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Unmaking Mistakes

When I read NTSB accident and incident reports, I usually lump them into one of three broad groups.

One group is incidents I learn some things from. They are almost always very valuable lessons that I file away to use if I ever get into a similar situation. The second group is stuff I think I would never (or at least should never) let happen to me. When I see these reports, I make some notes in my head on what I can do to be absolutely certain it never does. The third group of incidents is things that are similar to events that have happened to me but fortunately turned out differently. The key to learning lessons from these reports is to figure out what it was I did, or didn’t do, that changed the ending. What gets me most uncomfortable about this group is when there aren’t a lot of other differences between the events they report and what happened to me, besides the final few sentences.

I had one of those creepy déjà vu moments a few weeks ago when I read the final NTSB report recently released on the crash of an Airbus Helicopter AS350 B2 flying a sightseeing tour over New York City. The accident was typical of one of those group 3 reports and resulted from an improbable combination of circumstances that were similar to an incident of my own but fortunately ended differently. The helicopter was flying on a clear evening, March 11, 2018, when it lost engine power during cruise flight and crashed into the East River. The pilot sustained minor injuries, but tragically all five of his passengers drowned. A review of radar data and onboard video showed that as the flight was proceeding northwest over Manhattan at an altitude of 1,900 ft. the front passenger, who was facing outboard in his seat with his legs outside the helicopter, leaned back to take pictures with his phone. Each time he leaned back the tail of his seatbelt tether snagged a little tighter around the helicopter’s floor-mounted control pod. Just two seconds after he pulled himself up to adjust his seating position, the helicopter’s engine stopped and the helicopter fell out of the sky. As pilot started the emergency autorotation procedure he noticed that the fuel shutoff lever (FSOL) was in the shutoff position. It had been inadvertently pulled up into that position when it was snagged by the front passenger’s harness strap. Although the pilot pushed the FSOL down to restore fuel flow the helicopter was too low to allow the engine to power back up and the aircraft hit the water, flipped over, and all of the passengers, unable to release their harnesses, were trapped inside and died.

This accident reminded me of my own airborne adventure that happened a while back. My wife and I had rented a house on one of the Bahamian out islands for a few weeks to get totally off the grid with the kids. The place was solar powered (only), no TV or internet (thankfully), collected rain on the roof as the only source of water (purest water I’ve ever had), and the only bath tub was the beautiful warm clear South Atlantic Ocean right outside the front door. There was a little bar and “restaurant” on the beach for the locals where we ate conch fritters on a “table” that was the stump of a coconut palm while the kids built race courses and “encouraged” the hermit crabs running around in the sand to race each other and win a piece of conch at the “finish line.”

The only unique thing about the trip over from KFXE to MYAM, Marsh Harbor, was that my Turbo PA-32 was in the shop getting a new crank shaft after an AD had been issued to recall the old ones in the turbocharged airplanes due to cracks at higher turbo RPMs. Piper lent me a normally aspirated airplane to fly that was really similar to mine in most things but performance. I already had a bunch of hours and was very comfortable in my temporary machine. The trip over was uneventful and after a few days I flew back to the mainland to pick up our niece, who wanted to spend a few days with us so we could all go exploring caves and scuba diving together.

Fuel in the Bahamas is a bit pricey and with 5 hours’ worth of AvGas in the tanks and only having flown an hour trip out, I was comfortable waiting to get back to KFXE to top off at my usual FBO. The approach into KFXE was in some local showers, typical for summers in South Florida, but good visibility below about 800 feet and uneventful since I’d flown the ILS at least a thousand times. I pulled up to the line and as my niece got her things together I held an umbrella over the fuel ports so I didn’t get any rain water in the tanks while the line guys topped them off. I shook the wings, sumped the tanks and shook the wings some more, sumped them again just to be sure, and loaded up for the return flight to Marsh Harbor with my niece. That’s where the trouble started. At 8,000 ft. MSL halfway between KFXE and Marsh Harbor with nothing but crystal clear blue in sight – the sky above and water below – the engine quit. One thing that’s for sure, if you have only one engine and it stops turning the prop, you’re up a decision tree with no branches and, unless you stay calm and keep your head on straight to solve the problem, you’re going down. Although it might sound a bit odd to say it this way, the sudden silence that follows an instant after your only engine quits is truly deafening. It’s really hard, but really critical, to manage those feelings when it happens. We talked about the reaction and some ways to deal with it in the article on the startle response a while back.

I don’t have a video on board like the helo, but I know that my engine shut off just a few seconds after I had switched from the right to the left fuel tank that I had done to balance the wings halfway through the flight over to the Bahamas. I admit the sudden silence jolted me and it took a couple of moments to snap back and start running my mental emergency checklist. I pitched the nose down a few degrees to get to the published engine-off best rate of glide (the FAA has a nice review of the topic of best left/drag ratios for maximum glide) that’s 83 KIAS in my plane. But the prop was windmilling and that makes a big difference, but I figured I’d deal with that next. Working through my scan, I keyed the mike and announced to Miami Center that my plane lost power, but the frequency was busy and I didn’t get a reply, I might have given them my position but that was also a detail for another instant. As I continued running through my emergency memory items, something clicked in my head from my IFR training. I remembered going through a lot of drills keeping my hand on the instrument or lever that I adjusted in the clouds for a few seconds after making an adjustment. That way if something doesn’t work out as planned, your first reaction should be to undo the last thing you did. With your hand still on the lever you wouldn’t have to fumble around taking your eyes off the AI and losing your SA in the clag to find it and put it back the way it was. It’s like a momentary step back in time – only a really short moment under these circumstances. Fortunately, that lesson stuck in the back of my brain: to revisit the last thing you did and put it back the way it was.

