Below are links to a number of stories I have written on the topic of risk management. They contain the names and stories of men I knew, errors people made, and an indication of the costs. Note that this isn’t second hand tales, or mystery email names, There were real people I knew, and in some cases loved.
Aviation magazines are full of stories about accidents, but two things are different here. Almost never, does a magazine writer have the task of speaking of a person he knew. This distance doesn’t assure objectivity, it just allows condemnation without consideration. Second, I am one of very few business owners that ever makes comments about accidents. If you want people to blindly buy things, everyone knows you don’t talk about dead people. I know this too, but my goal isn’t just to sell things, it is to share the things that others before me took the time to teach me.
Above, a 2006 photo of our friends Bob and Sarah Bean. I can say without the slightest hesitation they are the finest human beings I ever met in aviation. Most people cherish others attached to them by blood, experience or common thought. I shared none of these with Bob; I loved him solely because he was the human embodiment of “Love thy neighbor.” It has been a number of years, but the loss of Bob and Sarah is still a spear in the heart that makes all other cuts seem small.
Risk Management, Experience vs Judgement. “I want to show people that when I am writing a simple sentence like “two personal friends of mine with more than 25,000 hours each” I am not kidding, and the point I am making isn’t some abstract Flying magazine platitude”
Risk Management – Human factors ” The evidence that fools present for the existence of luck is vague and anticdototal at best. Hard, proven and factual evidence for the existence
of Physics, Gravity and Chemistry can be found at any crash site.”
Effective Risk Management – 2,903 words “This was the first time I can clearly say I understood the cost of keeping your mouth shut. This was the first step to me becoming the kind of “Bastard” who publicly points out people doing dangerous things.”
“If only someone had told him……” “they chose to ignore the warnings or discount them for reasons that frequently seem hard to remember after the damage is done.It is not the lack of information, but the willful choice to ignore it that is at the root of trouble.”
Expert Witnesses in civil Aviation trials. “The important point that I would like traditional homebuilders to understand and take away is simple. All three of these men wrote books that purport to be grave warnings about terrible flaws in aircraft designs in aviation. I cannot comment on how strongly any of these men felt about these topics, but I will tell you that each of these men aggressively pursued legal positions on these subjects so they could hire
themselves out as industry experts in some very expensive and damaging lawsuits, including the highest one ever paid out in aviation.”
Steel tube fuselages, “Safe” planes and 250mph accidents “Keep factor #1 in mind: Who is flying? I would rather land a fast wooden plane at night with a zip lock bag of 100LL in my lap, a lit Cuban cigar in my teeth and my feet chained to the rudder pedals than take a trip around the pattern on a sunny day in a Stearman with some of the pilots I have met. I am serious. Avoid these people like your life depends on it, because it does. Make it your goal in aviation not to be one of these pilots.”
Greatest Book on Flying Ever Written, (Is your life worth $16?) “GPS, radios, arbitrary boundaries and written tests have nothing to do with flying. Don’t worry about the test from the FAA: be much more concerned about the one run by Physics, Chemistry and Gravity when you leave the ground as there are much greater consequences to failing theirs. Langewiesche is going to teach you to pass this far less forgiving exam.”
Above, My friend Bruce Smith, a 25,000 hour aviator for whom I had the greatest respect. He was the personification of why we used to hold airline pilots in great esteem. He was a classic Pan Am overseas captain in the Golden Age of jet travel. He was a man who lived life in a way that Teddy Roosevelt would have called strenuous. Bruce raised his children abroad and captained his own sailboat across the Atlantic many times. Eating dinner with him involved immodest drinking and commensurate storytelling. He’d always flown light aircraft. His Navion was the very first airplane I ever worked on as a newly minted A&P.His fun-loving side coexisted with his far more serious morality. His wife was on the Pan Am 103 flight that was blown up by Libyan terrorists over Lockerbie, Scotland. I met Bruce after this when he was living in modest circumstances. He was one of a very small minority of the victims’ families who refused to accept any compensation offered which did not include a Libyan acknowledgement of their involvement. He traveled to Africa and offered his services to anyone willing to do damage to the Libyan regime. He was principle above all else. In recent years, the Libyans admitted their role and denounced terrorism in order to get their assets unfrozen in the U.S. This never would have happened if Bruce and the handful of others had capitulated on their principles.Over the years that I knew him, Bruce spoke little on these subjects. He was far more concerned with getting the most out of the day at hand. But this was all done while living his life according to his code of what was right. The years I knew him were a sterling example of how a principled and resilient man lives. He was truly a pilot in command of his own life.He died in the crash of a certified Swift airplane. He was ferrying a plane only 10 miles. The plane had been sitting outside more than a year. It was not in good condition. The engine failed shortly after take off.
