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LESSONS from INCIDENTS

Postby JoeF » Thu May 28, 2015 10:58 am

LESSONS from INCIDENTS

:arrow: Describe or report an incident.
:arrow: Study the incident.
:arrow: What could be learned from the incident?
:arrow: Modified aims?
:arrow: Modified checklist? Schedule a certain item to check?
:arrow: Plan and fulfill practice of something?
:arrow: Schedule actions (inspection, practice, observation, study, purchase, instruction, tutoring, ... )

Let's keep things up and going, so as not to repeat a similar incident.

  "What will I do to stay free from what happened in that incident?"   :?:

"Do I have what it takes to avoid such an incident?" :?:
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Re: LESSONS from INCIDENTS

Postby Rick Masters » Thu May 28, 2015 12:55 pm

Joe, with a defined and refined airframe-equipped hang glider, it is difficult for me to find incidents that are not attributable to pilot error. Perhaps it would be a worthy endeavor to try to find hang gliding incidents that were NOT pilot error. Usually these are a result of wind force over-riding the ability of a pilot to effect weight-shift control, even though he had made timely and correct control inputs.

We categorize most of these situations as flying in conditions that are too strong. The pilot has usually elected, ON THE GROUND, to gamble with conditions in the air that may exceed his ability to successfully travel through.

Compare this to collapsible airfoils where the operator launches into conditions acceptable for a hang glider, or even too weak for a hang glider, but knows he may encounter thermal activity - a normal, everyday occurence of the atmosphere - that may result in a collapse within the PDMC, resulting in injury or death due to the inability of his chosen aircraft to remain an aircraft in turbulence. He has also elected, ON THE GROUND, to gamble with conditions in the air that may exceed his ability to successfully travel through. (Note that a hang glider does not stop flying unless it is stalled through genuine and generally inarguable pilot error.

Are these decisions, made ON THE GROUND, pilot error? Or does one need to be actually flying an aircraft to commit "pilot error?" I would offer that, in the same way that eskimos have a dozen words for differing types of snow, there are differing types of pilot error - and even compounding types of pilot error - made on the ground and in the air - that ultimately combine to result in incidents or accidents. Can "pilot error" for hang glider pilots and paraglider operators really be defined as the same thing?
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Re: LESSONS from INCIDENTS

Postby JoeF » Thu May 28, 2015 3:06 pm

Fertile focus, Rick: Pilot Error vs Non-Pilot Error

You encouraged some look at HG non-pilot-error incidents. Let's have a go on that for some minutes.

Here are some first-blush incidents that may not be pilot error:
  1. Meteor hit of HG that was not listed in any reasonably available scientific prediction.
  2. Illegal rifle shot hitting HG; no reasonably available clue that such would occur.
  3. HG spar breaks in conservative flight, even after robust inspections were made of the HG and good logs over the craft were kept. Very rare and uncommonly hard-to-detect manufacturing missed defect reaches to the flight and brings on an incident. Such an incident should be thoroughly investigated and reported to all HG manufacturers, so that mitigation procedures could be installed.
  4. v
  5. v
  6. v

Consider some incidents that some people would not consider as pilot error, but others would consider as pilot error. Controversial incidents!
  1. Spectating family's child darts out of the family clutch and runs over during launch at ramp to grab a flying wire; HG turns and smashes into the hillside.
    [[ I hold such to be pilot error; pilot did not confirm that spectators were at a clear enough distance from the launch. Anticipate that a child might dart out and become part of the action; launch with enough clear time-distance that would not let a child dart out to successfully reach the HG. Child could panic and hold onto the wire and get flung out over the drop for a miserable result.]]

Pilot errors and piloting errors? Certainly a pilot on the ground preparing for flight is not yet doing flight piloting; however, a pilot intending flight begins successes or fails during ground-based preparations. One might argue that incidents are most frequently seeded by what happens on the ground before flight occurs.

It is too easy to discuss PG: The ground decision to fly the PG from the ground is a poor decision in recreation-sport; incidents are guaranteed to occur at a rate that is poor as result of the PDMC unavoidable incursion. So, most soaring parachutist guys and gals are committing a serious pilot error while they are on the ground; and those pilot errors are resulting in a huge incident record.

