Risk Management, Judgement Error, money in the wrong place.

Builders,

Below is a five-year old photo of a 601XL built by a great guy named Ken Lien in WA.  Paint job on the plane is super detailed, and it easily could have been a champion at Oshkosh.  The major impediment to that happening is that Ken is dead and the plane was destroyed on the very first flight.

Although I spoke with him many times, I met Ken in person just once, at the Arlington airshow. By coincidence, one of his life long best friends has a hangar 700′ from mine and is in my EAA chapter. He told me many times what a great human being Ken was. I don’t doubt him at all; after 25 years in aviation I fully know that when builders make a serious error, physics, gravity and chemistry kill them without taking any consideration of what kind of life they led on the ground. It isn’t fair, but they are ‘inhuman’ like that.

I will share the highlights: Ken spent 18 months and thousands of dollars painting the plane. When I saw him at the Arlington show, he told me that the plane did not run well. We went over a lot of points, but I was pretty sure is was his MA3-SPA carb. To eliminate any possibility it was ignition, I handed him a brand new distributor. When he got home he confirmed that it ran exactly the same with new ignition. From this point he had the carb on and off the plane many times. What he did not do was send it into D&G fuel systems like I suggested for a $500 overhaul. He ran the plane up and down the runway several times, but did not run a ‘two minute’ full power test.

On the day of the first flight, he may not have intended to go, He had not flown in years, had no biannual and had no transition training. He took off and flew away from the airport. The engine quit a short time later. He crashed in a school yard, running into a brick wall inverted. Fortunately it was a Sunday and the place was empty. There was no fire. The airframe was destroyed, but in the news photos you could clearly see the flowing checkerboard paint job, with all it’s detail.

It is later found that he reassembled the carb incorrectly. It had floated over to idle cut off on its own. If he had run a two-minute test it would have done this on the ground; if he had spent the $500 for the overhaul it would have been correct; if he had stayed over the airport, he very likely could have glided back. But those are all things someone exercising good judgement would have done, along with getting back into flying in a controlled way. Again, I am sure he was a great guy. There are many people who are great people who don’t make good decisions around planes. There are also people who are first class A-holes who exercise good judgement.  Like it or not, the later live a lot longer.

You can read more about the accident on-line, but I want everyone to know I am not slandering the dead here. I have a hand written 4 page letter from a friend in Ken’s EAA chapter describing how people there tried to get Ken to have a professional look at the carb. Long after the accident report, I heard from the guy who covered it, and he confirmed the probable cause. 

It is well worth pointing out that this accident has absolutely nothing to do with Corvairs;The carb was the exact same model that a Continental O-200 uses. Had Ken selected an O-200 instead, he would have had the same carb, and there is no reason to believe he would have done anything different, and he would have ended up dead in the same spot, just the same. And before anyone goes there, it isn’t the carbs fault either, because any other person with good judgement would have just put it together correctly or had a pro do it. This accident had absolutely nothing to do with machinery at all. It was a 100% judgement error.

Ken’s story is not unique, I can think of dozens of builders who I have counseled that a 5th bearing and a good carb are a lot more important than a fancy paint job, a great interior, or any avionics. Think people listen to me? Less than 50% do. In many cases I resort to sharing the Ken Lien story, but it doesn’t change many minds. When a guy who I have worked with is about ready to go flying and he has a Dynon panel, a $2,000 interior and a paint job, but a poor carb, and no 5th bearing, and didn’t set the timing with a light, he may tell people he learned a lot from me, but in my book he didn’t learn a damn thing. If after several years of working together he still makes decisions like that, he missed everything important.

Go to any other website you like and I really doubt that you will find stories like the ones I write. Search for words like ‘Dead’ and ‘Killed’ words that I have used in dozens of stories; smart people never write about this stuff because they know it is bad for buisness…..besides, most people are not listening anyway. But I never learn, I still talk about these themes with the hope of getting people to think. If you are one of the people I am giving a hard time over poor decisions, it is your right to think of me as an A-hole. I’ll live with it. I don’t need to be liked, I am not in this to hold the hand of people without judgement and listen to their rationalizations while they walk straight to the graveyard. -ww

From 2007:  

“We’ve recently received a number of photos from 601 builders nearing the finish line. Check out the progress of Ken Lien of Washington,  Ken sent us a half dozen photos of his very sharply painted XL. “

Risk Management, Factor #1, Judgement.

Builders,

I was at the airport yesterday and spoke with Dan Weseman just after he completed test flight #4 on the Panther prototype. You can read the story of these flights on the Panther blog at:

http://flypanther.net/

Just like the first three flights, the fourth was mechanically flawless. Dan has inspected the aircraft carefully after every flight, but he has not had to make a single change nor adjustment.  This is how every test flight program should go. Theoretically, Dan is flying a new design on a just built conversion engine, and this is thought to be dangerous. But I contend that he is actually at very low risk, because of one single outstanding factor: He has, and exercises, good judgement.

For comparison, let me point out that a number of people are killed in proven homebuilts with certified engines on their very first flight every year. In my 25 years of experience working with homebuilts and homebuilders every day, it is very clear that the number one cause of such accidents is poor judgement.

Ask a 5,000 hour pilot what is the most important risk management factor, and he is sure to tell you it is experience, yet I will tell you that I have had 2 personal friends with more than 25,000 hours each die in a plane because they chose to do something unnecessary and foolish. Ask a PhD engineer what is important, and he is sure to tell you that education is the number one factor. I have had several friends with engineering degrees that had been educated to know better, but still willfully did their last act in aviation against better judgement. Ask a guy who has been getting away with doing stupid things for years and he will tell you it is just luck or fate. Only idiots speak that way. Ask the man of great faith, and he will tell you that God protects.  I will tell you that I have never met a man of greater faith than my friend Bob Bean, but when a poor decision and serious weather came together, Bob’s God protected his soul, but not his mortal life.

