2008 Nall Report - Aircraft Owners and Pilots Association

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takeoff Stalled during 2008 NALL climb REPORT 11 (6.8%) 8 (26.7%) Fatal Loss of control 9 (30.0%) 69 (42.6%) Weight/density altitude Accident conditions Runway 17 (10.5%) 1 (3.3%) Factors: Flight Planning and Decision Making 24 (14.8%) Other 2 (6.7%) 5 (16.7%) 19 (11.7%) 0 10 20 30 40 50 60 70 80 VFR into IMC IFR technique This and the following two sections of the Nall Report examine the pilot-related causal factors of GA accidents in more detail. The discussion of each factor presents detailed information on pilot qualifications and experience, aircraft class, type of operation, and typical types of accidents experienced for each factor. Representative accident case studies are presented throughout. This first section focuses on factors that are related to pilot planning and decision 11 (22.0%) making, and includes accidents related to fuel 11 management (26.8%) and weather. Fuel Management Thunderstorms 90 total/9 fatal Turbulence Icing Other Flight planning Systems operation Contamination 2 (4.9%) Total Fatal Most fuel-management accidents are the result of one of the 4 following (8.0%) reasons: 2 (4.9%) 5 (10.0%) 4 (9.8%) 4 (8.0%) 24 (48.0%) • Flight Planning – Improper preflight planning 2 (4.0%) resulting in insufficient fuel being on board for the 1 (2.4%) planned flight, or inadequate in-flight monitoring of ground speed. 0 5 10 15 20 25 • Systems Operation – Improper operation of the fuel system leading to loss of fuel to the engine, even though fuel is available in at least one tank. Types of Fuel-Management Accidents 3 (33.3%) 4 (44.4%) 2 (2.2%) 2 (22.2%) 22 (24.4%) 66 (73.3%) 21 (51.2%) Total Fatal 0 10 20 30 40 50 60 70 80 • Contamination – Use of fuel containing water, sediments, or other foreign substances that prevent proper operation of the engine. • Improper Fueling – Servicing of the aircraft with the wrong type of fuel, or adding the wrong amount of fuel even though preflight planning was accomplished correctly. Nearly three-quarters of the fuel management accidents (66) resulted from improper preflight planning (Figure 20). The systems operation category includes seven accidents, two of them fatal, caused by fuel line unporting due to aggressive maneuvering. Characteristics of Fuel-Management Accidents More than half (48 of 90, or 53.3 percent) occurred within five miles of an airport. They were not concentrated among inexperienced pilots: Half of the private pilots involved had more than 500 hours total time; three-quarters of the commercial pilots had more than 800 hours. At least three-quarters of the accident pilots at every certificate level had more than 20 hours of time in type, with median values of 166 hours among private pilots and 264 for commercial pilots (but only 75 hours for ATPs). Fuel exhaustion (insufficient fuel on board) and starvation (improper operation of the fuel system) accidents were not more common in the more complicated aircraft, but they were more likely to be fatal (Figure 21). Aircraft Involved in Fuel-Management Accidents All Accidents Fatal Accidents Single-engine fixed 65 (72.2%) 4 (44.4%) Single-engine retractable 15 (16.7%) 2 (22.2%) Multiengine 10 (11.1%) 3 (33.3%) Figure 21 Note: The SEF figures include three accidents, two of them fatal, in seaplanes. Figure 20 14 15
ACCIDENT FACTORS: FLIGHT PLANNING AND DECISION MAKING In other ways, fuel-management accidents are fairly typical of GA accidents in general, involving about the same proportions of private, commercial, and airline transport pilots. Student pilots were only involved in two. Eighty percent (72 of 90), including seven of the nine fatal accidents, occurred on personal flights. Instructional flights only accounted for three, none fatal. Ten (including one fatal) were on other types of working flights, with the rest involving three positioning and two business flights. One of the latter was also fatal. Nearly nine-tenths (88 percent), including seven of the nine that were fatal, occurred in daytime. Fuelexhaustion accidents in IMC were rare, but those that occurred in IMC or at night were more apt to prove fatal (3 of 13 compared to 6 of 77 in daytime VMC). Weather 50 total/41 fatal Typical weather accidents occur for one or more of the following reasons: • Continued VFR into IMC – These accidents often result in loss of aircraft control, or collision with the ground (CFIT) as the flight is continued into deteriorating ceilings and visibilities. • Deficient IFR Technique – Failure to follow appropriate instrument flight procedures, including descending below the minimum altitudes during an instrument approach. • Thunderstorm – Flying too close to, or penetrating, a thunderstorm. High winds, turbulence, and icing can result in structural failure and loss of control. • Turbulence – Turbulence associated with high winds, mountainous terrain, and other factors can result in loss of aircraft control. • Icing – Accumulation of ice on the airframe can lead to loss of lift and performance, as well as possible instrument malfunction due to iced-over sensors. Accident Case Study CHI08LA006 Piper PA-28, Festus, Missouri One fatality History of Flight The airplane impacted trees while reportedly en route to the destination airport located approximately 1.5 miles from the accident site. The wooded area was adjacent to a clearing and pasture. Examination of the wreckage revealed the left wing fuel tank was empty and the right wing fuel tank contained approximately one cup of water and one quart of aviation fuel. The right wing fuel line contained approximately one teaspoon of water and one teaspoon of aviation fuel. The electric fuel pump and gascolator contained water. There was no liquid in the carburetor bowl. The engine operated with no anomalies that would have precluded normal operation during a post accident engine run. The airplane flaps were in the fully retracted position and not in the extended position as would have been appropriate for a forced landing. Pilot Information The VFR-only private pilot, age 46, had 327 hours of total flight experience, with 54 hours in the accident make and model during the preceding 90 days. Weather Conditions were reported as night VFR (just before dawn) with clear skies, visibility 7 statute miles, and winds from 170 degrees at 3 knots. Probable Cause The pilot’s inadequate aircraft preflight, fuel system water contamination, and fuel starvation, which resulted in a loss of engine power during landing approach. An additional cause was the pilot’s failure to follow the emergency landing procedure after the loss of engine power. Contributing to the accident were the trees, and night light conditions. ASF Comments This pilot failed to perform the basic planning and preflight functions that every student pilot is taught. Determining fuel requirements that include an adequate reserve and making sure the fuel is free of contamination are critical. 15
Page 1 and 2: 2008 NALL REPORT Accident Trends an
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Page 5 and 6: Overview of 2007 Accident Trends an
Page 7 and 8: 0 1998 2 (22.2%) 2006 2007 ACCIDENT
Page 9 and 10: 30 1998 1999 2000 2001 2002 2003 20
Page 11 and 12: 5% 5% ACCIDENT ANALYSIS At the othe
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Page 15: None of the hours in the logbook ma
Page 19 and 20: Accident Case Study DFW07FA049 Cess
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Page 31 and 32: 31 (10.1%) 33 (11.4%) 30 (11.9%) 0
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Page 35 and 36: APPENDIX Interpreting Aviation Acci
Page 37 and 38: APPENDIX • Climb - From the time
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2008 Nall Report - Aircraft Owners and Pilots Association

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