Mentor Mortis (Part 1 of 3)

As you read the accident report, try and accept the fact that a mere 22 years ago, pilots often did things that were questionable at best.  To keep the job, to get your foot in the door, or to conform to norms in your company and culture you did silly stuff.  Never mind the customized approach to that god forsaken airstrip that you’d been sent to, you’d succumb to things that, technically, may not have been on the up and up with the FARs.

What is even more striking is that all of this “off script” behavior was rarely the stuff that got you hurt.  What killed my teachers, was a lack of simple risk mitigation, awareness, and plain old decision making that got the swiss cheese holes to line up.  In aviation we recognize that it is a series of things that typically lead to an accident.  Our job, to live and be safe, is to constantly be thinking the stacking of bad, vs. the stacking of good. (I wrote about this once upon a time for the turbine crowd here.)

This story is about the day I stopped flying, sometime in 2001, when enough of my mentors had died that I thought, at a minimum, I could take some time off to reflect.  I should take a good luck at my own suspect judgement, sub-par skill set and poor choices in equipment, destinations and jobs to fly.

Mostly, it was time to give thanks for the large scoops of good luck that had fallen on me in years where I was doing the riskiest stuff.

Youth, Dry Mouth, and More

When you first start flying, first as a private pilot and then not long after as a flight instructor, you don’t really think of dying, especially at a virile 22.  At least I didn’t.  I experienced close calls and stupid things – but they never struck me as lethal.  Just terribly uncomfortable dry mouth and then … a sort of “awakening.”

“Ok…so… we’re not going to do that again… at least not in this airplane.

These moments made you better, theoretically.  At least that is what I told myself as I piled on the hours along with new places, aircraft types and unplanned or rehearsed thrills.

So why the grim title?  Having been fortunate enough to start flying at 15, I was able to get into big trouble, early on.  What else can be expected of an entitled adolescent who does something no one else in his high school could do?  [Ok, except Austin Meyer who got his private around the same time, and made far better use of his aviating brain than I ever did.]

The time and opportunity to get into trouble, somewhere west of Concord, NH (and east as I buzzed various familiar haunts in Maine) was what my early flying was all about.  “Let me show them my power by bringing this Cessna 152 stupidly close to crew boat full of Harvard bound prodigy.”

As I advanced through the ratings, however, I began to feel what some professional pilots feel early on in their careers:

Maybe I’ve chosen the wrong career.

Flying can get pretty boring pretty quickly whilst IFR-ing it from Bar Harbor, ME (KBHB) down to White Plains, NY (KHPN) with the summer shuttles of social climbing Manhattanites.  When they weren’t feasting on lobster, gin and Hinckley yachts, they still had to work the weekdays at Goldman or JP Morgan to keep the whole thing going in Maine.

Sure there is the stress of flying on instruments, as a single pilot in a geriatric twin.  But as long as everything is working, aviating is pretty darn boring.  Flying only gets more boring the faster and better the equipment gets.  And when it’s not boring, being up in the crippled, confused, or lost airplane is the last place you want to be.  You decided to launch and now you are stuck up there, dry mouthed, second guessing, and carefully nurturing your family of ulcers.  But 99.99% of the time, it’s not that.  Once you leave the world of piston flying it is pretty much never that.

This laissez faire attitude towards personal development made me comfortable, and stupidly so:  Thanks to better and better autopilots, I could stay ahead of business development matters, read books, make cell phone calls on my massive 90’s “bag phone” that would happily hook up to many cell phone towers it could now see as I raced from Elmira, NY back to Portland, ME in any weather that stood in the way.

Reception was great and with the props pulled back to 2300 RPM, I would grow hoarse screaming instructions to the gang back home about other flights we had to face tomorrow, next week, and beyond.  In aviation we call this Fat, Dumb and Happy.  Or as I saw myself: Fat, Dumb and making most use of this infinite time between pick up and drop offs that was just so darn quiet.

I started flying in 1986.  Technically earlier, but in 1986 I got a logbook and paid for what is called “flight instruction.”  I was terrible.  As a ‘know it all’, who could demonstrate enough competency to add ratings, I covered a lot of ground in my first 2000 hours.  So much so, that by the the time I turned 29, I was seriously thinking about not flying anymore.

What helped was the death of some teachers.  Really smart, capable, seasoned and experienced pilots who had helped me.  Then they died in mistakes that I could easily replicate any time.

Mike “Bunny” Burns

When I first met Mike I had my instrument rating and commercial license and I used to hang around the Waterville, ME airport like a desperate little groupie would back stage at a concert.

The freight for the entire State of Maine was handled by Telford Aviation and Telford’s HQ was Waterville, ME.  If I was lucky I could fly any freighter any night I wanted, so long as I agreed to bunk with them in Manchester, NH where they did an overnight before they headed back out to points in Maine the next morning with a fresh load of UPS “Next Day Air”.

Mike flew a Cessna Caravan, a Beech 99 and an old Piper Navajo Chieftain.  It behooved any pro to be able to respond to fly anything in the fleet.  I would arrange my schedule to drive from Portland, ME to Waterville, ME just for the opportunity to fly these trips and learn about the world of freight, night, IFR and the culture that existed to support guaranteed on time delivery, no matter what the weather.  Never mind the fact that this was in airplanes that arguably were not equipped to fly in all the weather they were tasked to fly in.  Mike, and many of the people of that era of Telford Aviation, were supremely competent at their jobs.

