NCSA Safety Seminar - NCSA Safety Seminar - 20082008

Complacency…Complacency…The Accident Lurking Within UsThe Accident Lurking Within Us

Richard Pearl, CFIGRichard Pearl, CFIGFebruary 23, 2008February 23, 2008

Complacency: Complacency: A Feeling of A Feeling of Unwarranted Well-BeingUnwarranted Well-Being

• Alfred E. Newman

(Mad Magazine):

”What, Me Worry?” You Should!, Yes!

ACCIDENTS:ACCIDENTS:

““There are no new causes of aircraft There are no new causes of aircraft accidents … just new people making accidents … just new people making

the same mistakes”the same mistakes”

Addressing Soaring (and Flying) Bruno GantenbrinkBruno Gantenbrink

• “Freedom of Flight”

• Organizational Aspects to Accomplish

• Instructional Process

Total = 95%?

• SafetySafety

ArticleArticle: “Safety Comes First”: “Safety Comes First” Bruno GantenbrinkBruno Gantenbrink

• “Gliding in not intrinsically dangerous. It is the way it is practiced that makes it so.”

• “The sentence, ‘The most dangerous part of gliding is the trip to the airport’ is the dumbest, most ignorant saying that has dumbest, most ignorant saying that has found a home in our sport.”found a home in our sport.”

• Most of the accidents/incidents/events we can identify with appear to have a cause rooted in complacency

DEFINITIONS• ACCIDENT (NTSB)

– Accident – “An occurrence…in which any person suffers death or serious injury, or in which the aircraft receives substantial damage.” Substantial damage relates to damage which adversely affects structural strength, performance, or flight characteristics, and would normally require major repairs or replacement of the affected component.

• INCIDENT (NTSB)– Incident – “An occurrence other than an accident which affects or

could affect the safety of operations.”

• EVENT (Unreported)– Events, which falls outside the above definitions, are not reported,

but entail minor equipment bending or “but for the grace of God” situations that could have resulted in an accident or incident.

Event – Accident Pyramid

Aircraft Incident

Aircraft Accident

Hazardous Condition

Unreported “Events”

1

30

300

1,000

Accidents – Root Causes

• System errors or malfunctions –– 5% of all aircraft accidents

• Human Errors –– 95%

• Check List / Distractions• Proficiency / Currency• Complacency

COMPLACENCY:

• Based on Past Success

• Encourages taking things for Granted

• Affects those with the Greatest Experience– Belief in one’s own “press releases”– Successful Repetition– “Safety After Solo”

Phase of Flight

61%15%

9%

15%

Landing

Free Flight

TO/TOW

Ground

(SSA) 2005 ACCIDENT REPORT(SSA) 2005 ACCIDENT REPORT

NTSB GLIDER ACCIDENT REPORTS – 2006 & 2007

• Nationwide – 71 ACCIDENTS

– 7 FATALITIES

• CA / NV– 24 Accidents (24%)

2007 Western AccidentsWHERE A/C WHAT Phase of Flight

NTSB (Jan 06 thru Sept. 07)

Truckee G-102 Wind gust; hard landing; broke gear Landing - airport

Truckee VentusX-C flight; minor injury; a/c totaled; heavy sink; impacted terrain @ airport Landing - airport

Minden G-102Heavy sink in pattern area; glider on runway; landed off field Landing - airport

Llano L-13L-13 impacted stationary DG 505 on adjacent runway after touchdown. Landing - airport

Williams ASW - 27 Sink in pattern; landed short Landing - airport

Tucson, AZ G 103 PIO; tail section separated Landing - airport

Llano G103 Hard land; tail separated; student pilot Landing - airport

Heber Std. Cirrus Stall/spin; spoilers open; on approach Landing - airport

Hemet L-13Sink in pattern; collided with fence; flaps deployed; first solo since L-13 checkout Landing - airport

Minden G 103

Glider transition from PPL; first three solo landing too long…4th solo flt; encountered heavy sink - too slow and stalled short of Landing - airport

Minden Nimbus 3DMLocal flight; off field landing near airport; ran into ditch; minor injury Landing - off field

Lake Ellsinore SGS 1-26 Heavy sink on R-T-B; off field landing Landing - off field

Minden G 103Ground loop during off field landing; approaching storm Landing - off field

Williams ASW 24Off field landing short of airport; heavy damage landing - off field

Minden G103

Spoilers open on take off. Glider collided with telephone pole after an attempted RTB from approx. 100 ft AGL position. CFIG in command Take- Off

2007 Western AccidentsLOCALLY REPORTED EVENTS

Sailplane hit runway marker during ground movement; high wind conditions Ground opsGround crew knocked down by wing during launch Ground opsLow pattern approach (2) during Thermal Camp Landing - airport

Down wind landing…not required; disoriented visiting pilot Landing - airport

Gear up landing (2) Landing - airport

Hit runway taxi light; CFIG-piloted commercial ride flight Landing - airport

Wing hit runway marker on roll out Landing - airport

Off field Landing; poor site selection Landing - off field

Spoilers open on take off; tow pilot wave-off; no damage; CFIG error Take Off

Canopy opened on take off; wild aero tow Take Off

Motor glider on take off interfered w/ landing power traffic Take Off

Canopy opened on take off Take OffAborted take off due to opposite landing traffic Take off

Un-Latched canopies caught by wing runner prior to launch Take Off

Accident Table Revelations?

• Competency and Proficiency?– Most of accidents notnot the factor

• Checklist / Distractions?– Most of the accidents notnot the factor

• Complacency!!!– Most accidents are comprised of a chain of

events … the “complacency” evidence appears incontrovertible

Components of COMPLACENCY

• Overconfidence Invulnerability

• Preoccupation Distractions

• Accepting Lower Standards– Reduced Proficiency– Satisfied with status quo, i.e., “Good Enough!?”

COMPLACENCY COUNTERMEASURES

• Understanding root causes of Complacency

• Planning Ahead– (Wayne Gretzky: “I skate where the puck will be, not where it’s been.”

– Or more appropriately; “Think ahead of the aircraft”

• Check Lists – “DO” lists; Verbalization

• Face Reality as it is …

not as you hope it will be?!

“In any case, if you have a risk conscious safety strategy, that is a much more successful method of surviving this sport than to simply hope that you have more luck than your friend who takes a hit.”

Bruno GantenbrinkBruno Gantenbrink

“Those who cannot remember the past are doomed to repeat it.”

George SantayanaGeorge Santayana