Judgement is the vital element, and without it, the other factors, experience, education and all the rest, don’t add up to any protection. Are you new to aviation and concerned because your flight instruction didn’t cover judgement? If the instruction was good it did. Quality instruction spends a lot of time on the subject of “Decision Making,” and this is the topic of Judgement. If your instructor spent more time teaching you radio procedures, then go find a real instructor and correct this error, now, before you fly again.

Here is very simple advice for the new: Don’t spend any time hanging around people with bad judgement. Here is some easy ways to ID them. If they ever use the phrase “It should be alright”; If the person speaks of luck; If they preflight planes while speaking on cell phones; If they are in a rush; If they planned on being home by dark, but then decide night flight is ok because they ran late; If they are poor listeners and finish your sentence for you with the phrase “yeah, yeah, I got it.”; If they brag about things they got away with, pencil whipped annuals or biannual flight reviews where they didn’t actually fly;  If they are inherently cheap or complain about the cost of maintenance that is half what their car dealer charges; Any pilot who can’t tell you the Va speed of a plane he is about to fly;  If they have the slightest tendency to show off in front of people; If you see any of these things, have nothing to do with such people. All of these are signs of poor judgement, and ignoring them and flying with these people is the equivalent of continuing to play Russian roulette.

The past 36 hours brought several examples of poor judgement. An email from a builder who is now taking the advice of his local Corvair car expert over how I teach people to torque flight heads, complete with a follow on email from the expert on how I do things absolutely backwards;  A phone call from a builder who admitted to me that he ordered weak stainless head nuts by mistake, but was in a rush so he bolted the heads on with them anyway. In this process several of the nuts galled, but his solution was to just put more lube on them and put them back on (same man also used uncalibrated Chinese torque wrench to kill most of the studs in his engine on assembly); Third guy is trying to have an 8″ prop extension made for his Corvair, to be used on an airframe with a very high stall speed and little chance of survival in an off airport landing.

Now, back to my point about experience and education being no defense. One of the above people has a PhD in engineering and thousands of flight hours; another comes from a flying family and has attended two Corvair Colleges; another actually considers himself an aircraft mechanic. One of these people has been a paid expert witness at a civil trial over the mechanical judgement of others. I would not fly in any of the planes that these people are working on, and unless these people change what they are doing, neither should anyone else.  I have seen about 50 Corvair projects seriously compromised by people who followed car mechanics over me, including 3 destroyed planes; I have seen countless people use substandard or incorrect parts because they were cheap or in a hurry, this was the direct cause of a fatality on a first flight, and about a dozen destroyed engines; a 7″ prop extension broke a non-5th bearing crank a few hours after I said it would, aircraft destroyed, pilot seriously injured. 

Do you want your first flight to go like Dan’s Panther flights, or do you want me to be typing a story about your judgement in a few years? Is saving $10 that important? Want to “show” people something? Are you going to follow the advice of a car guy because he stops by your shop and pressures you? Think no one would do these things? They already have many times, and there is a long history of these things not working, at times with tragic results. I write about it all the time, but in one way or the other, 1/3 of builders make the same judgement errors. One out of five people flying today have never timed their engine with a light. Right now I could type in 100 stories of poor judgement off the top of my head; Flying 65 hours on break in oil, taking off for the first flight without a working charging system. Flying 4 flights without 1 spark plug connected, a take off and 90 mile cross-country with a completely blown head gasket. First flight with a car distributor with 45 degrees on mechanical advance. Static timing set to 32 degrees. etc, etc, etc.

Who can you trust? Yourself, that’s who. Every single one of the above things was unnecessary. In 75% of the above cases, people knew what they were doing was wrong, but they did it anyway, willfully. That is the definition of poor judgement.  Let’s make up a number and say 1 out of 1,000 people who builds a plane gets killed flying it. The first thing to understand is that it isn’t a random drawing. This is not a lottery, it is almost completely under the control of the people in it.  By my estimation, people who are chronically cheap, always in a rush, don’t do their homework, are show offs, or demonstrate any form of “get-ther-itis” are 50 times more likely to buy the farm. Having 5,000 flight hours is no defense compared to exercising good judgement.

 

I am not clairvoyant, but after 25 years of  studying builders and having the time pass to see how their story works out, I have come to posses a disturbing ability to accurately predict people coming to harm. Every airport has a guy who predicts every single person will come to trouble, and when  1 out of  his 10,000 predictions comes true, he wants to gloat over it. He would likely have a much more somber perspective, like I do if he had my track record of 1 out of 3. If I ever have a detailed conversation with you about rethinking your judgement, take it seriously. I don’t do it often, but I now need two hands to count the names of the people who thought I was kidding or not worth listening to.

 

If I ever seem short-tempered and cranky at times, much of it can be traced to a very ironic reality that I must live with. For 25 years I have worked to teach people they can participate in the best part of aviation, a path where they can learn to count on themselves, to really know what taking control of their life means. The Corvair itself is just good hardware, the real project is yourself. I have seen this work out for many, many people, and I find this very rewarding.  But it remains very ironic that when I am done, the experimental aircraft community will judge the value of our efforts not on the track record of the builders with good judgement who achieved the most,  but on the trouble caused by the ones who had poor judgement, people who would have had issues no matter what type of engine they chose. I have almost no control over this. This irony is true for most people who work in this field, they also know they have little control, so they wisely don’t ever bring up the subject. I’m not that smart, and every now and then, when I have a day with several examples of poor judgement, I try one more time to convince a few more people to exercise better judgement, just as if their life depended on it. -ww