SoaringCanada.riq.ca

[Ulli Werneburg]

Hi Dan:

Thank you for these reports and thanks to the people who submitted them.
What percentage of accidents which have actually occurred in Canada this year do you think these reports represent? Do we know how many insurance claims there have been?

Ulli

[lmorrow]

Dan, I am preparing for our clubs annual pre-season meeting. Are there any more accidents from 2004 that I can include in my report to the members.

Thanks
_________________
LARRY MORROW
Safety Officer
Winnipeg Gliding Club

[Dan Cook]

Accident Summaries 2004

Intro

In 2004 we have had 19 accidents reported of which two involved fatal injuries and the write off of five aircraft. These accidents can be a source of invaluable information, the analysis of which can contribute to a reduction in the number and severity of accidents down the line. This is why SAC has an accident reporting system and why the Flight Training and Safety Committee spends a considerable amount of time and effort examining accidents. Its intent is not to be critical, but rather to draw some good out of misfortunate events, which will help individual pilots and clubs reduce the risk of having future mishaps. Of course, we recognize that analyzing the decisions underlying an accident, with the benefits of hindsight and considerably more time, is a much less daunting task than taking decisions in the first place. In addition, reports from club safety officers with there own analysis of accidents/incidents within their clubs is invaluable. Incidents are too numerous to describe but support conclusions on accidents discussed. Please continue to forward your annual safety reports to FTSC to help us in our analysis. Also, note that we have changed the format to include lessons learned. This will allow us to de-link the lessons learned from the accidents later and keep a separate database available on the SAC web site (currently on the Roundtable).

Events

Major Damage. The tow pilot taxied the tow plane (tail dragger) back to the apron following 2.5 hrs of towing operations. The aircraft turned quickly in the grass parking area and the wingtip struck a nearby tree. Damage included several ribs, spars, frame, and wing support and attachment areas. Noted were possible human factors of complacency and overconfidence.
Lessons learned: It is necessary to exercise extreme caution when taxiing tow planes in confined areas. Shutting the aircraft down and moving it by hand are often called for. If we cannot eliminate obstacles then we should consider the restriction of apron areas by visual boundaries, such as painted lines or other means.


Major Damage. During a dual training flight, the glider (a Puchacz) was side slipped on a high final approach (450 feet AGL’) and with full dive brakes to increase the rate of descent. The canopy was destroyed when it opened, inflicting some damage to the wing while remaining attached to the glider at the hinge points. The instructor successfully landed the glider.
Lessons learned: Similar incidents have occurred with this type of aircraft before. The FTS Committee contacted OSTIV TSP members and one of the test pilots of this type, and did not find a design problem. One contact however, with experience of similar problems, said that investigations suggested the closed canopy locks were not fully over-centre, hence would be easy to knock open. The latching mechanism components can become loose/worn, and sideslips with full dive brakes may cause wake vibrations that rattle the canopy. This situation is not limited to this glider type, and side-opening canopies on other two-place gliders are susceptible to large side loads in slips. If a glider is equipped with powerful dive brakes, the FTSC recommendation is to avoid sideslips with the air brakes fully open. If slips are necessary, do so in a direction that the cross flow of air will not force open the canopy. Careful preflight inspection of canopy latching mechanisms before each flight continues to be paramount.


Substantial Damage. During his first flight in a newly acquired glider (HP-1, the pilot experienced control difficulties with the initial launch on aero tow. The pilot released. Selecting flaps down, the pilot was attempting to lower the nose but the glider rolled to one side and struck the ground. The glider was substantially damaged but the pilot was unhurt. Noted factors were pilot lack of currency and familiarity with glider type, C of G tow-hook location, rear C of G location in this aircraft, and club checkout procedures.
Lessons learned: Transition checkouts, especially to modified homebuilts may present special risks. Pilot currency and club method of transitioning pilots to new types are critical mitigation factors. This process must be thorough. Aircraft with aft C of G location are pitch sensitive, they lack a straightening effect of the pull of the tow rope in the initial takeoff roll, and are prone to kiting and getting high on the tow plane (a dangerous situation).


Fatal. During a passenger flight, the pilot released the Blanik L-13 off tow 250 feet higher than normal after the tow pilot reminded the glider pilot/instructor that they had reached release height. Later, observers noted the glider was low (approx. 300 feet agl) and they assumed the pilot was preparing to land downwind and taxi up to the launch point. However, inexplicably the glider pilot turned away from the field. It appeared to enter a spin, and then spiraled towards the ground until the front passenger (a power pilot) apparently raised the nose before impact. The instructor was fatally injured and the passenger suffered broken legs. Possible Human factors included the rear altimeter apparently miss-set for the airport elevation. The accident occurred very early in the gliding season and the pilot had only a few flights in the glider (new to the club) that season.
Lessons Learned: It is easy to misread an instrument especially when flying a new aircraft type and after a winter season of gliding inactivity. Currency in all flight maneuvers/emergencies is critical to a thorough spring checkout. FTSC recommends as part of an annual spring checkout a review of all items in the glider pilot test standards.


