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RV Accident Probable Cause Listings

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Moderator, Asst. Line Boy
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Regarding Doug's new sticky on RV accident probable causes:
http://www.vansairforce.net/AccidentsAndSynopsis.htm

I have to give DR a big atta-boy for creating this sticky. I believe Doug is putting real sweat into giving us what many want and all need: A safe place to discuss aircraft accident lessons learned. It’s a SAFE place because it helps us deal with FACTS without speculation. Forgive the long discussion, what follows is my reason for firmly supporting Doug’s Posting Rule #2:

Firstly, I do believe discussions on aviation mishaps have a time and place here in the VAF. Key phrase: Time and place. Consider my background: I am the former Director of Safety for USAF’s Air Combat Command, and the previous Chief of Aviation Safety for the Air Force. I was responsible for executing Safety Investigation Boards for every Air Combat Command mishap. The F-16 that overran the runway at Oshkosh? My staff executed that safety board for my 4-star general boss, who was the convening authority.

Of all the lessons I have learned in my career, and particularly as a flight safety officer, this is the single most important: You NEVER know what you don't know. Without the benefit of all the evidence, no amount of speculation is EVER accurate. Speculation (particularly on open media) taints investigation boards, inaccurately sways public opinion, feeds media sharks, and ultimately threatens GREAT harm fon an otherwise innocent pilot and his/her family. I spent a tremendous amount of effort keeping interested parties (including big scary generals and congressmen) OUT of my safety boards’ proceedings.

I had one advantage: Military safety boards are conducted under what’s called Safety Privilege. That’s an extension of presidential privilege granted by the Supreme Court to the Department of Defense for safety investigations…that’s SAFETY investigations, not legal investigations. Under Safety Privilege rules, the results cannot be released to the public: Not that it’s classified secret, but it just can’t be released outside the DoD and the actual parties involved in the type of aircraft or command. Why? Two words: Mishap Prevention. Safety Investigation results can only be used for mishap prevention. Not for punitive or litigation purposes, not for the media, but ONLY for mishap prevention. Knowing these protections are in place helps witnesses (including the pilot) to more eagerly assist the investigation…they will not get hammered for mistakes admitted to this investigation board.

So when the media reports that the Air Force has announced the results of their accident board, they are actually releasing the results of a SECOND independent investigation conducted by the Judge Advocate (JA). Yep, that’s the one that involves lawyers, and is used for media, punitive, and litigation purposes. The witnesses are read their rights. The JA’s board doesn’t exist for mishap prevention (it doesn’t even generate safety recommendations). In fact, the JAG’s accident board exists specifically to protect the Safety Board’s privilege. All military services follow this construct, in accordance with DoD instruction and Supreme Court edict.

So why do I agree with Doug? Because ill- and un-informed conjecture is the same as mis-informed conjecture, and it’s all poisonous. That’s why after four+ years as a member of this VAF forum, you have never seen me write about fresh mishaps. People have this inner need to guess and build opinions, but I don’t pass up a perfectly good opportunities to keep my mouth shut and listen.

I strongly disagree with any sort of discussions about an OPEN mishap investigation. So when SHOULD we discuss a mishap? Once the investigation has concluded and the results are released, THEN we have an obligation as pilots to discuss the results in the interest of mishap prevention. At that point, we should definitely discuss it, but I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator’s report, because therein lay the facts. I also submit: Rather than casting darts at what the pilot did, didn’t do, or should have done, we serve each other better by addressing how we can avoid the same calamity if we face a similar situation. What if I face that S-VFR weather in my Skyview-equipped -7A and one of my ADAHRS units has crumped? Would I also flip my -7A on that same grass runway if it’s wet?

Here, Doug has created a process to feed the latest info from CLOSED investigations with the investigators’ statements of probable cause. Now we can discuss these and what-if the event until we're blue in the face. :rolleyes:

Thank you, DR. You’re really working hard to satisfy the needs and wants of the VAF masses.

Fly safe, and CHECK 6!
 
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Colonel, I agree with 96.5%.

Here's the other 3.5:

...but I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator?s report, because therein lay the facts.

Do you truly think the civilian investigative bodies are infallible, or always do complete investigations of experimental crashes?

No sir, I don't.
 
Dan,
I can't disagree with you. However, right or wrong, they are the only entity in the chain that received exposure to the entire body of factual evidence. With that in mind, I'm compelled to base my conversation on their findings.

In any case, once its final, start talking.
 
