Operational Pitfalls (Part Two)

Loss of Situational Awareness

Situational awareness is the accurate perception and understanding of all the factors and conditions within the four fundamental risk elements (pilot, aircraft, environment, and type of operation) that affect safety before, during, and after the flight. Thus, loss of situational awareness results in a pilot not knowing where he or she is, an inability to recognize deteriorating circumstances, and the misjudgment of the rate of deterioration.

In 2007, an instrument-rated commercial pilot departed on a cross-country flight through IMC. The pilot made radio transmissions to ground control, tower, low radar approach control, and high radar approach control that he was “new at instruments” and that he had not flown in IMC “in a long time.” While maneuvering to get back on the centerline of the airway, while operating in an area of heavy precipitation, the pilot lost control of the airplane after he became spatially disoriented.


Recorded radar data revealed flight with stable parameters until approximately 1140:49 when the airplane is recorded making an unexpected right turn at a rate of 2° per second. The pilot may not have noticed a turn at this rate since there were no radar calls to departure control. The right turn continues until radar contact is lost at 1141:58 at which point that airplane is turning at a rate of approximately 5° per second and descending at over 3,600 fpm.

Wreckage and impact information was consistent with a right bank, low-angle, high-speed descent. IMC prevailed in the area at the time of the accident. The descent profile was found to be consistent with the “graveyard spiral.” Prior to flight, for unknown reasons, the telephone conversations with the AFSS progressed from being conservative to a strong desire to fly home, consistent with the pilot phenomena “get-home-itis.”

The 26 year old pilot was reported to have accumulated a total of 456.7 hours, of which 35.8 hours were in the same make and model. Prior to the accident flight, the pilot had accumulated a total of 2.5 hours of actual instrument time, with 105.7 hours of simulated instrument time.

The following abbreviated excerpt from the accident report offers insight into another example of poor aeronautical decision-making.

The pilot had telephoned AFSS six times prior to take off to request weather reports and forecasts. The first phone call lasted approximately 18 minutes during which time the AFSS briefer forecasts IMC conditions for the route of flight and briefs an airmen’s meteorological information (AIRMET) for IFR conditions. The pilot stated that he did not try to take off a day earlier because he recalled that his instrument flight instructor told him not to take off if he did not feel comfortable.


During the second phone call, the pilot stated he was instrument rated but did not want to take any chances. At this time, the AFSS briefer forecast light rain and marginal conditions for VFR. The third phone call lasted approximately 5 minutes during which the AFSS briefer gives weather, the AIRMET, and forecasts a cycle of storms for the day of flight. The pilot responds that it sounds like a pretty bad day to fly. During the fourth phone call, the pilot states that he has been advised by a flight instructor at his destination airport that he should try to wait it out because the weather is “pretty bad right now” The AFSS briefer agrees and briefs light to moderate rain showers in the destination area and the AIRMET for IFR conditions. The AFSS briefer states that after 1100 the weather should improve.

At 1032, the pilot calls AFSS again and sounds distressed. The pilot stated he wants to get home, has not showered in 1½ days, is getting tired, and wants to depart as soon as possible. The AFSS briefer briefs the AIRMET for IFR conditions and forecasts IFR en route. At 1055, the pilot phones AFSS for the final time and talks for approximately 7 minutes. Then, he files an IFR flight plan. The AFSS briefer states improving conditions and recommends delaying departure to allow conditions to improve. However, this pilot made the decision to fly in weather conditions clearly outside his personal flying comfort zone. Once he had exceeded his proficiency level, the newly minted instrument pilot had no instructor in the other seat to take over.

The NTSB determines the probable cause of this accident to be pilot loss of control due to spatial disorientation. Contributing factors were the pilot’s perceived need to fly to home station and his lack of flight experience in actual IMC.

Flying Outside the Envelope

Flying outside the envelope is an unjustified reliance on the mistaken belief that the airplane’s high performance capability meets the demands imposed by the pilot’s (usually overestimated) flying skills. While it can occur in any type aircraft, advanced avionics aircraft have contributed to an increase in this type accident.

According to the Aircraft Owners and Pilots Association (AOPA) Air Safety Foundation (ASF), advanced avionics aircraft are entering GA fleet in large numbers. Advanced avionics aircraft includes a variety of aircraft from the newly designed to retrofitted existing aircraft of varying ages. What they all have in common are complex avionics packages. While advanced avionics aircraft offer numerous safety and operational advantages, the FAA has identified a safety issue that concerns pilots who develop an unwarranted overreliance on the avionics and the aircraft, believing the equipment will compensate fully for pilot shortcomings.


Related to overreliance is the role of ADM, which is probably the most significant factor in the GA accident record of high-performance aircraft used for cross-country flight. The FAA advanced avionics aircraft safety study found that poor decision-making seems to afflict new advanced avionics aircraft pilots at a rate higher than for GA as a whole. This is probably due to increased technical capabilities, which tempt pilots to operate outside of their personal (or even legal) limits. The availability of global positioning system (GPS) and moving map systems, coupled with traffic and near real-time weather information in the flight deck, may lead pilots to believe they are protected from the dangers inherent to operating in marginal weather conditions.

While advanced flight deck technologies may mitigate certain risks, it is by no means a substitute for sound ADM. The challenge is this: How should a pilot use this new information in flight to improve the safety of flight operations? The answer to this question lies in how well the pilot understands the information, its limitations, and how best to integrate this data into the ADM process.

According to AOPA, government information gathering on accidents does not contain definitive ways to differentiate between advanced avionics aircraft and non-advanced avionics aircraft; however, it is known that the aircraft in the following accident was an advanced avionics aircraft.

In 2003, during a cross-country flight, the non-instrument- rated private pilot encountered heavy fog and poor visibility. The airplane was destroyed after impacting the terrain in a wildlife refuge. Wildlife refuge personnel stated the weather was clear on the morning of the accident. However, later that morning, the weather deteriorated, and the wildlife refuge personnel stated, “the fog was very heavy and visibility was very poor.”

An AIRMET, issued and valid for the area, reported the following: “occasional ceiling below 1,000 feet, visibility below 3 miles in mist, fog … Mountains occasionally obscured clouds, mist, fog …” On the day of the accident, the pilot did not file a flight plan or receive a formal weather briefing from an AFSS.

Examining this accident in more detail offers insight into the chain of events that led to this accident.

  1. On the morning of the flight, the pilot used the Internet to complete three sessions with the Direct User Access Terminal Service (DUATS), filing his VFR flight plan during the third session. He departed in VFR conditions and requested and received VFR flight following until he approached a mountain range at which point he canceled his flight following services and continued en route without further FAA contact.
  2. During the last leg of his flight, the pilot initiated a right turn of about 120°. This turn, which he initiated about 3,600 feet MSL, resulted in the aircraft flying along a narrow valley toward up-sloping terrain. The pilot continued in that direction for another 2 minutes before colliding with a number of trees near the top of a ridge.

The NTSB determines the probable cause(s) of this accident as follows: The pilot’s inadvertent flight into IMC and failure to maintain clearance with the terrain. A contributing factor was the pilot’s failure to obtain an updated preflight weather briefing.

The ASF offered the following comment for educational purposes: the non-instrument-rated pilot in this accident may or may not have been tempted to continue his flight when encountering IMC conditions because he had advanced avionics aircraft equipment on board.

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