Fatal. During the early stages of a winch launch, a glider (HP-1 was observed climbing rapidly, then rolling and impacting the ground. The pilot was fatally injured.
Lesson learned: To raise a possible deterrent to these types of accidents the BGA gliding web site posted an article on winch launching stating that the target climb speed must be 150 % of the 1g stall speed before rotating into full climb attitude (for a 34 kt stall speed you would need 51 kts).


Write Off. The pilot of a Schweizer 1-34, flew a normal (no wind) circuit to land, and selected full dive brakes on final approach and an approach speed of 60 mph. Surface winds were reported gusting from 16-22 mph and upper winds were observed much stronger. The pilot experienced heavy sink and loss of airspeed (40 mph) on final and reduced dive brakes to ½ to extend the glide. The glider continued to undershoot on the final approach until it struck the ground. The pilot was not able to recover from the dive and appeared to make no attempt to flare. The pilot was not critically injured. Human factors include low experience on type and in gliders in general.
Lessons Learned. Strong winds, lower performance gliders, and lack of experience and familiarity on type do not go together well. Use of dive brakes before establishing that the glider is in an overshoot situation often leads to problems. If you cannot maintain glide slope and air speed, you must close the dive brakes completely until an overshoot situation at the proper airspeed can be re-established. Then only use enough dive brakes to prevent the overshoot situation. In addition, this pilot appears to also have been caught off guard by the classic effect of wind gradient. The approach speed selected for these conditions was on the low side and was not maintained. It is possible that the pilot thought he was stalling (high rate of sink) and continued to push the stick forward until impact. Club analysis of training factors in the accident report did not include the techniques taught to the pilot in pre-license training. The new SAC curriculum has identified recognition of an overshoot and the establishing an overshoot condition before using dive brakes as pilot skills that must be emphasized in training. In addition, the analysis did not indicate the club procedures to control type checkouts and requirements for low-time pilots attempting early flights in difficult conditions.


Write Off. In calm conditions, a student in a Blanik L-13 completed the circuit and arrived too high on final. The instructor took over control and performed a side-slip with what was thought to be the dive brakes, but was in fact were the flaps. The instructor did not recognize the different forces on the handle and the abnormally low rate of descent. Approaching the round out, the instructor could not put the glider on the ground before the end of the runway. The instructor closed the flaps, thinking they were the air brakes. He attempted a right climbing turn in order to land in the opposite direction in the adjacent field of corn. The right wing tip touched the ground during the turn and the glider rolled on its nose and then on its left wing. Human Factors include the poor ergonomic design of handles in this type of glider and the instructor’s lack of experience.
Lessons Learned. This situation over confusion with flap and dive brake handles in Blanik L-13s continues to catch both students and instructors. The technique of confirming visually the selection of the correct handle by looking at the dive brakes for correct operation was not done in this situation as the instructor was distracted by the urgency of the situation. Training gliders with powerful dive brakes should not need to be slipped to reduce height in an emergency. Certainly, slipping techniques should be taught but dive brakes are more effective. Human factors have proven that students will make mistakes and in urgent situations pilots can fall victim to tunnel vision and losing sight of other options. We must continuously be re-evaluating the situation and our decisions. We must guard against students putting themselves in a situation where extraordinary actions must be taken. One way to condition ones self against tunnel vision is to expect that what can go wrong will go wrong and to practice and/or visualize as many different options you might have for each key point of the circuit. For example, write down a decision matrix for variables in the circuit. At various decision points (high/low/too close/too far) indicate what action the pilot can take. Some clubs have changed the feel of the grip with some success but this has not eliminated the problem completely due to the proximity of the handles. In addition JAR 22 requires colour coding of controls to prevent confusion. This common problem is not unique to the Blanik L-13s. Visual confirmation on the wing of air brakes every time you reach for the handle remains one of the best safeguards. Remember if the result in aircraft performances is not as expected, reconfirm visually again and consider other options (SOAR technique).

Substantial damage. Tow plane gear collapsed on landing, causing a prop strike and damage to the wing.
Lessons Learned. There have been several other similar accidents in the past with sprung gear tow planes. High landing cycles have demanded careful preflight inspection for hairline cracks in the gear near the bolts for the wheels and near the Kingbolts. Examine also the Kingbolts carefully in the preflight inspections. Some clubs remove the gear annually to have them inspected by non-destructive testing, usually x-ray. If you operate a Citabria/Scout or similarly geared aircraft, you should consider adding this process to you maintenance practices.

Major Damage. During the pilot’s second flight in a newly acquired glider (SZD 55) the wing touched down after 30 ft take off ground roll and began to ground loop. The pilot released after attempting to lower the wing with the controls, but the glider became airborne and touched down tail first. After the accident, the observed wind was 90 degrees cross wind. Grass on the take off area was long and the runway slightly sloped and factored into the ground loop.
Lessons Learned. This type of glider can be more prone to ground loop under certain conditions (cross winds etc) as is common with C of G tow hooks and some higher performance wing designs. The recommended procedure stated in the SAC training material, for a wing touching the ground on take off, is to release immediately. In addition, attention to grass cutting operations is essential to mitigate ground loop risks. Type transition is a higher risk activity and all conditions (runway/wind/etc) for the first few flights should be benign.