I have to agree with Dan on this one - the civilian investigating entities are usually not as thorough as what we see in the service. Meaning that a little post-closure speculation helps us all identify where WE may have gone astray in a similar situation. If all we discuss are the exact findings we will inevitably miss an opportunity to learn, teach and/or improve our own methodologies. Think of a new pilot who has never experienced anything like the incident in question and perhaps doesn't even know what COULD lead to the incident - discussing what MAY have gone wrong that would lead to the final result, whether it directly is made clear in the investigation report, brings awareness to the specific set of risks inherent to that phase of operation.

Just my humble opinion...

[ed. If the probable cause has been published, then you're free to discuss all you want! And thanks for the comments. v/r, dr]
 
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Sid, well said.

Very closely aligned with the way things operated in my former life as a fireman.

Speculation before the investigation was finished was very often just simply wrong.

It takes a lot of training and experience to dig all the facts out of a pile of smoldering ashes-------whether the remains of a plane or house. Letting the experts do their job is how the truth can best be found.
 
Do you truly think the civilian investigative bodies are infallible, or always do complete investigations of experimental crashes?

No sir, I don't.

Hardly. Some GA accidents get embarrassingly short shrift. I know of a banner tow crash involving an engine failure after a pickup attempt. NTSB probable cause listed as "pilot?s failure to maintain adequate airspeed while maneuvering near the ground, which resulted in an aerodynamic stall". No mention at all of the engine failure and that crash pics clearly showed one prop blade folded under the airplane, buried in the dirt, and the other blade without a scratch on it. Engine not running. NTSB was never onsite. I guess some crash reports are phoned in by whoever shows up onsite from the local FSDO. I would not expect manpower or money exists to perform detailed investigations of every GA crash.
 
Broad Base of Flight

Doug, thank you very much for collecting and illustrating the RV Accident Probable Cause data in such a comprehensible format. There's so much to learn.

I am an old (53 years old) new pilot (160 hours TT, 20 hours RV-8), so not much to contribute but lots to learn from all of you. I don't want to learn any of these lessons the hard way but rather through the experiences of others. Avoidance is key.

In review of the data under the heading, "Broad Base of Flight" the info provided is very telling.

Is there a simple way to categorically (electronically) sort this info by, "Landing", "Takeoff", "Go Around", "Approach"...?

Can this info be easily imported into an Excel spreadsheet?

[ed. Yes! Just tap Ctrl-A in your browser, then Ctrl-C, then paste into Excel. Play w/the data then as you wish. v/r,dr]

My thought is to take one subject (landing) at a time and learn how to best mitigate against an accident in that category then move to the next one down the line.

Can someone offer a better approach?

Thank you again,
 
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Right on mike.:)

Sid, well said.

Very closely aligned with the way things operated in my former life as a fireman.

Speculation before the investigation was finished was very often just simply wrong.

It takes a lot of training and experience to dig all the facts out of a pile of smoldering ashes-------whether the remains of a plane or house. Letting the experts do their job is how the truth can best be found.
 
I believe pilots should base their comments entirely on the evidence and conclusions captured by the NTSB or FAA investigator’s report, because therein lay the facts.

Please allow an example. Our own Ted Chang suffered an inflight fire after a fuel line b-nut allowed a leak. The report mentions (1) smoke in the cockpit, (2) that the floor burned through, and (3) identifies the b-nut as probable cause.

However, it doesn't investigate the cause of smoke so bad that Ted had to jettison the door. It doesn't mention that the smoke/fire in the tunnel continued to smolder on the ground, or that the fire department had some difficulty getting it to stop. It also fails to mention that the floor burned through only in the narrow area under the tunnel.

We only know these things because Ted, a good and honest man interested in the safety of his fellow pilots, supplied photos and information directly to the group. He had insulated the tunnel with Thermozite, a polyester fiber mat with an aluminum foil reflector. It was sold by a popular vendor as "firewall insulation", which is like saying napalm can be used as bath soap.

Here's the point...a rule, self-enforced or otherwise, required strict adherence to only the information found in NTSB/FAA reports may miss valuable safety information.

[ed. I think I have mentioned this a few times before, but will again. Once the probable cause is published, PLEASE discuss it! If more information comes out, we all benefit. This case you describe here is a great example of that, and thanks for the feedback Dan! v/r,dr]
 
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Accidents

Hardly. Some GA accidents get embarrassingly short shrift. I know of a banner tow crash involving an engine failure after a pickup attempt. NTSB probable cause listed as "pilot?s failure to maintain adequate airspeed while maneuvering near the ground, which resulted in an aerodynamic stall". No mention at all of the engine failure and that crash pics clearly showed one prop blade folded under the airplane, buried in the dirt, and the other blade without a scratch on it. Engine not running. NTSB was never onsite. I guess some crash reports are phoned in by whoever shows up onsite from the local FSDO. I would not expect manpower or money exists to perform detailed investigations of every GA crash.

