Post on 14-Jan-2016
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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