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Do we learn from GA accident reports?

I must have read more than a hundred of these.

Most of them identify one of the following

  1. something to do with flying technique
  2. something to do with maintenance
  3. something to do luck (e.g. mid-airs)
  4. no idea what the cause was

1 you can learn from, but you get this generally only if the pilot survives
2 most pilots have no control over (you would have to buy your own plane and get very pro-active about who and how works on it…)
3 most pilots have no control over without changing their style of flying (avoid flying below 2000ft to the maximum extent possible)
4 is the majority of fatal crashes; the report ranges from reasonable speculation to pure bunk e.g. “flight was in VMC” when it’s obvious all 3hrs were in IMC

Administrator
Shoreham EGKA, United Kingdom

I am missing a category, and quite a relevant one for as much as I have read the reports:
0. mindset of crew
in fact a fearsomely large part of accidents are caused by pilots too confident in their own and/or their plane’s capabilities.

EBZH Kiewit, Belgium

… in fact a fearsomely large part of accidents are caused by pilots too confident in their own and/or their plane’s capabilities.

This is what CRM/human factors research summarises under the term “complacency”.

[flying technique] 1 you can learn from, but you get this generally only if the pilot survives

Not necessarily. I have read many accident reports which at some point stated “the pilot was known for doing …” which can be an exlanation, even if it can’t be proven to have been the cause for the accident.

[maintenance] 2 most pilots have no control over (you would have to buy your own plane and get very pro-active about who and how works on it…)

Certainly. But knowing that maintenance is performed by humans and humans do make mistakes should always be kept in mind by every pilot. We all know that the most dangerous aeroplanes are those that come right out of maintenance. We all know that the best designed and maintained engine will fail eventually if someone applies the wrong torque to some important bolt. Reading reports about maintenance related accidents should keep us alert and should remind us to always leave some safety margin for that. (I already mentioned several times that I don’t fly single engine IFR unless I have at least 1000ft of clear air between the overcast and the ground. Exactly for that reason: Leaving some space for maintenace errors/technical faults).

[“bad luck”] 3 most pilots have no control over without changing their style of flying

So yes, why not change one’s style of flying if it increases safety? I am sure that I changed mine a dozen times over the years and some of the changes were triggered by reading accident reports. A lot of these changes were also triggered by attending (mandatory…) CRM seminars, which themselves are nothing but the essence of fifty years of ongoing accident investigation. We are supposed to adapt our “style of flying” in accordance with the latest conclusions from accident investigators. Ideally, the factor “luck” should get away from the accident statistics completely.

[no idea] 4 is the majority of fatal crashes;

If that is true (that it really is the majority), then it will supply the best argument for installing some kind of recording device. Just as it did with commercial aviation five decades ago.

EDDS - Stuttgart

1. Even when the pilot dies, the reports often concludes about maneuvering, e.g. improper correction for crosswind, flying too slow on approach or lifting the nose too high letting speed bleed of after go-around. Sources are traditionally radar tracks, witnesses and the wreckage, but increasingly also GPS logging. It seems that critical maneuvering errors are not as often due to lacking skills as to other things like playfulness or show-off.
2. The pilot may have limited control over critical maintenance errors, but his knowledge, experience and flying skills may well determine whether he will be succesfull in handling the ensuing electrical failure, engine failure, fire, control difficulties or whatever happens.
3. Lack of luck is involved in most accidents, and especially in mid-air, but mid-airs are still rare. Giving information about yourself (transponder and R/T) and getting information about everyone else (R/T and lookout, fancy equipment) still has some effect.
4. If there was an engine failure for undetermined reason, we can learn how to – or how not to – handle it as a pilot. Of course there is a small number of accidents that are just plain mysteries, but it is rare that nothing can be learned.
5A. Weather. In many reports the main conclusion is that the pilot did not get, understand or respect the available information about weather, before or during the flight. This is often about decision-making, which often seems just as critical as flight specific disciplines.
5B. External pressure is present in a number of GA accidents – often weather related, but can also be fuel related or be about ignoring technical defects. A VFR pilot promised to pick up his family so that they could go on a short holiday, but the weather deteriorated to marginal VFR, for which he was not prepared/proficient. He died. Proud pilots are frequently tempted to promise “delivery” at a specific time.

Last Edited by huv at 02 May 11:52
huv
EKRK, Denmark

Proud pilots are frequently tempted to promise “delivery” at a specific time.

It always gives me shivers when pilots on this very forum (!) write about their “dispatch rate”, ideally being 100%. No airline or other commercial operator has ever had that kind of a dispatch rate or would be aiming at it. When there is a technical fault not covered by some procedure, the aircraft stays on the ground. And if there is no spare aircraft available, the flight is cancelled and the passengers get their refund. If the weather at departure, destination and/or alternate(s) is below minimum, the flight is delayed or cancelled. We don’t take off and see “that we can get in somehow because it always worked” if the requirements are not met beforehand. It has taken decades to establish this kind of safety culture in the commercial world (with a lot of victims along the road) but now it is there and it works well. I think it is time that (private) GA of all sizes – and this includes the self flying businessman in his Citation X trying to fly into a VFR airfield in IMC at night – starts to forget about it’s 100% dispatch rate and shift towards 100% accident free operation.

