In this article, I will ask readers to suspend disbelief until you have read the article completely. I am sure you will have your own opinions, about both the article and my own motivation in writing it. I believe, however, that most of you will appreciate the message I am trying to convey and that you will also observe how the stakeholders in aviation safety may be approaching the subject in completely different ways. The key questions are not only about how effective they are individually but how they can remain complementary.
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Ground Rules
The following two pilots are fictitious and not intended to resemble any actual person or pilot. The trouble is that they may resemble pilots that we know. In addition, I have perhaps stereotyped the two examples.
The pilots’ common objective is to plan and execute a safe flight between Northwest Alabama Regional Airport (MSL) in Muscle Shoals to Capital City Airport (CXY) in Harrisburg, Penn., a great-circle of 604 nm. The direct route crosses mountainous terrain in Kentucky, West Virginia, Maryland and Pennsylvania. The two pilots are attending the same conference in Muscle Shoals but are unknown to each other. They also are headed for the same dinner event in Harrisburg where each is scheduled to give a speech and are expected at an informal cocktail reception before the dinner. The last event of the Muscle Shoals symposium ends Friday at 1200. The cocktail reception in Harrisburg begins at 1730 and the dinner and speeches start at 1900. Sunset in Harrisburg is at 1800.
The weather in MSL is good VFR but forecast to deteriorate steadily, thanks to a low-pressure area over western Pennsylvania. The weather is VFR in Alabama, Georgia and South Carolina but marginal VFR in Tennessee, North Carolina and the six New England states. It’s IFR in Kentucky, West Virginia, Virginia, Delaware, New Jersey and New York, with low IFR in Maryland, Ohio and Pennsylvania.
The two pilots fly nearly identical aircraft—1980 Beech V35B Bonanzas. Both aircraft have nearly identical avionics, including a two-axis autopilot, an IFR-approved large screen multi-mode moving map with COM/VOR/ILS/GS/GPS capabilities. The back-up nav/com radio also has a glideslope. Both aircraft have Mode C transponders and weather data link. Pilot A’s Bonanza has a single alternator and instrument pressure pump. Pilot B’s Bonanza has a second pressure pump, a standby alternator and a backup wing leveler.
Pilot A carries no portable navigation devices, considering them redundant since his airplane has the large-screen moving map. Pilot B is carrying a portable GPS with moving map and weather data link attached to a yoke-mounted bracket. He also carries a spare battery for it in the Bonanza’s glove box.
Pilot A’s Flight
Pilot A skips breakfast and attends the full morning seminar in Muscle Shoals to continue networking with attendees. He stayed out late last night partying with his colleagues and maybe had one too many drinks. “Not a problem,” he thought, since it will be more than eight hours by the time he takes off for Harrisburg and he should no longer be under the influence of the alcohol.
He stays to converse with the last speaker, and by the time he arrives at the airport, it’s 1300. He rushes through the pre-flight, noting the left navigation light is out. The autopilot is inoperative, also. It failed several days ago and there wasn’t time to have it fixed. On the inbound flight to MSL, the backup radio failed. Pilot A grumbles to himself about the avionics, but he takes additional time as he scurries around for paper and tape so he can placard the inoperative navigation light and radio). He had placarded the autopilot earlier.
He obtained a complete weather briefing by phone and filed an IFR flight plan. His calculated time en route to CXY is 4+00. He had a hard time finding a legal alternate, but Poughkeepsie, N.Y., (POU) just made it. It’s another 1+00 if he has to miss at CXY, but that will still give him the legal 45-minute reserve, with taxi and climb allowances, using his standard 60-percent power settings.
While taxiing out, he checks his clipboard to verify the VOR accuracy log is up to date and is relieved to see his last entry was 29 days ago. It records a +6 degree error on the number one VOR and a -4 degree error on the number two, using an airborne checkpoint. “No problem,” he thought again, since it’s within the regulation. But maybe that’s why the controller on a previous flight complained he wasn’t on the airway centerline.
