September 1, 1994
By Bruce Landsberg
Flying, although not a totally forgiving pursuit, generally allows us to make one mistake and get away with it. Make two and it could be serious. Three strikes and you're out. A recent accident proves this adage.
Most of the time, we fly well within the envelope of the aircraft. There is plenty of margin even if we don't exactly handle the machine with finesse. However, when you go to the outer edges, it is essential to understand the limitations of the equipment. We should also understand that our own limits as pilots will be most conspicuous in the first 100 hours of experience in any aircraft. For the five aircraft types that the AOPA Air Safety Foundation has studied for safety reviews, it comes as no surprise that accident probability is the highest when a pilot is new to the model.
The accident discussed here is still under investigation, so these observations are speculative based upon the preliminary reports from the accident investigation team.
The 26-year-old pilot was an active member of a flying club. He had earned his commercial certificate and multiengine rating within the two months preceding the accident. His logbook showed total flight time of 420 hours but only 4.6 hours in the Beech Sierra involved in the accident. It had been more than a month since the pilot had flown the Sierra, although he had flown other aircraft, notably twins, frequently while preparing for his check rides.
The airport where the accident occurred is a genuine short field with only 2,600 feet of runway. That doesn't sound so short until you consider the obstacles. The trees at the approach end of Runway 33 are probably taller than the typical 50-foot obstacle referenced in most performance charts. At the departure end of the runway is a railway embankment and, beyond that, some buildings. I used to train at this airport, and about once a year, a transient pilot would learn the hard way about short-field procedures. Usually the damage to the airplanes was minor.
The aircraft in this case departed its home base with two on board and picked up two more passengers at a mid-trip refueling stop. It then continued to the destination, where things unraveled quickly.
The winds were variable at 8 knots according to a nearby weather sensor not located on the airport. It was estimated that there would have been a crosswind or possibly a slight downwind component affecting the active runway. With a heavily loaded aircraft, a noticeable amount of wind, a short runway, and a pilot with low experience in type, the margin separating a safe flight and a problem was razor thin.
According to aeronautically qualified witnesses close to the runway, the Sierra "touched down hard on its nose gear. The airplane then went back into the air and traveled another 50 to 100 feet and then touched down hard again. The airplane went back into the air and touched down a third time and bounced back into the air." The bounces were described as quite high rather than flat skips.
There was some debate about whether the propeller hit the runway or if the nose gear was damaged because of the bounces. According to some witnesses, it looked as if the nosewheel had been bent back. "After the third bounce, the pilot applied full power. The flaps looked like they were down about halfway. After full power was added, the airplane started a slow turn to the left and climbed to about 50 feet above the ground. The airplane continued in the slow left turn but did not gain any more altitude and impacted the building."
The Sierra struck a one-story structure off the end of the runway. There were no survivors. The airplane did not burn, and no one on the ground was injured.
In reviewing this accident, we looked for factors that might explain this pilot's actions.
Error number one: Too heavy — According to the preliminary calculations, the aircraft was at least 120 pounds over the maximum allowable gross weight. This would have made it more than 200 pounds overweight on departure at the intermediate stop.
This seems like a deliberate error for a newly rated commercial pilot to overload an airplane to that extent. Many sages who tell you that there is plenty of overload margin have gotten away with it for years. They don't usually talk about short-field situations. We don't know whether the pilot got a full gross check-out, which really is essential in a four- or six-place airplane. They aren't nearly as sprightly when fully loaded, and it's guaranteed to alter your opinion of the performance.
Error number two: Improper configuration — If half flaps were used, as stated by a witness, then the aircraft was not prepared for the short-field environment. If we're going to get the performance stated in the pilot's operating handbook and the steep glide angle that clears the obstacle at a slow speed, full flaps are essential.