Minor Damage. Pilot landed out on a cross-country flight and ground looped on landing. The field selected had longer grass than expected (18”-24”) after the aerial inspection. Pilot was very experienced.
Lessons Learned. This type of accident is too common even amongst experience pilots. Seasonal changes to field increase risk. Freshly cut fields, cultivated dirt fields and short crop fields provide reduced risk of ground loop.

Major Damage. Pilot was landing an L-33 Blanik on a gusty day (wind 20-25 kts 45 degrees crosswind) and was observed landing fast and long. The glider landed hard and bounced several times on the main wheel damaging the fuselage. Pilot had 18 hrs experience total and 10 hrs on type.
Lessons Learned. In this case, the pilot maintained a higher approach speed to landing to compensate for wind gradient. Landing speed should be only slightly above normal to compensate for cross winds. The L-33 has a very low crosswind limitation (7kts) and should not be flown in these conditions especially by low time pilots. High-energy landings increase risk for accidents exponentially.

Major Damage? The pilot of an L-33 Blanik was high in the circuit and selected partial air brakes to loose height. The air brakes were sucked out when the pilot diverted attention to operate the GPS onboard Too much height was lost to reach the field. The pilot attempted to land off field and struck a metal rod supporting an electrical fence on short final damaging the wing and fuselage.
Lessons Learned. On many glider types, the air brakes will suck open if you release the handle after unlocking. The pilot’s attention must stay focused on the landing task and not distracted to instrumentation or other activities.

Minor Damage. A glider (Grob) was inspected after assembly and discovered to have cracks in the leading edge of a wing and was sent for repairs. The wing was likely damaged in a previous dis-assembly and not reported.
Lessons Learned. A careful preflight is always required, as damage is often not reported. We can attribute many reasons why a pilot might not report damage. Ignorance, indifference, or fear of retribution could be factors. Proper training, supervision of assembly, and club policies that do not intimidate reporting (payment of deductibles, fines, etc) can mitigate this type of problem. Not detecting this problem could lead to serious situations.

Substantial Damage. The pilot was returning from a second 2 hr + flight on a hot and humid day. On final approach, the pilot was attempting to land short and undershot the threshold failing to reduce the airbrakes. The glider settled into 5 ft high grass, began to rotate to 90 degrees, and then exited the grass landing sideways on the runway. Fatigue, dehydration, hypoglycemia were listed as potential factors. The pilot was very experienced.
Lesson Learned. All pilots regardless of experience are at risk to misjudgment if they do not guard against dehydration/fatigue. The problem is by the time you might notice the effects it is too late. Keep hydrated, bring food on flights longer than 1 hr. Do not skip meals and take a break from other gliding activities before you fly. Consider your clubs grass cutting operations. Have you planned your operations with a long enough undershoot area. Field layouts with approach hazards near thresholds are setting pilots up for failure.


Major Damage. The pilot was attempting a takeoff on a paved 75 ft wide lighted runway slightly downhill. Modified tow procedure used was to apply brake (ASW 20) with end of travel on air brake handle until taking up the slack on the towrope. Tow plane then applied 80% static power and both glider and tow plane were to release brakes simultaneously. On this flight the tow plane released before the glider, the sling shot effect, and C of G hook on glider resulted in launching the glider into the runway lights and off the strip. Ergonomic position of the release handle in the ASW 20 made it difficult for the pilot to immediately release from the tow as the pilot was holding the brake handle vice near the release handle. The wing was damaged when it struck the runway lights. Additional factors stated in this accident included complacency, impatience, slight crosswind, and glider tow plane alignment.
Lessons Learned. Modified procedures may make sense at the time but they must be well thought out to anticipate risks. The best way to handle this is to discuss procedures in a knowledgeable group well in advance and “what if” to identify risks.

Major Damage. Canopy of Jantar discovered broken when hanger unpacked in morning.
Lessons learned. It is unlikely that the culprit did not notice this damage at the time the event took place. The damage was not reported likely because of indifference or fear of retribution. Why the damage occurred is likely from moving gliders with too few personnel which was not consistent with club policy.

Major Damage. Tow plane was tied down outside on an open airfield t a flying camp. A hailstorm damaged the fabric and control surfaces.
Lessons learned. Remote operations have increased risks from severe weather. Options to deal with wind /hail need to be considered. Padded wing covers or returning aircraft to hard cover (hangar) may be the only alternatives even if ferrying is required. Always plan for the potential of hail if CBs are forecast/possible.

Minor Damage. Scout tail wheel broke on normal landing.
Lessons learned. This is common reported problem with this type of tail wheel assembly despite frequent inspections. Middle spring breaks first at the relief hole drilled in the spring to fit the dimple in the long spring. You need to know where to look on the DI. The club has requested a solution from the manufacture. In the meantime, be vigilant.

Minor Damage. Two tow planes were parked next to each other outside the hanger with brakes on. A change in wind direction and gust swung one tow plane wing to strike the other.
Lessons Learned. Brakes are not sufficient by themselves to prevent this type of common accident. Always use wheel chocks when parking aircraft unattended outside hangers. In addition, park all aircraft when subject to possible wind effects such that if they swing or wings move up or down cannot strike another aircraft or object. Check out your club policies and see if your aircraft are at risk.

