NTSB Safety Alert SA-020 - Reduced Visual References Require Vigilance

Reduced Visual Reference s Require Vigilance

Preparation and proficiency may help prevent accidents

The problem

 Historically, a bout two -thirds of all general aviation (GA) accidents that occur in

reduced -visibility weather conditions are fatal.1 These accidents typically involve pilot

spatial disorientation or controlled flight into terrain.

 Even in visual weather conditions, flights at night over areas with limited ground

lighting ( which provides few visual ground references) can be challeng ing.

Related accidents

Sadly, the circumstances of each new accident are often remarkably similar to those of

previous accidents. This suggests that some pilots are not taking advantage of the lessons

learned from such tragedies that could help them avoid making the same mistakes . The

following accident summaries2 provide examples of some common —and preventable —

accident scenarios related to flight in conditions with reduced visu al ground references :

 A pilot with an airline transport certificate was killed when his Aero Commander

680FL airplane collided with mountainous terrain during a personal flight to return his

airplane to its home base . No flight plan had been file d, and the re was no record of

an official weather briefing . During the flight, the pilot flew t he airplane under a cloud

layer and about 1,000 feet above ground level (agl) through a mountain pass. About

1 minute before the crash , the pilot reported that he was having difficulty maintaining

flight under visual flight rules (VFR) and requested an instrument flight rules (IFR)

clearance. His request came too late to prevent the collision.

1 Each year, the NTSB investigates about 1,500 GA accidents in which about 475 people are killed. See the

NTSB data for Review of U.S. Civil Aviation Accidents, Calendar Year 2011 , which is available from the

NTSB’s Aviation Statistics web page at. http://www.ntsb.gov/investigations/data/Pages/aviation_stats.aspx .

Also, t he NTSB safet y study, Risk Factors Associated with Weather -Related General Aviation Accidents , can

be accessed from the NTSB’s Safety Studies and Special Reports web page at

http://www.ntsb.gov/safety/safety -studies/Pages/SafetyStudies.aspx .

2 The accident reports for each accident referenced in this safety alert are accessible by NTSB accident

number from the NTSB’s Aviation Accident Database & Synopses web page at

http://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx . (The NTSB accident numbers are WPR11FA078 ,

NYC08FA157 , and ERA11FA412 , respectively.) Each accident’s public docket is accessible from the NTSB’s

Docket Management System web page at http://www.ntsb.gov/investigations/SitePages/dms.aspx .

SA-020 March 2013 , revised December 2015

 An instrument -rated private pilot and his passenger (the airplane’s builder, who did

not hold an instrument rating) were killed on their way to a popular fly -in when the

pilot lost control of the experimental RV -10 airplane due to spatial disorientation in

instrument meteorological conditions ( IMC). During the last 14 minutes of the flight,

the pilot repeatedly deviated from his assigned altitude and heading and failed to

intercept an instrument approach course . While executing a missed approach , the

pilot advised the air traffic controller that he was going to check the weather at

another airport . Shortly thereafter , the airplane crashed . The pilot was highly

experienced in airplanes equipped with conventional instrument s; however , the

accident airplane had a glass cockpit configuration .

 A private pilot and his passenger were killed when the pilot lost control of his

Cessna 182S airplane while flying under VFR near the destination airport in dark

night conditions . The pilot experienced spatial disorientation while maneuvering the

airplane in an area described as a “black hole.” The airplane made two 180° turns

near the approach end of the runway before it descended in a steep turn. The

investigation found that the airplane’s radio was not configured to transm it. The

circumstances suggest that the pilot may have maneuvered near the runway while

attempting (unsuccessfully) to activate the airport’s pilot -controlled lighting .

What can pilots do?

 Obtain an official preflight weather briefing , and use all appropriate sources of

weather information to make timely in -flight decisions . Other weather sources and

in-cockpit weather equipment can supplement official information.

 Refuse to allow external pressures , such as the desire to save time or money or the

fear of disappointing passengers, to influence you to attempt or continue a flight in

conditions in which you are not comfortable.

 Be honest with yourself about your skill limitations. Plan ahead with cancellation or

diversion alternatives . Brief passengers about the alternatives before the flight.

 Seek training to ensure that you are proficient and fully u nderstand the features and

limitations of the equipment in your aircraft, particularly how to use all features of the

avionics, autopilot systems, and wea ther information resources.

 Don’t allow a situation to become dangerous before deciding to act . Be honest with

air traffic controllers about your situation , and explain it to them if you need help.

 Remember that , when flying at night, even visual weather conditions can be

challenging. Remote areas with limited ground lighting provide limited visual

reference s cues for pilots , which can be disorienting or render rising terrain visually

imperceptible . When planning a night VFR flight, use topographic referen ces to

familiarize yourself with surrounding terrain. Consider following instrument

procedures if you are instrument rated or avoiding areas with limited ground lighting

(such as remote or mountainous areas) if you are not .

SA-020 March 2013 , revised December 2015

 Manage distractions : Many accide nts result when a pilot is distracted momentarily

from the primary task of flyin g.

Interested in more inform ation?

Education and training are essential to improving GA safety. The Federal Aviation

Administration (FAA) Safety Team (FAASTeam ) provides access to online training courses

(many of which were developed by the Aircraft Owners and Pilots Association [AOPA] Air

Safety Institute) , seminars , and webinars as part of the “WINGS —Pilot Proficiency

Program,” which includes targeted flight training designed to help pilots achieve flight

proficiency and develop skills to assess and mitigate the risks associated with the most

common causes of accidents. The courses listed below and others (many of which were

developed by the AOPA Air Safety Institute, a d ivision of AOPA Foundation ), as well as

seminar and webinar information, can be accessed from the FAASTeam website at

www.faasafety.gov . (Course access requires login through an existing or creation o f a free

FAASTeam account .)

 Weather Wise Courses: Ceiling and Visibility and Air Masses and Fronts

 IFR Insights: Cockpit Weather

 Accident C ase Studies: VFR into IMC , Cross -Country Crisis , and Time Lapse

 A Direct Approach to Private Pilot Preflight Briefings

 Aeronautical Decision Making for VFR Pilots

 NTSB – Weatherwise

Other resources:

 The AOPA Air Safety Institute offers several interactive courses, presentations,

publications, and other safety resources that can be accessed from its website at

http://www.aopa.org/ Pilot-Resources/Air -Safety -Institute . (Course access requires

creation of a free account .)

 Pilot's Handbook of Aeronautical Knowledg e (FAA -H-8083 -25A) discusses

aeronautical decision making and risk management in chapter 17 . It provides basic

tools (includ ing the “IMSAFE ” health evaluation , the “DECIDE ” process for

aeronautical decision making, and other tools) to help pilots assess and manage risk.

The Risk Management Handbook (FAA -H-8083 -2) provides a more in -depth

discussion of risk management principles. Both handbooks can be accessed from the

FAA's website at www.faa.gov.

 A Personal Minimums Checklist (based on the “PAVE ” model) that you can print and

tailor to your skill level can be accessed from the FAA ’s Guidance and Documents

website at www.faa.gov/training_testing/training/fits/guidan ce/.

This NTSB safety alert and others , including “In-Cockpit NEXRAD Mosaic Imagery ,”

“Controlled Fl ight Into Terrain in Visual Conditions ,” and “ Thunderstorm Encounters ,” can be

accessed from the NTSB’s Safety Alerts web page at http://www.ntsb.gov/safety/safety -

alerts/Pages/default.aspx .