My immediate thought was that, in spite of every effort to keep water out of the tanks when I topped off in the rain, I had water in the left tank that I had flipped the fuel selector to and maybe all I needed was to undo that and get back to the other side. When I looked down at the fuel selector lever I saw that I hadn’t repositioned it on the left tank, I had pushed it past the left tank position and actually into the fuel shut-off position. Simple math; no fuel no engine; no engine no altitude. I flipped it back to the right tank and the windmilling prop turned into an asset as I was able to use that inertia to quickly restart the engine. The engine lit up, the noise was delightful, and I had only lost about a thousand feet of altitude. By then Miami Center was on the radio asking what the problem was and I was able to tell them things were straightened out and no emergency declaration was needed. Unfortunately, my niece didn’t recover as quickly and still talks about it like it was yesterday.

How this happened to me was as much a quirk of fate as what happened to the unfortunate helicopter pilot. After we landed I took a hard look at the fuel tank selector lever handle. In spite of having flown the plane before, it was still only a lender so I hadn’t noticed a little issue with the fuel selector lever track guide – the plastic was cracked. The lever sits on the floor between the two front seats and passes along a guide track with three positions, right, left and off. There’s a detent rod that acts as a blocker designed to obstruct the path of the lever getting into the off position that’s the next stop to the left of the left tank position. Normally you have to push that blocker into its retracted position to get past it any farther to the left to shut off the fuel flow. That’s a pretty good system to prevent you from shutting off the fuel accidentally – just what I had done by sliding past the left tank position into the off position. The crack allowed the detent rod to ride forward out of the path of the fuel selector lever and not blocking the off position. When I flipped the lever from right to left without paying much attention, it slid in front of the detent rod into the off position. My niece’s purse was on the floor between our two seats pushing the broken piece of plastic forward and opening up the tract just enough to allow the extra room for the fuel selector to slip past the detent rod unhindered. With only a few hours in the airplane, I had never noticed the crack or the possibility that it would open up the fuel selector travel assembly enough to allow the tanks to be shut off by mistake.

The things that made my little incident an amusing tale on my niece’s Facebook page and not a tragic headline in the newspapers were several, and all worth remembering. For one thing, I’m much more rigorous in my pre-flight brief for non-pilot front seat passengers to keep their hands, feet, and all loose carry-on items away from the flight controls. Also since that flight, I maintain my self-imposed IFR rules even in clear blue skies and never just flip the fuel selector, or any of the other flight control levers anymore; I guide it all the way into the new position and keep my hand on it until the new tank engages and I confirm the engine is continuing to purr. I also had the luxury of altitude that the tour copter pilot didn’t have, and altitude buys you the most precious commodity in an emergency – time. I always go as high as I can over long stretches of wilderness and water knowing my glide ratio under the best of circumstances is about 10 miles per mile AGL but the best I could hope for at only 8,000 AGL in the normally aspirated airplane was about a 15-mile glide, not nearly enough from where I was to firm land. In my own turbocharged airplane I would have been up at 15,000 or so, which would have given me twice the distance, about a 30-mile glide range, and twice the time, enough to get close to a shoreline to the east or west depending on the wind direction. Last month we remembered some aviation humor. There’s another old pilot’s adage, “Speed is life, altitude is life insurance,” that really isn’t funny but it’s certainly very true, and I’m sure it’s based on exactly this little bit of physics. And lastly, just to be triple sure it didn’t happen to me again, I took off out of the Bahamas on the return flight with the fuel selector on the left tank to start so the change was to the right where there was no risk of inadvertently selecting the off position.

But with all that said, the most important lesson I learned is that not all mistakes need to have an unhappy ending. Some mistakes are just irreversible and we talked about that in the article on “Why Pencils have Erasers.” There’s no doubt that making a mistake is bad, but it doesn’t mean you can’t try to fix it, but to do that you have to figure out what you did wrong. If you take a step backwards in time, sometimes you can “unmake” that mistake. Think about the last thing you did before the poop hit the fan and undo it. It’s rare that you can unmake a mistake, but it’s worth a shot and it never hurts to try.

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in adapting principles of aviation safety to the healthcare industry for patient safety. He also writes and teaches pilot safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery, surgical critical care and general surgery and holds an active ATP certification and a 20-year member of the AOPA. Dr. Stahl practices surgery full-time and is Healthcare Division President for Convergent Performance, an industry leader in teamwork, checklist and accountability training and consulting. He can be reached at [email protected]

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