Write Off. Twin Grob 102 crashed on landing attempt when wing tip struck a tree on short final in an undershoot. The pilot experienced a faster than normal down wind and strong wind gradient. Approach speed was 60 kts with a low ground speed and high sink rate noticed. Pilot attempted to increase speed but could not clear trees on final approach.
Lessons Learned. Insufficient approach speed for wind gradient. Winds aloft appeared faster than surface winds of 10 kts (broken thermals, fast down wind). Circuit was modified in the accident but base leg would need to be closer to reference point. Pilot commented that 45 degree leg would have helped to prevent flying too far down wind.

Analysis

Some of the accidents and several incidents reported demonstrate there is some confusion over approach speed and landing speed. Many new pilots are carrying “high energy” approaches to touch down. Approach speeds should be used in accordance with the Pilot Operating Handbook for each glider or if not available use the SAC recommendation of 1.3 x Vstall + Vwind. Once the glider has descended, down through the wind gradient, slow the glider to normal landing speed with a minimum energy landing (notwithstanding slightly higher landing speed in cross wind technique).

We also had several accidents/incidents with the Blanik L-33 this year. This is a good handling aircraft but the crosswind limitation is only 7 kts and the air brakes require adding an additional 10 kts to the approach speed if the air brakes fully opened. If reducing the air breaks to ½ before the flare is not completed, the pilot will have to rotate so nose high that it will damage the tail when it strikes the ground first. Conversion to type briefings must be thoroughly done and supervised. Several clubs require L-33 type conversions to include dual flights in a glider with powerful air brakes to have the candidate demonstrate the techniques stated in the last two paragraphs. Letting a low time pilot fly this aircraft on a gusty day without good conversion training, is setting them up for an accident.

Type conversions continue to be higher risk flying and we do not seem to be learning anything from past accidents. Clubs must review how they are handling conversion training and formalize the process more. A fellow pilot pointing out some of the characteristics and reading the POH is inadequate. In addition, difficult wind conditions are also not the time to test your skills in a new type. CFIs need to supervise this training.

Several accidents/incidents indicated Clubs need to look at their operating procedures and should include their grass cutting operations. Has a team of club members looked for hazardous situations in the way you operate lately? Risk reduction can be easy to achieve with little effort. It also appears that it is cheaper to insure a glider than provide adequate hard shelters to protect them. This strategy may work in the short term but long-term consequence may be an inability for all of us to get insurance. There are low cost shelter solutions. Clubs need to examine their operations to find out if you are doing all that they can do to reduce risks.

Undershoot accidents/incidents and stall/spin situations point out that we have not perhaps done our past training in the best way. The new training curriculum includes new exercises that emphasize pilots should be taught to recognize an overshoot situation before using air brakes. In addition, the training has new exercises to build stall/spin recognition and avoidance. Apparently, not all licensed pilots are aware or familiar with these exercises. CFIs have the challenge to correct this!

Air proxies’ incidents continue to be a challenge in many locations
Relatively minor adjustments in checkout procedures for air space limitations, flight line management, and/or communications among pilots can materially assist in risk reduction.



Conclusion

The lessons learned here are not exclusive or all encompassing. You may have identified several others yourself. The SAC Roundtable has a safety subject area where you can add your own thoughts that could help other pilots. Some have commented on the Roundtable that they feel the SAC curriculum is too long. We have used Lessons learned and comparison with other OSTIV countries to analyze and improve our basic training exercises. Our goal is to improve our resistance to some of these accidents. The new curriculum only adds a few more flights to the average and mainly consists of an increased number of exercises in a specific order to improve the quality of instruction. Our training is now similar to the training conducted in countries with lower accident rates. The results may take many years to achieve because many pilots have not had the benefits of these exercises and many clubs continue not to use them because they prefer to stay with current methods.

Part of the accident rate challenge is that “Safety first” is not being applied. Chris Wilson from SOSA has pointed out in his Club Safety Report conclusions that “alertness” the ability to be aware of the situation, the application of “judgment” using one’s experience from knowledge gained and the application of a generative “attitude” along with self discipline will reduce accidents. Along the line of his recommendations, FTSC has recommended a “Safety First” campaign for 2005.

In addition, clubs have the power to really change safety. Many members including FTSC are frustrated with the number of serious gliding accidents. Most OSTIV panel countries are doing better than Canada. Transport Canada web site describes the Systems approach to safety. Please visit this site. This program maps out that safety is a leadership issue. Clubs have the authority and the challenge to improve safety. A committee or an association cannot be delegated safety without authority. The leadership that controls the flying must control safety. Pilots will cooperate when they realize the club will not tow them or not let them use the club facilities if they choose to fly unsafely. Accidents will continue to happen to “safe” pilots because they are accidents. However, we can eliminate many accidents by putting more efforts in training, safety culture, and human factors understanding through club leadership. The TC web site describes how to do this.

Dan Cook
SAC Safety Officer
FTSC
Feb 2005
_________________
Dan Cook

FTSC Chairman

[Anonymous]

...

[Dan Cook]

It is a small addition to the HP-18 crash on page 2, if this is possible:
Last sentence of lessons learned - suggest addition of "with a cg hook" as follows:

Aircraft with aft C of G location are pitch sensitive, with a cg hook they lack a straightening effect of the pull ...