Pilot A finally departs MSL at 1330. He knows he might be late for the cocktail reception and considers increasing power. He finally decides not to, realizing he would jeopardize his legal fuel reserve. The flight is choppy since his direct route quickly enters an area of moderate turbulence where tops are between 20-30,000 feet. At least there’s no icing, but the constant turbulence, hand-flying the Bonanza and the lack of quality sleep the night before are taking their toll as Pilot A misses a couple of radio calls.
He is at least satisfied he is legally current for the IFR flight, having executed six approaches under the hood about five months ago. A 300-hour flight instructor who had just received his instrument instructor rating was safety pilot then and was grateful for the flight time, but he didn’t offer much practical insight other than to wonder what it must be like to actually fly in the clouds.
He finally reaches the Harrisburg area at 1730 and notes the ceiling is now 300 feet with ¾-mile visibility. As he is vectored by the controller to the ILS Runway 8 at CXY, he reviews the approach chart one last time. He looks up, puzzled by the sudden stop in the controller’s communication. He quickly notes the two flags on the HSI and then turns to look at the screen on the number one radio.
It’s blank.
Pilot B’s Flight
Pilot B has enjoyed the Muscle Shoals conference but decides to skip the last part of the morning session. While reviewing the forecast weather the previous evening, he decides to retire early and has a single glass of wine with an early dinner. A colleague wanted to have lunch after the morning seminar, but Pilot B takes him to breakfast instead. He also contacts the conference organizers in Harrisburg to tell them he may not be at the cocktail reception but is eagerly anticipating the address he is scheduled to make afterward.
Pilot B leaves the morning session after the keynote speaker finishes at 0930 and takes a cab to the airport. He conducts a careful preflight, noting the right navigation light and marker beacon lights are inoperative. He takes no further action on these discrepancies. The main autopilot exhibited a pitch control problem a couple of days ago and Pilot B took a day off to take the Bonanza to the shop and have the problem diagnosed. A faulty pitch servo was removed for repair and the autopilot is functional in the lateral but not the vertical mode. Neither the shop nor Pilot B made any record or notation about the removed servo or autopilot functionality.
Pilot B notes the weather situation and is concerned about range issues. Instead of flying direct to CXY, he plans a dog-leg route with a fuel stop at Smith Reynolds Airport (INT), Winston-Salem, N.C. The dog-leg adds only 64 nm to the distance and with the “pressure pattern” circulation, it will actually only add 14 minutes to his flight time. Allowing for the fuel stop, this should make the total time en route five hours, rather than four.
Pilot B is wheels-up at 1100. The flight to INT is at 11,000 feet, on top in smooth air with a nice tailwind. Before descending into INT, Pilot B goes on oxygen from his portable bottle for about 15 minutes. As on each leg of every flight, he also notes the accuracy of the two VOR receivers, comparing them both against each other (only one degree difference on this leg) and against his ground track made good. He does not record the results.
After refueling, he departs for CXY, cruising at 9000 feet. The weather slowly deteriorates as forecast, but Pilot B is pleased this leg is generally over lower terrain than the direct route and there is also no turbulence. He’s also grateful he had an intense workout with his favorite instructor four days ago. Although retired, she gave him the equivalent of a thorough instrument proficiency check, including five approaches under actual IMC conditions. These were the only approaches he had in the last six calendar months, although he regularly flies in the system IFR and often in IMC conditions.
Per mutual agreement, the proficiency flight was conducted as a scenario that emphasized risk management, workload and task management, automation management, working in the ATC system, maintaining situational awareness and realistic failure scenarios. Items like standard holding pattern rules got short shrift since both Pilot B and the instructor agreed that all that matters in entering a hold is staying in protected airspace. Since her instructor certificate recently expired, she apologizes that she is not able to sign off the proficiency check in Pilot B’s log book.
Pilot B finally arrives in the Harrisburg area at 1600 and is vectored for the ILS to Runway 8 at CXY. The weather is 400 overcast with one mile visibility but the temperature/dewpoint spread is dropping.
Pilot B tunes both radios for the ILS, but a minute later during his scan he notices the number one radio has failed. He switches to COM 2 and informs the controller. After the final vector, he hand-flies the approach, breaks out at about 400 feet agl and lands. He is pleased with the safe flight but gently chides himself for having inadvertently left both his pilot and medical certificates back in his other briefcase in his home office before the current round of flights.