Error number three: Too fast/too hard — When there is enough energy to bounce an aircraft three times, it's a pretty good bet that the speed is excessive. One factor may have been that the pilot was accustomed to flying a twin, and the approach speeds in the Sierra may have seemed particularly slow. In polite aviation circles, it's considered bad form to put the nosewheel. down first. It happens most frequently when the pilot is anxious to get the aircraft on the ground in a hurry, such as a short runway. if you find that the airplane is not settling and you're tempted to lower the nose, that's an excellent tip-off that the landing isn't worth salvaging.
Error number four: Too far down the runway — The pilot's home base had a 3,800-foot runway. When we don't routinely operate off a short strip, it takes regular practice or the short-field skills will atrophy quickly. This pilot may have waited too long before starting the go-around, assuming no damage to the aircraft. The rule of thumb says that if you're not on the ground in the first third of the runway, then don't agonize, don't procrastinate — go around, and come back for a second try.
Error number five: Attempting to go around — Timing is everything. If you passed up the chance to go around earlier, take your lumps at the airport boundary, on the ground, at 30 knots. This is far safer than wishing for airspeed and altitude that you don't have 50 to 100 feet up.
The investigators could not determine for sure if the prop was damaged in the bounces, but there is some strong suspicion. The prop was curled in a manner suggesting a prop strike. But the impact area on the building was asphalt-the same material as the runway-so it was impossible to tell from looking at the foreign material on the prop. It was not possible to link the several prop-strike marks on the runway to this accident. There is an understandable desire to spare the aircraft any further damage, but after a prop strike, it's extremely risky to go around. The thrust output may have been critically reduced, not to mention the balance and structural integrity of the prop.
Getting back to our original premise — that it usually takes more than one goof to get you — it's plausible that this accident could have been avoided had the chain been broken at number three. After the first bounce, there was probably time and distance enough to try it again.
But there are other scenarios. Had the airplane been significantly lighter, there might have been enough climb performance to pull out of a bad situation. And, of course, had this all happened at a longer runway, it would have been just another botched landing, assuming no damage to the prop or nosewheel. When all the factors come together and the pilot doesn't take positive action to break the error chain, the consequences can be severe.
The summertime accident record in Alaska is not what the chamber of commerce would like you to hear. June through September, when the hunting and fishing seasons are at their peak, is also the time when many pilots overlook caution to keep the customers satisfied.
The Alaskan Region of the FAA, the Alaska Air Safety Foundation, and the AOPA Air Safety Foundation are asking pilots to weight the risks versus the rewards. Public-service messages on the radio and television are being tried this year to raise safety awareness.
The "anything goes approach" to loading an aircraft frequently results in disaster. Too much game or fish or too many passengers sometimes lengthens takeoff runs right into the trees. There isn't always room for one more.
Inadequate takeoff and landing sites, both on land and water, are another source of problems. When customers are paying $1,000 per day to bring home an Alaskan trophy, the pressure is on the lodges and pilots to deliver.
Marginal weather figures in many of the crashes. Pilots are pressured by their employers to take the trips and make sure that the passengers are delivered to that special fishing spot. The competition between lodges and the air service is intense. The long days and big dollars are seductive.
The cost of summer accidents is phenomenal in terms of insurance, loss of life, and damages. The aviation industry is the key to survival for many of the lodges and must be exercise responsibility when pressured to perform beyond safe boundaries. Although the short-term reward may seem substantial, the key to business and personal survival is sometimes to "just say no." — BL
See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.
April 29, 2016 ePilot Training Tip: DPE scenario 2.0
April 29, 2016 Rare Boeing 247's final flight; Skylane crosses US on biofuel
If the theme for last year's Aircraft Electronics Association convention was Automatic Dependent Sur...
VOLUNTEER AT AN AOPA FLY-IN NEAR YOU!
SHARE YOUR PASSION. VOLUNTEER AT AN AOPA FLY-IN. CLICK TO LEARN MORE >>>
VOLUNTEER LOCALLY AT AOPA FLY-IN! CLICK TO LEARN MORE >>>
BE A PART OF THE FLY-IN VOLUNTEER CREW! CLICK TO LEARN MORE >>>