Reporting accidents is probably 98% of claims submitted which is a dramatic improvement from last year.
_________________
Dan Cook

FTSC Chairman

[Anonymous]

[Anonymous]

7 kts sounds about right; I won't fly our L33 if the xwind is 90 degrees and even gusts that high. (more skilled pilots- of whom there are many- may be able to handle more. )
The L33 is a great ship, but is certainly won't handle the cross wind that the L13 can take!

Dave

[Dan Cook]

Accident Summaries 2005

Intro

In 2005 we have had 18 accidents reported of which one involved 2 fatal injuries and the write off of 4 aircraft. Reporting was somewhat sketchy to non-existent in some cases (4 SAC reports received). However, a few clubs had sent their annual accident reports to SAC and this has provided some valuable insights. Many thanks to those who participated in providing information by filing an individual accident report or annual club report.
For the purpose of classifying accidents below major damage indicates repairs approximately $10K or more, substantial damage $1K to less than $10K, and minor damage less than $1K.

Events

Fatal. Puchacz was observed flying towards the circuit to land. The glider was then seen to make an abrupt turn towards the circuit and appeared to enter a three-rotation spin. Both pilots were killed in the steep nose down impact.
Lessons Learned: The Puchacz has a surprisingly fast entry into a spin and this combined with the steep nose down entry and ground rush from circuit height it would be a psychologically difficult situation for most pilots. One must definitely move the stick forward to recover the Puchacz from a spin and this would be difficult against instincts to raise the nose. Often in two seat trainer accidents it is difficult to determine who was attempting the recovery. So close to the ground perhaps both pilots were on the controls? In general, who is PIC and would initiate a recovery must be well understood between pilots before the flight. Lastly, this accident emphasizes three aspects of spin training, recognition, avoidance, and recovery. All three need emphasis.

Write-off. After a normal take off at 200’ AGL the Citabria tow plane banked steeply and the glider released. The tow plane appeared to stall and plunged nose first into the trees. Weather was very hot and humid and the pilot had been towing 4-5 hrs. Pilot suffered serious injuries. No mechanical factors were described.
Lessons learned: Not having more detail in the report one must surmise that heat fatigue/dehydration may have been a factor in this accident. Do you have a water bottle in your tow planes/at the flight line? Are tow pilots encouraged to take regular breaks every couple of hours? Again stall/spin recognition/avoidance training cannot be understated.

Write-Off. Blanik L-13 crashed during a winch take off. Glider was being launched with a “Y” bridle attachment. At start of the launch the wing dropped into grass initiating a yaw. Pilot attempted to raise wing with controls. When release was initiated one side of bridle did not release yawing the glider further. The winch operator did not respond to stop command on radio and the pilot successfully did egress. Glider continued to climb to 250’ AGL then back released and entered a turn down to 50’AGL where it spun into the ground inverted.
Lessons learned: Bridle attachment for launching gliders has been abandoned in Germany for winch launching for many years now. This method should not be used in Canada. Communications method should have visual back up systems and/or alternate ability of flight line to communicate with winch operator. Grass cutting operations continue to be critical high-risk area for glider operations. Last, pilots must release immediately when a wing drop occurs.

Write-Off. DG 100 was ground looped on landing when wing caught crop in off field landing attempt. Pilot was attempting 500 km flight but when lift decayed a known field was selected for off field landing. Thermalling was attempted under a near by cumulus cloud but strong winds drifted aircraft from selected field and a poorer alternate with crops was used.
Lessons Learned: Pilot fatigue and preoccupation may have been factors. The temptations to move towards down wind clouds in strong winds when an out landing seems imminent will bite you most often unless you are lucky. Good technique is to keep looking for lift until committing to down wind but the search area should be upwind in strong winds. Keep luck out of it.

Major Damage. Blanik L-13 wing hit tree on landing. During landing roll glider was turned off runway with too much speed to avoid tree.
Lessons learned: Other options were available to the pilot to roll out strait ahead or turn in other direction (no obstacles). The habit of turning off runway in same direction can create tunnel vision (Human Factors). HF Studies indicate teenagers have more difficulty developmentally to assess risk factors adequately until they reach adulthood. Training emphasis for youth should be to develop options for critical situations and use scenario based training to teach SOAR technique at every opportunity.

Major Damage. Citabria main left landing gear failed 10 cm from the fuselage on taxing to hangar. The wing and propeller were damage by striking the ground. Pilot was observed making a normal landing.
Lessons learned: All too common an occurrence with the Citabria when used in towing operations. Many clubs that operate this tow plane use non destructive testing (x-ray) annually to inspect the gear. Also, a common factor is rough grass fields for tow operations. Has your club done a risk analysis of airfield hazards and come up with short term and long term risk mitigation strategies?

Major Damage. Lark ground looped on landing damaging wing tips and tail wheel. Two instructors (one being checked out on type) ridge soaring return to the airfield to land in a steep wind gradient (3000’/30 kts to surface/15 kts). During the approach, flaps are increased two more times and each time the spoilers are sucked out reducing the airspeed eventually to 50 kts on short final resulting in undershooting the threshold. During the flare the wing touches the ground yawing the glider to 60 degrees on landing.
Lessons Learned: Risks are greater in strong wind gradients and energy management is critical. In strong winds flaps are usually not necessary and at higher approach speed many gliders are susceptible to having the spoilers “sucked out”. This should be part of the type checkout briefing before flight. Instructors need to stay ahead of the student and take control as soon as the instructor starts to get uncomfortable.