Now to HG:

  1. Risk managing decisions may be made while on the ground and some more while flying. It is a pilot error to be sloppy in appraising the sizes of risk factors; managing risks implies knowing risks AND the sizes of the risks. Estimates may be rash/naive or be a result of appropriate study/consultation. Recreational sport hang gliding allows one to decide not to launch; if there is extant some serious reason not to launch, then the pilot should seek out that reason with as much expertise as can be mustered; back out of a launch plan when a serious reason is found; not looking for reasons not to launch can be chalked up as "pilot error" looking for an incident. We know many reasons to launch; but just one reason not to launch that is overlooked and not respected could end being kept from being blessed with a successful flight at another time. Pre-launch correction of such a pilot error: Was a robust effort comprehensively made to find potential reasons not to launch? Make that effort. Discover if other people see any reason not to launch. Have a specific checklist that lists all the reasons not to launch; do some of those reasons apply to your planned flight? If some are found, what are the sizes of the found risks/reasons? Do you take 100% responsibility for launching a flight that involves the found items?
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Re: LESSONS from INCIDENTS

Postby Bill Cummings » Fri May 29, 2015 3:50 pm

Pilot error that may occur due to an untenable status quo situation.
Likely scenario:
The accident pilot while moving to the cliff launch ramp called out for a nose wireman.
A 37 plus year hang gliding veteran with expired USHPA membership volunteered.
The only alternative was a student HG pilot with only tow experience under a six months introductory USHPA membership but having on record a signed waiver.
The accident pilot turned down the wire assist of the 37 year HG veteran due to the veteran’s expired membership for fear of jeopardizing the site insurance policy in accordance with the USHPA’S risk mitigation procedures and had the H1 student do the nose assist.
Upon yelling “Clear,” the new student forgot that after jumping to the pilot’s right that he had to duck clear of the right flying wire.
The right flying wire came in contact with the student and caused the glider to ground loop.
The strong vertical wind flow up the cliff face lifted the left wing rapidly causing the accident pilot to be pole vaulted up hill over his right wing tube.
The accident pilots body tragically impacted on a mother of a clutch of seven ducklings. All eight birds were lost.

Conclusion: The accident pilot in a selfish act put at risk the bottom line of our site insurance company which has a direct cause and affect to raise our premiums.
The desired and proper course of action would have been to back off of launch since there were no experienced, insured, waiver signed, pilots available to wire assist.
We must never lose site of the concept that the primary goal is not that individual free flight take place but that the insurance companies bottom line must be protected at all costs for the benefit of all USHPA pilots. ----- There must be a better way.
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Re: LESSONS from INCIDENTS

Postby Rick Masters » Fri May 29, 2015 8:04 pm

Yeah. I had a drunk wire assist me at Point Sal once. It was crankin'. I yelled three times for him to get down. Then I knocked him over.
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Re: LESSONS from INCIDENTS

Postby Bob Kuczewski » Fri May 29, 2015 9:10 pm

RickMasters wrote:Then I knocked him over.


:srofl:

That reminds me of Uncle Billy from "It's a Wonderful Life" after stumbling into the garbage cans:

             I'm aaaallll right.      I'm aaaaallllll right.
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Re: LESSONS from INCIDENTS

Postby wingspan33 » Fri May 29, 2015 9:58 pm

This is a very interesting thread topic. The "pilot error" question is a deep issue.

There are certain facts about our aircraft (HGs). Our planet's lower atmosphere, the troposphere - and its own lower regions where we typically fly - very often move in a similar speed range as our own wings (~ 0 to 60 mph). Nearly all other aircraft have higher speed ranges than the hang glider. Considering our speed range and that of our aerial environment, it's very easy for the wind to match our flying speed - on coming, following, or from any other side (up, down, left, right).

With our atmosphere being as dynamic as it is there are times when our wings will simply cease flying at otherwise unpredictable moments. At our best, we can use our basic knowledge of meteorology (micro and macro) to avoid those times and almost always remain safe - and flying. But every once in a while the air around us will be moving in such a way as to unbalance our wings - or to even move at our own forward speed resulting in an unanticipated and unwanted stall. Hang gliders in serious thermal turbulence can even be "tumbled". Such a tumble is probably the closest that HG pilots come to a soaring parachute's partial or complete deflation (although it takes much less to cause one of their nasty moments).

Since I started flying 40 years ago, I have experienced a number of times when I could not have predicted (even with a solid background of weather knowledge on the day) moments of aerodynamic instability imparted to my wing due to the dynamic nature of the invisible air around me. Had I been killed as a result of one of these situations, every pilot claiming "pilot error" on my part would have been wrong.