The NTSB reports have recently started adding a "disclaimer" to the prelims, stating that investigators may or may not have traveled to investigate---. The reality is that most GA accident investigations are done by the FAA FSDO Office. Their investigators may have reasonable accident investigating training and skills, all too frequently they do not. The information they produce is then passed on to the NTSB, the NTSB eventually produces a final report, nearly always with a probable cause.
I know of one very widely publicized EAB fatal where the FAA, "aided by an EAA Chapter member" investigated the accident. There were an unusually large number of witnesses to the accident, many of them very qualified. Everyone except the FAA and NTSB knows that the cause of the accident was fuel exhaustion on takeoff. The probably cause is listed as engine failure for undetermined reasons.
It also appears the NTSB is getting further behind on final reports. They are very quick to use "continued VFR into IFR conditions, even when there is no evidence to support this. But an accident that occurred in the same month still remains open, approaching two years now.
 
Dan and JRS,
I concede that EAB NTSB investigations aren't as rigorous as they could be or ought to be. As Doug said, once the probable cause is published, PLEASE discuss it here.
 
In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George
 
In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

That was my experience. After my RV accident I naively thought the investigators would inspect my engine and systems and run it in a test cell. Nope, I've been watching too many TV investigators. The local FAA guy showed at the scene and then the wreck was trucked off to the salvage yard and never viewed or touched until I bought it back. Probable cause - engine failure on approach for unknown reasons with a contributing factor of no suitable place to land.

Nobody other than me was hurt and there was minimal property damage other than the airplane. They're just not going to spend the time/money without fatalities, newsworthy damage or celebrities involved.

[ed. Greg, thank you for your post! Very informative, and stuff I didn’t know. I watch too much CSSI also <g>.
Kindest and best,
Doug]
 
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In my engineering career, I have participated in and led many formal and informal root cause analyses. One of my morbid hobbies is reading accident reports from many industries, as I believe it can help my awareness of potential problems, technical, personal, and organizational in nature, in my own work as a chemical process engineer.

I have noticed that many NTSB reports tend to quote verbatim the pilot's own description of events (to the extent that bad editing on the investigator's part reveals this often when they fail to change first person pronouns to the second person in the report). The style of reports varies greatly, from excellent ones where the condition of various pieces of equipment and instruments is meticulously described to ones where it is clear the investigator never looked at the wreckage with anything like a critical eye.

It is often easy to tell into the first few words of a report what the probable cause will be, as the style of the report often signals it unwittingly.

I understand from experience that doing a good true root cause analysis can be a long and difficult process due to insufficient data, and sometimes outright deception on the part of the parties to the investigation who wish to preserve their reputations, jobs, and wallets (against liability suits).

I don't know how to fix it, but I strongly believe that more money for the NTSB or FAA is not necessarily the way to go. I would like to see an independent, nongovernmental agency that has no stake in reaching predetermined conclusions to support increased regulation, nor to protect pilots, maintenance staff, and manufacturers from liability, but to reach the true root causes of as many accidents as possible, in the interest of the safety of pilots and the passengers who trust them with their lives.

I understand that the NTSB was made an "independent" organization for this purpose but for every report they generate that does a good job getting to the bottom of an accident, there seem to be several that are quick to just parrot the easy solution: that the pilot in command, being responsible for the safety of the flight, somehow failed to accomplish that task. Some reports seem to be written in ways to support certain pet issues that the FAA or NTSB identifies as common problems that need fixing, with less than stellar backup for those conclusions in the facts contained in the report dockets.

I could ramble on about this for a long time but the fact remains that our analyses could be quite a bit better than they are, to the benefit of all. I respect DR's rule that we wait until the official probable cause is out to begin speculation, BUT I have little faith that those reports are complete in most cases.
 
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FAA

In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

I know of one FAA FSDO office where the staffing has increased by a factor of six since around 1990. The main issue with FAA staff availability is that the FAA too frequently is focused on the wrong issues.
 
Accident Reports

I just reread an accident report from Apr 14, 2007. Information that I expected to find is no longer available. There is no mention of pilot ratings and experience.
The private information that I have gotten is that this was an attempted turn back maneuver following an engine failure on takeoff. There is no mention of the turn back in the report.
In the previously available information it was stated that the accident was investigated by a FAA FADO Inspector. That is no longer mentioned.
The cause is listed as engine failure for undetermined reasons. Everyone that I have talked to knows that the cause was fuel exhaustion.
This accident was widely discussed shortly after the event, including an article in Sport Aviation. Despite the limited information now available it is an excellent opportunity to study how badly things can turn out when a VERY experienced pilot basically ignores all protocols and even common sense and decides to turn a first flight into a three ring circus.
It pains me to say this but there were also some very qualified people present who should have put a stop to the flight. Unauthorized person on board for a first flight.
 