Major Damage: L-13 is damaged in a hard landing when student fails to rotate for the flare. On final approach the instructor twice verbally cued the student to raise the nose by giving the command “pull”. With the student unresponsive the instructor had to forcibly move the control stick to rotate the glider before contact with the runway. This student had similar difficulty before (freezing) but had been flying well this flight.
Lessons Learned: Student freezing on the controls is a difficult situation for any instructor. Some have even given up teaching. Some students are petrified of flying or the landing situation. In this case the CFI must decide if it is in the best interest for everyone to continue with instruction of the student. Often slowing down the training until they are more comfortable with the landing phase may be all that is necessary. Instructor must be aware the problem exists and not let their guard down. Easing the student into exercises can help (reduced approach angle, more follow through practice). Sometimes the problem is where the student is looking on final at reference point and not moving their gaze up to the end of the runway for the flare. In the ground rush they cannot judge their height and freeze. Do you know how you react in high stress situations?

Substantial Damage. Grob 103 Wing damaged when removed from trailer for assembly. No SAC accident report received.
Lessons learned: Several of these types of accidents have been reported recently. Could standard operating procedure be used to minimize risks? Was a “ rigging team leader” used? Were tires in place to reduce likelihood of damage? Were sufficient personnel used to complete the task?

Substantial Damage. DG damaged. Wind blew the wing stand over when pilot was using one man rigging system.
Lessons learned: Labour saving devices have risks of their own. Uneven ground, wind, and faulty mechanisms have led to similar accidents. Hangar location is the ideal setting to use these devices otherwise more assistance is needed to be safe in other than ideal conditions.

Substantial Damage. DG motor glider propeller damaged. No SAC accident report received.

Substantial Damage. Standard Cirrus canopy damaged when pilots head struck it. No SAC accident report received.
Lessons learned: Previous canopy damage accidents have been caused by improper seat belt adjustment, use of too soft seat cushions which compress easily in turbulence, and ball caps with a hard button on top.

Substantial Damage. Pik 20 ground loop in off field landing. On final the pilot attempted to land glider much farther down intended landing field to reach an access road. The result of moving reference point up was an overshoot situation when the reference point was lost. The attempt to turn glider away from trees at the end of the field on the ground run with rudder resulted in dropping a wing.
Lessons learned: As a rule in off field situations it is better to get the glider into the field in the first third of the available space, land straight as possible into wind and minimize the ground roll.

Substantial Damage. ASW 15 gear up landing. Pilot modified procedure for downwind checks to complete water/wheel item when approaching airport. Distracted by traffic closer to the pattern this item was missed. Once in the circuit gear was assumed to be down as it was habit to do so earlier in flight.
Lessons learned: Modifying standard procedures have increased risk for failure. Always visually confirm handles are in the correct position if possible and/or get used to listening to the changes in wind noise created by down gear. Gear controls should be labeled “open” and “closed”.

Substantial Damage. DG Motor glider damaged in off field landing with motor out. No SAC accident report received.
Lessons learned: Similar accidents in the past has led FTSC to draft a checkout procedure for motorized gliders with the aim to reduce the risks associated with this type of aircraft. This document is available and will be on the SAC web site.

Minor Damage. ASW 20 overshot runway floated down landing field and over fence landing gear up in adjacent field. Pilot had pulled on the gear handle instead of air brakes. Wind was 10 kts 050 landing on runway 14.
Lessons learned: Confusion between air brakes and flaps cause similar accidents annually, usually with more serious consequences. There are ergonomic measures to deal with this such as different coloured levers and textured handles, but the visual check if possible by looking at the air brakes on the wing when you move what you believe to be the correct handle. Get used to feeling the aerodynamic differences on the controls. Discipline yourself to make this a habit and also with your gliding students. Discuss this point at an instructor meeting.
Landing downwind increases the risk factors in this type of situation.
Human Factors also indicates that when a pilot does not get the response they expect they can become mentally paralyzed into inaction (deer in the headlights). We are all susceptible to this and when we are surprised by an unfamiliar outcome we need to reassess. Practicing similar drills in various scenarios has proven to be a method of training ourselves out of inaction. In this case the brain goes into automatic mode and falls back to what was learned as a drill. No drill –no action.

Minor/Major Damage. L33 Solo damaged during de-rigging. A maintenance inspection was planned on the spacers for the wing studs. The wing tip was dropped from about 3 feet.
Lesson Learned: Gliders are slippery in and out of the air. Although this may not have been a factor in this accident as a general rule employ sufficient people to do the job and prepare the work site with tires underneath the wings to support and minimize damage.

Minor/Major Damage. LAK landed on pavement gear up. No SAC accident report received.