EDDS - Stuttgart

I made the comment to another pilot recently that pilots, while generally prepared to accept others could make big mistakes, rarely accept that they could. Instead they spend money on gadgets and worry a lot about mechanical problems. Given that most accidents are pilot induced, more focus and money spent on understanding how you fly, and getting training to become even better is likely to be a far better investment than a BRS system IR synthetic vision. All of those things contribute to safety but really only make a big difference if the pilot is at the top of his/her game.

And dispatch rate is an output of a form of operation in a particular aircraft – not a target.

Last Edited by JasonC at 02 May 13:19
EGTK Oxford

However, nobody is going to be retrofitting BRS and IR into a plane. If you want the smell of a new plane with a Porsche-like interior, and have the required $750k, you will get these goodies anyway.

Then it comes down to whether you put in the effort to learn to fly it properly.

Last Edited by Peter at 02 May 13:52
Administrator
Shoreham EGKA, United Kingdom

Accident reports are one of the single most important source of learning for any pilot. I’ve been reading them and, for a while, been contributing to them, since before I made my first license in 83 and still find aviation incidents and accidents to be extremely valuable in terms of what can be learnt from them.

Flight Safety is one of the paramount factors in any flight operation. Accident prevention therefore is the paramount goal of every participant in aviation and the conciousness of accident causes and their consequences is much larger amongst the aviation community than in any other form of individual transport.

1 you can learn from, but you get this generally only if the pilot survives

I don’t think so. Most accidents can be analyzed and the cause found despite the fact that the unfortunate crew are no longer with us. Accident analysis today is a highly advanced science and generally quite accurate. Therefore, for the purpose of investigation, it is helpful if the crew can contribute but not absolutely necessary.

3 most pilots have no control over without changing their style of flying (avoid flying below 2000ft to the maximum extent possible

Change of personal behaviour is one of the most evident consequences of learning from accidents. If you thought a particular technique was correct and learn from one or several accidents that it is not, this is one of the essential consequences of accident analysis.

If pilots learn and as a consequence will have less accidents, the pressure by accident investigation boards on the regulators will be less founded to introduce more and more restrictive rules following each incident than if we turn a blind eye.

4 is the majority of fatal crashes; the report ranges from reasonable speculation to pure bunk e.g. “flight was in VMC” when it’s obvious all 3hrs were in IMC / no idea what the cause was.

Don’t know whose reports you are reading but normally, if a cause can’t be determined with any degree of satisfaction, the reports say so.

One very important aspect of accident investigation is that it, as per ICAO Annex 13, has the purpose of PREVENTION and not judistical review and sanction. Unfortunatley, in recent years this has changed in as so far that regulators as well as civil claimants and insurances keep violating this purpose for their own ends and turn accident reports into prosecution papers. This is a fact which has been undermining safety efforts drastically and also has underminded the trust people have in the AAIB’s work, even if the investigators themselfs are not to blame for this development. However, the blame game which has by now invaded a lot of aspects of our lifes to a very high degree has unfortunately had a very negative impact on the way accident investigation reports today can be a benefit for flight saftey.

Best regards
Urs

LSZH, Switzerland

It always gives me shivers when pilots on this very forum (!) write about their “dispatch rate”, ideally being 100%

Now I don’t want to destroy a good shiver, but while “dispatch rate” is fairly well defined in a commercial setting, it isn’t in a private pleasure flying scenario. While the desire to go somewhere in a commercial setting is mostly uncorrelated with the weather, it’s different in the pleasure flying scenario.

I usually (and I bet most people in this forum as well) have at least 3 desirable but mutually exclusive things to do on a weekend. In order to decide what to do I do some ranking. And the desirability of those things that involve flying quickly falls through the bottom if the weather, especially at the destination, is crap. It’s not my idea of pleasure to get wet feet. And that is well before any dispatch consideration is even being made.

Furthermore, for private trips, it’s often an option to shift departure by a couple of hours, which depending on the weather situation, can make a big difference.

So while my dispatch rate may be 80%, it’s because the plans are already correlated partly with the weather.

I’ve largely stopped reading accident reports, it’s just a waste of my time. The conclusion of those reports is just way too predictable, it’s always the pilot. It’s never the aircraft manufacturer, almost never the maintenance company, and certainly never the agency/regulator.

And then the recommendations are often so wrong it boggles one’s mind.

Take for example HBPRE

The airworthiness review necessary for a registry transfer wasn’t done properly by a CAMO, no less. It didn’t bother the maintenance company at the last 100h check that half the engine was to be found in the oil filter, in bits and pieces. Nobody was bothered by the engine running very rough and sputtering.

Now what was the recommendation? Exactly, to add more mandatory inspection and replacement. They were seriously suggesting to require commercial maintenance standards and procedures also for private operation.

So the recommendation in effect was to add more of the very things that failed in this case, i.e. maintenance and CAMO.

But it’s very typical to see recommendations that:

  • might have worked in the case at hand but that’s not even certain
  • no evidence or even investigation whether those recommendations might work over the whole fleet, and whether they are beneficial for the whole fleet
  • no cost-benefit analysis
LSZK, Switzerland

I find this whole safety culture to be exaggerated for private flying. It’s a dangerous hobby for sure, so is driving a motorcycle. People die from time to time, usually because they make mistakes. So what, that’s the risk of life. A private plane crash is like a road accident to me. Reading about a 20 year old drunk and stoned in a car or somebody trying to force a landing on a VFR airfield in heavy IMC is of little use to me. I wouldn’t do either and it’s not my problem if others do.

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