Above our friend Ken Terry, A man of huge influence on Grace’s flying. A pilot of tremendous skill, he had flown more than 40,000 hours. As much as his ability it the cockpit was impressive, it was his human character I respected. He was a hard and principled man who had a difficult time sharing space and conversation with people who chose not to care about, nor get involved in the troubles of their fellow man. He could be gregarious and his friendship came both with great trust and the expectation that you would live up to your side. For people who need others to be “nice”, he was intimidating. If you needed a man with principles who was always willing to fight for them, literally if required, Ken was a person you would have treasured.
At the bottom of this story is a commentary I wrote on human factors several years ago. It was prompted by an internet discussion where several builders were proposing complex arrangements for engine controls and questioning the value of the Nason switch we recommend for engines with electric fuel pumps.
The recommendations we make are in accordance with the things I know about human factors in general aviation. My degree from Embry-Riddle is in Professional Aeronautics, which is basically accident investigation. The classes were a broad variety of subjects in aerodynamics, performance, meteorology, statistics, etc., but we spent a lot of time studying human factors. Most people have heard the saying “Guns don’t kill people, people kill people.” If you had seen all the accident reports and investigations we studied, you would understand my variation “Planes don’t crash, people crash planes.”
Any discussion of risk in GA aircraft that excludes human factors, or even how humans react to an equipment failure is not worth having. Yet, most of the conversations about risk management in experimental aircraft all get focused on reliability of the mechanical systems, as if the people in the plane were never a factor in any homebuilt accident. Know this: Most accidents in homebuilt aircraft are caused by people willfully doing things that any objective observer, even a novice one, could pre-identify as poor decision making.
Lets say you are new to home building, or maybe even aviation in general. You are concerned about safety. One of the most unsettling things to you is reading about accidents, or equipment failures that happened to pilots with 20,000 hours or builders with PhD’s in engineering. If experienced people like that have had problems, what possible hope does a green new guy without experience or specific education have?
Actually, the new guy can be at far lower risk.I have said plenty of times that managing risk is about exercising judgment, period. Experience and training are only a defense if they are combined with exercising good judgment. without the latter, Experience and training only allows the person without judgment to push the envelope further or flirt with how much they can get away with.
The is an age old saying that a new pilot starts off with a full bag of luck and an empty bag of experience, and his has to fill the experience bag before he drains the luck bag. Take this story as 100% bullshit entertainment for non-aviators. In reality, every pilot must be trained in judgment (“Decision making”), and then exercise it while flying as PIC within the limits of his skills, as the day, plane and situation present themselves.
Stay away from any person in aviation who actually believes in ‘luck.’ They have abdicated from the responsibility for taking care of their lives. Understand, even though they ‘sent in their resignation letter’, Physics, Gravity and Chemistry don’t accept these resignations, and they still hold him fully responsible. The evidence that fools present for the existence of luck is vague and anticdototal at best. Hard, proven and factual evidence for the existence of Physics, Gravity and Chemistry can be found at any crash site. The new statistics that used to be people didn’t run out of luck. Most of them didn’t run out of experience or training either. Most of them just decided that it ‘would be alright’ if they tried something that was poor judgment.
The most important thing for a new guy to understand is that it is called “Human Factors”, and not called “random chance.” If accidents happened to people at random like the way people win lottery tickets, the only thing for accident investigators to do would be to divide the total hours flown by the number of accidents, and then brief every single pilot that they would face the same rate. The very premise of accident investigation is that they are inherently preventable.They each have their own probable cause, and humans, not luck, almost always played a role. Understand that role, don’t repeat it yourself, fly within your personal envelope, and you are practicing effective risk management. -ww.