Incidents

Several incidents reported included:

 Krosno spoiler and aileron controls improperly rigged by assembly crew (similar problem on Jantars).
 Puchacz trim cable wear near trim tab discovered by positive control check of trim controls.
 L33 spar stub carry through brass washers can fall off when wings disassembled allowing for/aft play on wings.
 Pilatus B4 kiting problem on take off with Cof G hook and powerful tow panes/winch
 L23 crotch seat buckle falling into control sleeve blocking controls (also possible on Puchacz) passed to technical committee.
 Inadvertent spin entry from thermal gust.
 L33 C of G hook used for aerotow instead of aerotow hook.
 Lark almost loses directional control on take off when wing touches the ground.

Analysis

Nine accidents have training related factors as major elements and most have significant operational factors influencing their outcomes. Club policies/procedures can have major impact to help prevent many factors that can help cultivate an accident environment. Grass cutting operations, airfield conditions, rigging standards in club, checkout policies, control/reception of visitors, etc will mitigate risks. A club review of risk factors is needed to identify these latent conditions. Club training should also be reviewed for risk factors. Does your club train pilots to release immediately if wing touches the ground? Do instructors do this at your club or do they try to use their experience to save the launch?
Two areas for this report to focus on deal with stall/spin accidents and human factors judgement. OSTIV Training Safety Panel have identified the stall/spin, air proxies and judgment as the three highest risk areas for fatal accidents. Air proxies are less so in Canada as we do not soar in congested areas as much as they do in Europe but this factor should not be discarded. Knowing risk areas, recurrent education and understanding the limitations of sight and mental perception are required.
Our two most recent fatalities and tow accident relate to stall/spin situation and are our number one problem. Aircraft that spin easily will be around for many decades so our emphasis has to be education and training until technical solutions catch up. Spin recovery training is emphasized each spring but is only 1/3 of the equation. Recognition of situations that lead to stall/spin is also needed. This is best achieved in scenario based training situations so that conditions leading to stall/spin are easily recognized and thus avoided. Spin avoidance also deals with reacting to the stall before a spin has a chance of developing. The wing drop stall recovery (start of a spin) should be emphasized in initial and recurrent training. This recovery can be initiated at any altitude to avoid the spin. Lastly in the event of a spin, recovery needs to be instinctive. Glass gliders typically require the stick to be moved forward to stop the rotation, which is not always typical in most of our trainers. How many pilots spin solo at altitude to practice? Does your club do wing drop stall recovery as part of spring checkouts?
Many of the accidents were related to Human Factors in what we can call judgement. When the aircraft does something we don’t expect a pilot can become unresponsive/indecisive. Some argue that judgement is something we are born with good or bad. All of us are susceptible to poor judgement at times even instructors; it is the way our brains are wired. What can be done is to train for situations where we have predetermined course of actions or drills that we can use in emergencies. For automobiles it is called defensive driving. Nothing more than drills (best practices) to rely on in driving situations. Pilots can do this with an instructor or practice for themselves resolving several options for situations that could happen. Instructors also need to plan ahead and react as soon as they feel slightly uncomfortable with a situation. By this time the student may likely be very uncomfortable but silent. Little skill training value is present in emergencies.
More often than not if you speak to a pilot that made the right decisions in a difficult situation they will say at their darkest moment they went back to their training a did what had been drilled into them by their instructor! Judgement can be taught but not ignored.

Conclusion

SAC is about to introduce a Safety Management System (SMS) at the national level. This requires SAC to develop and improve its own program. This will require clubs to enhance their existing safety programs or develop new ones. Simply this is a leadership based safety program to manage safety. It will require analysis of risk areas in the organization and develop risk mitigation strategies. The program requires documentation to keep track of what we want to do and a means to follow up on our successes. Training and retention are often argued as conflicting requirements. They are not. Improvements to our training are intended by the FTSC to reduce injury and preserve aircraft. Problems with retention are more often related to how well people are treated and how well that training is delivered. Scheduling and instructor consistency are more important, not the number/content of lessons. The reason for SMS and more emphasis on initial and recurrent training can be answered by looking at the list above and in the past years reports. Lets all pull in the same direction!


Dan Cook
SAC Safety Officer
FTSC
Mar 2006
_________________
Dan Cook

FTSC Chairman

[Anonymous]

Just as in 2004, a great report and much appreciated. Unfortunately, the report is not getting any shorter. The goal should be a simple ... "nothing to report".

[Jean Richard]

[f1dave]

[Dan Cook]

In the club in question it is their safety policy to not use the C of G hook as they have both, therefore the "incident". In the brevity of the safety report sometimes the details are lost. For clubs that have both fitted to the aircraft avoiding use of the C of G hook for aerotow can help reduce risk of kiting and possible tow plane upset. I deemed it was worth mentioning therefore included the incident.
_________________
Dan Cook

FTSC Chairman

[Dan Cook]

Further clarification has been received an a couple of accidents. Puchacz fatal the glider was flying "towards" the circuit not "in". The Lark undershoot the pilots stated they did not experience "yaw from the crosswind" before the wing struck the ground.
_________________
Dan Cook

FTSC Chairman

[Dan Cook]

Write-off. PIC 20E engine lost some power on take off at 320 ft AGL and the pilot attempted to complete a low circuit on partial power. The engine would not maintain the altitude and the glider settled into the trees.