Forgetting collapsible canopies, hang gliders are the aircraft most easily subjected to (unpredictable) aerodynamically destabilizing lower atmosphere turbulence. Since there is no way to absolutely know that a random act of atmospheric unkindness may find us - on any given day - then there are also occasions when "pilot error" will have nothing to do with a particular hang gliding accident. As long as the pilot is not killed, a "not my fault" accident report will probably be made out (if any accident report IS filled out). If the pilot is killed, good guesses and speculation - as well as other external evidence - will partially determine "pilot error" or not.

Rick is right about most hang gliding accidents resulting from a stall - typically near the ground (or at the top of a loop). But some of those stalls are the result of our wings being "overwhelmed" by the sometimes very dynamic air moving - not always in our aerodynamic favor - around us.

As things stand, "Human" error may always be blamed for an aircraft accident. The point being, . . . not being born with wings may indicate that we should simply stay on the ground. . . . :?:
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Re: LESSONS from INCIDENTS

Postby Bill Cummings » Sat May 30, 2015 11:51 am

Down drafts and microburst’s. (Virga)
Just after I flew in the 1985 Nationals at Chelan Butte Washington there was a jet plane crash at Dallas Ft. Worth International Airport on August 2, 1985 most likely due to a microburst.

http://en.wikipedia.org/wiki/Delta_Air_Lines_Flight_191

Shortly after that there was much talk about installing weather radar at airports to detect downbursts or microburst.

While the FAA was hemming and hawing about why these jets were falling out of the sky I had already figured it out.

One XC day while landing at Creston WA from the Farmer tow site. (Maybe 45-50 miles) A microburst caused by Virga under a single cloud switched my WSW wind and blew strong out of an easterly direction for maybe 10 to 20 minutes. It happened so fast I just about flipped the glider while I was trying to nose it into the wind. (Wow, I thought, what if that happened while I was landing?)

Flying mostly in Minnesota where the relative humidity is always high being rained on while flying most times was not a problem.

Flying in the much drier air mid Washington State near a rain cloud can cause extremely strong downbursts of cooler air because of the fast evaporation under the cloud. (Virga)
50 to 60 mile per hour gust fronts will explode outward in a big dust ring on the ground directly below the cloud and many times all the rain will evaporate and never reach the ground. (Virga) That doesn’t happen too often in high humidity areas.
The desert SW can pose a deadly situation for pilots that are used to only flying in states that have a high relative humidity.
If you drive through and area, city, or town and see big evaporative coolers on the roofs of houses remember that these coolers only work in dry areas. If you are going to fly in these areas keep a close eye out for overdeveloping clouds.
When these clouds let loose they have the power to hold off a prevailing wind for up to 10 or 15 minutes and actually reverse the wind direction on the ground locally.
The best course of action if you see a dust front almost directly below you is to fly away from the cloud that caused it, try to stay ahead of the dust front until it weakens. There will be an abundance of lift as this cooler air travels under the warmer air that you are flying in. It is not a good idea to seek out this type of lift.
Your best course of action is to try to fly out ahead of this gust front and land beyond it but not too soon.

http://en.wikipedia.org/wiki/Doppler_radar
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Greg Porter in 2013. Challenge with false positive FTHI

Postby JoeF » Mon Jun 08, 2015 6:10 pm

GregPorterChecklist2013PreFlight.png
GregPorterChecklist2013PreFlight.png (497.96 KiB) Viewed 7530 times

GregPorterChecklist2013.png
GregPorterChecklist2013.png (189.16 KiB) Viewed 7530 times

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Re: LESSONS from INCIDENTS

Postby JoeF » Sun Jun 14, 2015 8:39 am

Salplane and Gliding, Dec. 1980-Jan 1981 wrote:
What went wrong?
I was trying too hard in competition conditions and I thought
that it could never happen to me. I had selected good fields but
the decision to land had been left too late. In retrospect I had
been leaving my decision to land too late on previous occasions.
What effect 'has it had on me?

The joy at my recently acquired Gold badge with, two Diamonds
disappeared in misery. My ego suffered tremendous
damage. I only now realise how lucky I was not to injure myself
and perhaps be unable to continue my work as a surgeon .

The lessons
Choose your field at an adequate height and make a firm
decision to land.
Always remember that if you crash you will not only risk
injury but also spoil the enjoyment of the sport for your partners.
Never let yourself think that it can't happen to you.
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