I'll offer an example based on something that happened to someone 'close" to me.

Plane crashes on final. Pilot lives and is, luckily uninjured.

Result of "investigation": Pilot Error - ran out of fuel.

What actually happened: Pilot Error - pilot for got to switch tanks and ran one dry at just the wrong time.

The difference is critical in my mind in that the investigating body based their conclusion there was no gas in the tanks. Of course not because the tanks ruptured on impact and the gas ran out on the ground (no fire for some lucky reason).

Conclusion implied "careless and reckless" action implying poor pre-flight.

Pre-flight as fine as aircraft had sufficient fuel to not only meet FAR minimums but extended reserve for flight planned. Actual cause was distraction and inattention once in flight, not before it. Minor difference - maybe but critical one nonetheless.

The point is to agree with the Colonel to only comment once the report is out but to do so with the firm knowledge that the investigation will only be cursory at best in the case of civilian light planes - especially so if there are no fatalities.
 
In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

....Back in the 70's there was an accident that occurred at or rather near my home airport in So-Cal. This fellow was a very accomplished pilot with many ratings, 13000 hrs. several meticulously maintained aircraft. After the accident and a great amount of time had passed, at least enough for most interest to fully die down. It was determined that the cause was "He didn't have a radio operators license"! Now that is what I would call a comprehensive investigation...:rolleyes:
 
N820RV

Great thread and congrats for making a venue to discuss accidents... it can only help...IMHO...

Once the probable cause is released by the NTSB for N820RV I will be more then happy to share a ton of detailed info and hundreds of pics of the investigation...

I will say right up front.... The NTSB investigator ( Zoe Kelleher) sp? did a VERY indepth investigation over 4 days it was in my hangar where I stored the wreckage under lock and key.... I guess most experimental crashes are just dismissed, but this gal in not like any other NTSB person I have read about...

She even asked to fly in my experimental and we spent a couple of hours taking aerial pics and simulating the entire crash sequence........ I was VERY impressed with her thirst for an answer to the crash...

Ben.
 
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Definitions?

Doug now has plotted the phase of flight when each of the accidents occurred. Does anyone know the FAA definition of each phase? When does take-off end and climb-out begin? When does approach end and landing begin? Etc.

There has to be a regulation that breaks it down.

[ed. Here's the pie chart Philip is talking about. dr]
 
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....Back in the 70's there was an accident that occurred at or rather near my home airport in So-Cal...It was determined that the cause was "He didn't have a radio operators license"!
Speaking only for myself, I would make sure I had personally read that conclusion in an NTSB document before repeating that story.
 
Does anyone know the FAA definition of each phase? When does take-off end and climb-out begin? When does approach end and landing begin? Etc.

There has to be a regulation that breaks it down.

Excellent question Philip.

I did a little Google research and found The International Civil Aviation Organization (ICAO) and the Commercial Aviation Safety Team (CAST), which includes Government officials and aviation industry leaders, have jointly chartered the CAST/ICAO Common Taxonomy Team (CICTT). The team was charged with developing common taxonomies and definitions for aviation accident and incident reporting systems. The common taxonomies and definitions are intended to improve the aviation community?s capacity to focus on common safety issues. CICTT includes experts from air carriers, aircraft manufacturers, engine manufacturers, pilot associations, regulatory authorities, transportation safety boards, and ICAO, and members from Canada, the European Union, France, Italy, Japan, the Netherlands, the United Kingdom, and the United States. CICTT is co-chaired by a representative from ICAO and a representative from CAST.

I knew there had to be a very bureaucratic document that defined the phases of flight.

Enjoy!
http://www.intlaviationstandards.org/Documents/PhaseofFlightDefinitions.pdf
 
Safety of flight exception?

As one of Scroll's investigators at Air Combat Command and the AF Safety Center I have to agree with my former boss.

It is always frustrating when the accident board results conflict with what we found on the safety investigation. Just as it is frustrating to have first hand knowledge that is in conflict with accident board conclusions.

The standard should be to wait to discuss until the results are released.

The only exception we had to discuss prior to release of the public findings was in the case of a safety of flight issue. That is an issue that might cause consideration for grounding the fleet of aircraft, in which case waiting might cause the loss of additional life or airframe. It should be a very high threshold.

Respectfully submitted.
 
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