Then Mike died.  The accident and subsequent diagnosis by Bill Gianetta of the FAA, during one of my many FAA checkrides, sobered me up.  Mike had died responding to a situation the same way all of us had been trained to do.  Bill’s simple words were:  “There but for the grace of god go I.”

The accident report (and NTSB report here) doesn’t give as much of the story as we knew.  Mike had a turbocharged engine that failed.  He also flew turbine aircraft a bunch.  For those of you that do both you know some stuff about differences:  In the turbine, “no torque” gives you a big fat “zero” on your power gauge, whereas in a piston, you see what could be interpreted as “some” power – i.e. 29.92 inches of mercury on a standard day.

Mike thought he had some, when in fact he had none.

When a piston engine is running the negative pressure of the air intake region of the engine allows you to “throttle back” to inches below 29.92 or ambient.  But as soon as you shut it down, you’ll notice it flops back up to ambient pressure, or what to the turbine person would like “some power.”  This is very much like the corresponding gauge on a turbine engine – pull lever back, less power; shove forward, more power.

A zero torque engine reading on a turbine is what you see when the engine is off, whereas the somewhat devious and tricky piston shows the power needle about halfway through (in the case of turbocharged engines) or at the top of the green arc of power in normally aspirated engines.   After you start the piston engine the vacuum pulls it down to read “inches of mercury” below what is termed “ambient.”  (More on the subject here.)

Mike’s Chieftain N744W had an engine failure that was so catastrophic that it swallowed parts of the turbocharger, thereby “killing” the engine in such a way that the prop was now free spinning – free wheeling, as it were.  Turning plenty fast… and according to his manifold pressure gauge, not reading “zero” but 29.92 inches of mercury.  (I forget exactly now, but Piper Chieftains will pull as much as 38 or more inches when run up to full power.)  Normally aspirated piston engines will only show “inches” of mercury that are equivalent to ambient pressure – so full power is whatever it is outside – which is somewhere around 29 to 30 inches of mercury.  Mike – investigators surmised – thought that his engine had some power since it didn’t go to zero (again, he’d been in a Beech 99 the week prior, flying two PT 6’s which behave this way) and the 29 inches was somewhere in the green band of power.

This is where all went wrong for Mike:  Thinking he had something when he had in fact, nothing.  The accident report talks of Mike reporting a rough running engine, not one that lost the ability to make any compression or power, that he probably should have feathered.  Feathering the prop, we are all taught, gives us a possible chance of surviving a “go around” in a twin.  Not so in a heavy PA-31 Chieftain.  But with a “rough running engine” and perception of some power showing on the gauge (the “no power” power) the deception is enough to think “well maybe I should not feather that prop?”

 


Feathering the prop isn’t going to save you if you get too slow, but Mike probably experienced cognitive dissonance as to why he has so slow since he had not feathered the problematic engine as he believed it was giving him some power.

As you learn how to fly multi-engine aircraft you are required to show the examiner the pitfalls of “too much power” on the good side, getting slow and then essentially losing control of the aircraft due to a Vmc roll.  Essentially one wing is flying really well, while the other wing ceases altogether and any amount of aileron, rudder, etc. is not going to help you … since you are, well… way too slow for the “air to care” about your control inputs.  That wing is going to flip you on your back as the well funded Canadian investigators have documented so well.  The only way to survive the Vmc experience is to pull both engines to idle and then get the aircraft flying again like an airplane vs. a corkscrew.

Mike very likely had the scenario sneak up on him as he thought he had two engines or at least one developing some power.  It was not the cookie cutter “you lost an engine” and you must immediately feather the liability side of the house.

Mike, genuinely thought he had something else going on that would make the approach and if necessary go-around, easier or even possible.

Mike’s Legacy

Mike was the first of three teachers I had that died in a way that *any one of my colleagues* at the time would have admitted they would have perished also.  The Monday morning quarterbacking that invariably comes from accident deconstruction is easy to jump into.

As one of my favorite people at the Portland, ME FSDO offered, we’d all likely have reacted the same way if we have been bouncing back and forth between different aircraft types as Mike had.  And what his accident did was contribute to a larger body of knowledge:  Look at all the moving parts including your most recent training, the assumptions you make about what an engine failure sounds like and feels like.

If Mike had done very deep “differences” training on the PA-31 vs. the Beech 99 and had also been an IA / A&P with years in the shop trouble shooting and working on the engines, there is a chance he would have recognized that his only salvation was to feather the offending engine and treat it like a real emergency vs. a quasi-emergency.

I’m not sure what my lesson to impart here on my first dead mentor story is, other than to think of why Kelly Johnson once offered:

Always question, never defend.

If we can find a way to make sense of incongruous data that is streaming in, during an impossibly bad time, then there’s a chance we’ll get through it.  But Mike, like many of us are wired to do, simply went with what seemed to be unfolding and fell into a trap that he couldn’t see his way out of.

 

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airwebster

Aviation, technology, trends, society and the economic drivers that make it all happen is what makes me tick.

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