Teaching the Teachers
By James Williams
Reprinted with permission from FAA Aviation News
In a previous article (“Beyond the $100 Hamburger,” May/June 2007, available online at http://www.faa.gov/news/safety_briefing/2007/media/mayjune2007.pdf), I touched on the importance of preparation and training, especially for flying in mountainous areas. One of the resources mentioned was The Mountain Flying Bible by Sparky Imeson. Mr. Imeson’s book is widely regarded as essential for any pilot thinking of flying in the mountains.
A few weeks later I read about an accident in Winston, Montana, on June 3, 2007. Media reports told a story of a pilot crashing with an instructor on board due to a down-draft. As the story unfolded I learned that instructor was none other than Sparky Imeson and the accident occurred during a mountain flying safety seminar.
The National Transportation Safety Board (NTSB) conducted an especially fast investigation of this accident, issuing its probable cause on July 25. The Board cited “the pilot’s failure to main-tain an adequate airspeed while maneuvering at low altitude in a canyon that led to a stall” and “the pilot’s decision to fly along the canyon wall at a low altitude and low energy state….” (NTSB-LAX07CA187) This was a troubling event because it happened in a training environment. As aviators, we pride ourselves in our strict training to rigid performance standards, but in training there should always be safety built into the system. According to the report, the pilots were flying 300 to 350 feet above the canyon in order to practice the canyon turns. They were expecting to gain added lift over a patch of warm rocks. Instead, they crashed into the rocks after stalling, when the anticipated lift never materialized. As evidenced by the rapid turnaround by NTSB, the “how” of this accident is pretty simple, but the “why” is more difficult to understand. The goal to recurrent training, and all training for that matter, is to build proficiency and enhanced safety. With that in mind, why would any instructor operate so closely to the limit, as to have no safety margin, if things don’t work out exactly as planned?
In an effort to answer these questions I contacted the FAA Aviation Safety Inspector investigating the case and Mr. Imeson. Both provided many useful details and valuable insights. Mr. Imeson, in particular, provided a detailed narrative covering the incident and some of the lessons learned from the experience. For the sake of training and safety, Mr. Imeson put issues of pride aside and critically examined his own actions and those of his fellow pilot. Just as importantly, we must recognize that, if it can happen to him, it can happen to any of us. For a complete copy of Mr. Imeson’s account, you can visit his Web site at http://www.mountainflying.com.
According to his account, Imeson initially set a comfort level of no lower than 500 feet above ground level (AGL) for the flight to allow for a safety margin. Later in the flight Imeson revised his assessment. As he stated, “After flying more than 40 minutes and evaluating the aircraft performance, I told J.C. [the pilot/aircraft owner] that I would revise my comfort level down to about 300-feet AGL.” Imeson also related the accident sequence from his perspective.
Prior to the crash we flew along the side of a large bare and rocky hillside on our right. I would estimate that at this point we were about 500 feet AGL. This was about two miles up the South Fork of Beaver Creek, as the crow flies. I was comfortable and maybe somewhat complacent, while looking down at my lap to check the lesson plan to determine what would next present a challenge for J.C. to perform.
While I was looking down, J.C. transitioned to our left and descended to a small ridge to the south.
When I looked up, we were nearly over this small ridge. I was startled to see we were only about 20 feet above snags that appeared to be at least 80 feet AGL. There was a small drainage on the south side of this ridgeline. I should have said, “Let’s make a left turn and get out of here.” In-stead it turned out to be a grievous mistake to state loudly, “We’ve gotta get out of here.” Someone yelling like that would have scared me (and I’m fearless). This must have startled J.C, because he made an immediate climbing right turn. Although I pushed on the stick and yelled, “Nose down, nose down,” the airplane stalled.
It took some time for the pilots to be located. The aircraft was initially reported missing by Mr. Imeson’s wife, Siew Hwa, at 3:30 pm on the day of the accident. The crash site was located at 9:40 am the next day, nearly 23 hours after the crash and just over 18 hours after the aircraft was reported missing. According to the Associated Press, Mr. Imeson may have made this more difficult by attempting to walk out of the accident area in search of cell phone coverage. Initial reports in the press stated that in more than 18 hours of walking over two days he covered only about 1.5 miles due to his injuries and the rough terrain. Mr. Imeson later re-traced his path with a handheld GPS and determined that he covered over 5 miles in that period. From his re-tracing, he also determined that he had only about 3⁄4 of a mile left to reach houses with telephones. His concern was that the other pilot’s injuries may be more severe than initially visible. He explained his decision as follows, “I figured that if the wreckage was located during an aerial search, then J.C. would be rescued; if not, I had a chance to expedite the rescue effort. So without reservation I told J.C. that I would head down the creek.”
In a safety seminar environment, there should be controls in place to quickly ascertain not only that an aircraft is missing, but also where it could be located. One way of accomplishing this is through the use of Visual Flight Rules (VFR) flight plans. No flight plan was filed for the accident flight. “Through my complacency we had not filed a flight plan.” Imeson said. He continued, “I told my wife we were heading west and would return in about an hour.” Imeson says that the route of flight was more to the northwest and that he feared this would delay rescue. This also factored into his decision to leave the scene.
In researching flying seminars and the safeguards used, I found one in particular that is worthy of noting and that was the Beechcraft Pilot Proficiency Program (BPPP). The BPPP is closely associated with the American Bonanza Society (ABS). The BPPP provides model specific training for Beechcraft pilots via a two and a half day initial course and a two day recurrent course. The courses are held about 12 times a year at various locations around the country. I spoke with Fred Brooks, a member of the BPPP Board of Directors in charge of safety. I also spoke with other members of BPPP while at EAA® AirVenture® 2007 this past summer one of the keys to safety is standardization. All BPPP instructors are standardized every two years and are required to participate in nine of the 12 seminars. This provides an experienced and proficient instructor corps that is well-versed in tried and tested Standard Operating Procedures (SOPs). The strong SOP concept provides a uniform and rigorous training environment that will stay with the student, much like air carrier training systems. The concept of initial and recurrent training is also modeled on the air carrier world. This concept of continuous training in something that FAA is embracing with the launch of the new “WINGS” program from the FAA Aviation Safety Team (the FAAS Team’s Web site is http://www.faasafety.gov.).
BPPP is currently working with the FAASTeam to get its curriculum approved as a part of the new “Wings” program. The curriculum was approved under the old safety program, which expired at the end of 2007.
Another safety feature of the BPPP is the briefings with the air traffic controllers and local pilots to make sure instructors and pilots are well versed in local air traffic procedures and issues. These briefings can also include any difficulties encountered in the previous clinics or in the prior day’s operations. In this way, potential problems can be detected before they become major issues. Instructors and students also review accidents and incidents that involved Beechcraft aircraft to see what lessons can be applied.
The use of VFR flight plans for the training flights is greatly encouraged in case the worst should happen. Pilots are also required to check in and out with a designated operations officer, who monitors the flying sessions to insure that all aircraft and pilots are accounted for. These procedures are strictly enforced. In most cases there are no complaints, because the procedure benefits everyone.
The BPPP is a good model to follow. As the accident in Montana shows, training can be every bit as dangerous as our real world flying. Safety Seminars should be leading the way in providing not only training, but also a safe environment to do it in. Aviation will never be completely without risk. However, our goal should be to reduce that risk where possible, while retaining the fidelity of the training experience. In this way the BPPP is an excellent example for those looking to set up a safety seminar of any kind. Of course, most type of clubs, even those without proficiency programs are excellent sources of valuable safety information and that is what it is all about—flying safely.