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Almost correctAlmost correct

By David Jack Kenny

Flight requires greater precision than most other activities. Stop your car four feet early at a traffic light, and the driver behind might honk at you. Flare four feet too high, and you’re looking at a hard landing or worse. Getting a fixed-wing aircraft in or out of short, obstructed strips requires not only correct configuration of the hardware but exact control of airspeed. Even relatively routine tasks—initiating the descent at the end of a cross-country, for instance—involve details that provide little margin for error. And while some of us might tolerate compromised equipment in our ground vehicles, there’s no place for this in the air.

At about 9:45 on the morning of Dec. 18, 2013, a turbocharged 1980-model Beech Bonanza left Woodbine Municipal Airport in New Jersey on an IFR flight plan to Charlottesville, Virginia. The weather was fine and the flight proceeded without incident. At 11:04 a.m. the pilot was handed off to the Charlottesville tower and reported that he was 13 miles east at 4,300 msl. The controller directed him to enter a left base for Runway 21 and report three miles out.

Four minutes later, the 2,200-hour commercial pilot declared an emergency because his engine was “dying.” He confirmed that he was the only one on board and estimated that he had two hours’ worth of fuel remaining. His last radio call came two minutes after that when he transmitted that he’d be unable to reach the airport.

The airplane came to rest about three miles east of the field. The 200-foot wreckage path began with damage to two trees and ended in the front yard of a home. The outer portions of both wings were separated, and blighted vegetation along the debris field confirmed that the tanks had contained fuel at the time of the crash. The pattern of damage to the propeller blades showed that the engine was not producing power. After it was removed and shipped back to the manufacturer and some impact-damaged components were replaced, that engine started immediately and ran without hesitation at all throttle settings up to full power.

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The reason for the power loss became clear almost immediately. The fuel selector was found set between the left- and right-tank detents, a position in which no fuel could flow. The investigators noted the before-landing checklist in the Bonanza’s POH called for setting the selector to the “tank more nearly full” and concluded that the timing of the power loss was consistent with his having attempted to do so after his initial contact with the tower. Somehow he failed to turn it completely to the intended position—then apparently didn’t recheck it as part of any efforts to restart the engine during those last two minutes of glide.

Photographs of the crash scene showed that the airplane’s fuselage remained largely intact. The NTSB concluded that the accident probably would have been survivable—had the pilot’s shoulder harness not given way in the area of the D-ring behind his shoulder. Wear from the ring had frayed enough of the webbing to render it unairworthy by the manufacturer’s published standards, a fact that should have been detected and corrected during the Bonanza’s most recent annual inspection just one month earlier. The material that remained was inadequate to the stresses imposed by the aircraft’s deceleration, and parted in overload. The autopsy attributed the pilot’s death to “blunt force trauma of the torso.”

The nature and proper use of checklists is one of those matters on which reasonable people can differ. On the argument that the manufacturer knows its products better than any individual operator, some insist on always following them exactly as written. Others counter that the purpose of a checklist is to make sure nothing is overlooked; providing every item is indeed considered, deciding which of them promote rather than detract from safety is the responsibility of the pilot in command. Any time the risk-benefit reward appears unfavorable, it’s legitimate to consider deferring that item or forgoing it altogether. Extending full flaps during preflight could be one example. Switching away from a tank that still contains enough fuel for an approach, go-around, and climb back to pattern altitude might be another. But of course both sides agree that every item undertaken must be performed correctly.

This accident was doubly tragic: It never should have happened, and even if it did, it shouldn’t have cost the pilot’s life. The combination of a moment’s inattention to a routine task he’d performed a thousand times before and accumulated wear on a component most aviators would never think to check became yet another demonstration of the extent to which aviation is “terribly unforgiving of any incapacity, inattention, or neglect.”