After the cab ride to the hotel, Pilot B takes a short nap and is so refreshed that he goes to the cocktail reception and mingles. He later gives a well-received address to the dinner audience. After the dinner in the lounge, there is a lot of talk about the other speaker, who did not show up and has not been heard from.
Some Questions
Is this a setup? Of course! Even in a serious safety journal such as this one, it’s acceptable to postulate hypothetical situations such as this one and be somewhat judgmental.
First of all, the obvious: Pilot A is a poor risk manager, but in my view he is not atypical from a lot of pilots out there. Pilot B doesn’t get a pass either (more on that below), but let’s look at Pilot A’s risk management sins using the commonly applied “PAVE” risk identification acronym (Pilot, Aircraft, Environment, External pressures). These are summarized in the sidebar on the opposite page. Several of the unmitigated risks that Pilot A assumed had potentially “catastrophic” consequences (defined as resulting in fatalities and/or aircraft loss) and at least a “remote” chance of happening if not “occasional” or “probable.” Yet in this set piece scenario, he failed to take actions to mitigate them, such as Pilot B did.
What will happen to our intrepid Pilot A, who prides himself in regulatory compliance? If he still has his wits about him and doesn’t suffer any more “unfair” equipment failures, he might climb away from Harrisburg as he squawks 7600 and then 7700 and dead reckons his way east. He might try to let down off the New Jersey coast and scud run his way north in the darkness, until he finds marginal VFR around New York City (!), perhaps navigating up the East River (hopefully not turning west into downtown Manhattan), and then safely plunking it down at La Guardia. Since it’s about 6 or 7 pm on a Friday night, this course of action would be viewed dimly by controllers and isn’t likely to win more friends for general aviation among politicians and the media.
Compliance vs. Managing Risk
Some time ago, as the FAA’s former lead general aviation executive, I noted the FAA’s inspector training material stated “a pilot can be in compliance with the regulations and still conduct unsafe operations.” So we have Pilot A ending up in dire straits because he was a poor risk manager, even though his flight presumably fully complied with the regulations. Pilot B, on the other hand, arrived safely by properly managing the risks even though he was clearly in violation of at least the following regulations (and probably more).
• 61.3(a)(1) and (c)(1), Carriage of pilot and medical certificates;
• 61.57(c)(1)(i) and 61.57(d), Instrument currency and proficiency check;
• 91.213(d), Inoperative equipment;
• 91.171(d), VOR receiver check;
• 91.407 and 43.5(a), Return to service following maintenance.
I was at one time tempted to postulate “Wright’s Corollary” to the FAA Academy statement: “A pilot can be in non-compliance with the regulations and still conduct safe operations.” This will not work in my view because of one simple reason: It’s not professional.
Unless he is involved in an accident or incident, Pilot B’s non-compliance will not attract attention from the FAA. But we can’t give him a pass because he crossed a line we attribute to all professionals: They comply with all regulations and standards, even when they don’t make sense and even if they’re stupid.
I will postulate this standard applies to any pilot with passenger-carrying privileges.
Some Practical Advice
Using Pilots A and B as models for what not to do is useful, but it’s better to suggest steps that pilots can use to avoid the missteps of these two fictitious characters. Here’s what I suggest if you fly in high performance general aviation aircraft under IMC regularly.
• Take risk management training and use effective risk management techniques on every flight.
• Be especially wary of certain equipment outages that might leave you with a single layer of capability.
• If you fly in IMC regularly, consider installing backup capability for critical systems, such as electrical and vacuum/pressure systems.
• Autopilots are especially critical in risk management. An inoperative autopilot in my view demands higher minimums or other pilot risk mitigation.
• Minimum regulatory fuel isn’t enough for many IMC situations. Plan accordingly.
Robert Wright is a former FAA executive and President of Wright Aviation Solutions LLC. He is also a 9300-hour ATP and holds a Flight Instructor Certificate. His opinions in this article do not necessarily represent those of clients or other organizations that he represents.