Our 601XL on final to arrive at Oshkosh 2004. The airport, city and Lake Winnebago can be seen in the distance in the photo above. The layout of the controls, including the starter button right above the throttle and the A/B ignition switch above the VSI reflect things I know about Human Factors. We set up the 601XL with 2 fuel pumps and 2 ignitions. If the engine had any kind of a hiccup, the procedure is to throw the A/B switch, go full rich and apply carb heat, period. If it is going to get better, that will take care of it. Pilots who thought that lots more switches would allow them to analyze the instruments in a hiccup, decide if it was fuel pressure or ignition related, then select a different switch combination are kidding themselves. The first thing that disappears in an emergency for a 200 hour pilot is his analytical skills. He is far better off with simple procedure and practice.
Above are 13 Nason switches. These are Part No. SM-2C-5F. In our arrangement, this is the switch that automatically turns off the electric fuel pump when the plane is on the primary ignition but it has no oil pressure. In an accident, the pilot does not have to turn the master off, or even be conscious, this part does the job. Yet, I have read many internet Chuck Yeagers say that if they were about to have a forced landing they would always remember to turn the pump/master off. In 25 years of flying I have been the first person at the scene of four crashes, and the master was on in all four. Human factors training tells you this is an important system.
Think human factors applies to just new green pilots? It doesn’t. I have worked on both Mig-15’s and 17’s. Above is the cockpit of a 15. It is not an easy nor forgiving plane to fly, and their pilots had to have significant training just to survive the plane, far less combat. Look at the panel and see the vertical white stripe; When this plane enters a spin, the procedure is to have the pilot jam the stick forward and align it with the offset white stripe. Even professional pilots benefit from the simplification of procedures. People who like to complicate things rarely are willing to acknowledge any possibility that such a design and their own lack of training under pressure is the actual weak link in the system.
(* note that soviet attitude gyro colors are reversed from western ones, a very serious potential human factor issue.)
Below, the 2008 comments:
Touching on human factors in aircraft; It is a big topic in aviation, a sub discipline in which you can get a Ph.D.. In our application it boils down to this: The least reliable part in most well built planes is the pilot. The funny thing about saying this is people who don’t fly are offended or disillusioned to hear this, people who do fly for fun all have a personal memory or two that keeps them from arguing the point, and people who work in aviation know that this is absolutely true.
Before anyone is too offended, let me say that I include myself in the category of least reliable parts. I have been around enough great pilots to know I am not one. Yes, I can fly stick and rudder planes just fine, and can do so without working instruments etc. But three times in the last 12 years I have been in a plane that was not functioning correctly. At this point, most people, myself included, will fall back on their most basic training and procedures. The saying is that “Your skills will not rise to meet the challenge, they will sink to the level of your training and practice.”
If the training was good and the procedures are simple, good. If you have zero experience with being PIC, it is easy to daydream that under pressure you will have all the analysis skills of a B-36 flight engineer, but you won’t, and if you set your plane up in a way that requires multistep procedures and cross checking instruments and decision paths, you will probably even forget to fly the plane.
I know pilots, like Dan Weseman, Gus Warren, Anthony Hanson and our friend ‘Frosty’ who are immune to stress in the air. Most of us are in a different category. Safety lies in honesty, and honesty requires each of us be truthful when evaluating our skills and laying out or planes for the pilots we can train to be rather than the ones people daydream they are.
Having been in a stressful situation, it is very hard, once safely back on terra firma, to continue to believe that you are in the ‘ice water circulatory system club’, if you have just seen your skills shrink under real pressure. I am OK with this revelation, and I use it to my advantage.*(see below)
Because the Corvair started out life as a car engine, a lot of people with a good background in cars feel like they know a lot about how a plane with a Corvair engine should be arranged. Some things do translate, but if I had to name the single facet of aviation that car people fail to understand, it is how little of their troubleshooting and analysis skills will function when the fan stops. For this reason, the layout should be simple, and the emergency procedures well practiced.
*Risk Hierarchy of piloting:
Most Safe: Daydreamer, never finishes, never flies, dies at keyboard choking on potato chip. Not an aviation statistic.
Moderate Risk: OK training, self illusions never challenged
High Risk: OK training, finds way out of a few jams, thinks he is in ice water club, keeps taking more risks. Often incorrectly eulogized as a member of ice water club.
Acceptable Risk: Good training, realistic self evaluation, practices emergency procedures, OK with getting autograph of guy in ice water club.
Very Low Risk: Card carrying member of ice water club.