, I’ve got an open shot over the butte.”

The pilot began the flight 1½ hours after his weather update, neglecting to weigh the risks created by a very volatile weather situation developing across the state.

The National Transportation Safety Board (NTSB) determined the probable cause of this accident was the pilot’s failure to maintain control of the airplane after an inadvertent encounter with IMC, resulting in the subsequent impact with terrain. Contributing factors were the pilot’s inadequate preflight planning, self-induced pressure to conduct the flight, and poor judgment.

Unfortunately for this pilot, he fell into a high-risk category. According to the NTSB, pilots on flights of more than 300 nautical miles (NM) are 4.7 times more likely to be involved in an accident than pilots on flights of 50 NM or less. Another statistic also put him in to the potential accident category: his lack of an instrument rating. Studies have found that VFR pilots are trained to avoid bad weather and when they find themselves in poor weather conditions, they do not have the experience to navigate their way through it.


Continuing VFR into IMC

Continuing VFR into IMC often leads to spatial disorientation or collision with ground/obstacles. It is even more dangerous when the pilot is not instrument rated or current. The FAA and NTSB have studied the problem extensively with the goal of reducing this type of accident. Weather-related accidents, particularly those associated with VFR flight into IMC, continue to be a threat to GA safety because 80 percent of the VFR-IMC accidents resulted in a fatality.

One question frequently asked is whether or not pilots associated with VFR flight into IMC even knew they were about to encounter hazardous weather. It is difficult to know from accident records exactly what weather information the pilot obtained before and during flight, but the pilot in the following accident departed in marginal visual meteorological conditions (VMC).

In 2007, a Beech 836 TC Bonanza was destroyed when it impacted terrain. The private, non-instrument-rated pilot departed in VMC on a personal flight and requested VFR flight following to his destination. When he neared his destination, he contacted approach control and reported that his altitude was 2,500 feet above mean sea level (MSL). Approach control informed the pilot that there were moderate to heavy rain showers over the destination airport. The pilot reported that he was experiencing “poor visibility” and was considering turning 180° to “go back.” Approach control informed the pilot that IMC prevailed north of his position with moderate to heavy rain showers. Their exchange follows:

At 1413:45, approach control asked the pilot if he was going to reverse course. The pilot replied, “Ah, affirmative, yeah we’re gonna make, we’re gonna actually head, ah, due north.”

Approach control instructed the pilot to proceed to the northeast and maintain VFR.

At 1414:53, approach control asked the pilot what was his current destination. The pilot responded, “We’re deviating. I think we’re going to go back over near Eau Claire, but, ah, we’re going to see what the weather is like. We’re, we’re kinda in the soup at this point so I’m trying to get back, ah, to the east.”

At 1415:10, approach control informed the pilot that there was “some level one rain or some light rain showers” that were about seven miles ahead of his present position.

At 1415:30, the pilot asked approach control, “What is the ah, ah, Lakeville weather? I was showing seven thousand and overcast on the system here. Is that still holding?”

Approach control responded, “No, around [the] Minneapolis area we’re overcast at twenty three hundred and twenty one hundred in the vicinity of all the other airports around here.”

At 1415:49, the pilot stated, “I’m going to head due south at this time, down to, ah, about two thousand and make it into Lakeville.”

Approach control responded, “…you can proceed south bound.”

At 1416:02, the pilot responded, “…thanks (unintelligible).”

The radar data indicated that the airplane’s altitude was about 2,600 feet MSL.


There were no further radio transmissions. After the last radio transmission, three radar returns indicated the airplane descended from 2,500 feet to 2,300 feet MSL before it was lost from radar contact.

A witness reported he heard an airplane and then saw the airplane descending through a cloud layer that was about 400–500 feet above the ground. The airplane was in about a 50° nose-down attitude with its engine producing “cruise power.” He reported the airplane was flying at a high rate of speed for about four seconds until he heard the airplane impact the terrain. The observed weather in the area of the accident was reported as marginal VMC and IMC.

The NTSB determined the probable cause(s) of this accident to be the pilot’s continued flight into IMC, which resulted in spatial disorientation and loss of control.

Research can offer no single explanation to account for this type of accident. Is it the end result of poor situational awareness, hazardous risk perception, motivational factors, or simply improper decision-making? Or is it that adequate weather information is unavailable, simply not used, or perhaps not understood? Extracting critical facts from multiple sources of weather information can be challenging for even the experienced aviator. And once the pilot is in the air, en route weather information is available only to the extent that he or she seeks it out if their aircraft is not equipped with operational weather displays.

No one has yet determined why a pilot would fly into IMC when limited by training to fly under VFR. In many cases, the pilot does not understand the risk. Without education, we have a fuzzy perception of hazards. It should be noted that pilots are taught to be confident when flying. Did overconfidence and ability conflict with good decision-making in this accident? Did this pilot, who had about 461 flight hours, but only 17 hours in make and model overrate his ability to fly this particular aircraft? Did he underestimate the risk of flying in marginal VFR conditions?

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