LS 4 was damaged in a ground loop landing after an interrupted launch. The tow plane momentarily lost power on take off from fuel starvation in one tank. The glider released at 150 ft AGL and turned to avoid trees and landed on a perpendicular but soft runway.

A Glider landing in an off field-landing attempt during the National Soaring Contest was damaged and the pilot injured. Pilot was not a SAC member and no report received.
_________________
Dan Cook

FTSC Chairman

[Dan Cook]

SAC SAFETY REPORT 2006

Intro

In 2006 we have had 6 accidents reported which include the write off of 2 aircraft. There was one non-SAC related gliding accident in which the pilot was injured in a land out but the information is not included in this report. 2006 is marked improvement from previous years where the average has about 18 accidents per year including a fatality. There has been speculation that the reason could be the implementation of the SAC Safety Management System but it is too early to interpret any direct results from this program. It could just be the fact that there has been more discussion about safety and we are all a bit more self-aware. Whatever the reason, it is a trend we need to keep working on if we wish to sustain a better track record. Ideally, if safety systems function properly we will have to address less reports of accidents and rely more on the reporting of incidents to identify risk mitigation strategies. Safety systems require continuous analysis of hazards and risk to take appropriate actions to improve safety. Club safety officers need to continue to seek this information from their pilots for their analysis and forward their finding to FTSC to keep the national system functioning. You are on a great start but please keep up the work to implement the process.

For the purpose of classifying accidents below major damage indicates repairs approximately $10K or more, substantial damages $1K to less than $10K, and minor damage less than $1K.

Accident Summaries 2006

Write Off. LS 4 on initial climb out, the tow plane suffered a power loss due to fuel starvation at 150 feet AGL. The glider pilot immediately released. Insufficient runway remained to land straight ahead so the pilot executed a 110 degrees turn to the right to avoid the trees and landed on another runway. Landing on very soft terrain a ground loop followed, damaging the right aileron and fuselage. The tow pilot was able to restart the engine and continue climb out.
Lessons learned: Tow pilot to apply proper procedures in fuel management and to execute the approved take-off checklist. Some clubs have a hazard/risk zone in towing operations where a glider pilot has few low risk options during launch interruptions.

Write Off. Self-launching glider lost most of its power at 320 feet agl at a soaring camp operating site. The pilot thought enough power remained to make a circuit around the heavily wooded area. On down wind the glider lost more power and settled into the trees.
Lessons learned: Self-launch motor gliders require special handling techniques for launch interruptions because of the added drag from the wind milling propeller. Landing straight ahead is usually the only option below a critical height. The critical height to turn back to the field with a wind milling propeller can be significantly higher than a conventional glider by hundreds of feet. A partial power loss should be treated as a complete power loss.

Minor Damage. Pilot was towing the ASW 27 to the line as directed by the club down a newly designated grass (long, uncut, un-inspected) taxiway, the wing dolly snagged the hidden top of an abandoned steel tie down post and damaged one aileron and scuffed some gel coat a bit. No SAC accident report received.

Minor Damage. L- 33 pilot intended to touch down on the runway then let the glider continue to roll close to the hangar end of the runway. As the wheel touched, the pilot closed the partially deployed spoiler to let it “taxi”, but the result was the glider became airborne. The reflex reaction of the pilot was to open the airbrakes. The glider then “quit flying” and dropped onto the runway at about stall speed. Minor damage to wheel shroud resulted from the hard landing.
Lesson learned: L-33 approach normally with “partial spoiler”, but in the L-33 you must NOT fully open the dive brakes during the flare or hold off. It simply quits flying and drops abruptly.

Minor Damage. Grob 102 Glider was damaged in its trailer towing to and from winter storage. The club had made a trailer change for the two Grob 102s, which resulted in improper tail security and to the damage of the rudder.

Minor Damage. SZD 51-1 Junior – out landing hit rock? No SAC accident report

Incidents

 K6 slightly damaged while being rolled onto the wrong handling dolly.

 Grob G103 Acro had a small hole punched under the wing when someone likely lowered the wing onto the K6 tail dolly.

 K13 tail was lifted too high by a pilot and caused the nose skid to impact the left wing of an ASW19, causing a dent in the gelcoat.

 K13 was moved into the hangar near a workbench and was slightly dented in the rudder's trailing edge.

 Towrope was progressively getting shorter at a club. Pilots were either bouncing around in the prop wash or electing to stay higher on tow. Current rope is about 120' verses 180' normally used.
 Glider gear up landing. Pilot hears a bang in flight (gear dropped), returns to field and on downwind checks raises gear.

 PW 5 Pilot making first flight on type finds canopy was rather noisy. After landing the canopy levers were opened and pushed up, the entire canopy came off. DI did not detect that emergency canopy release had been pulled and not reinstalled properly.

 Krosno rudder pedals slip forward in flight because locking pin not fully seated in locked position. Lack of lubrication.

 Krosno canopy unlocks in flight. Passenger’s knee may have moved locking lever that does not have a positive latch mechanism. Ongoing problem.

 Grob 102 took off with air brakes not locked. Confirmed visually but not pushed over center to lock. Familiarity on type may have been a factor. Also similar incident occurs with a Puchacz.

 Several incidents of gliders taking off or attempting to take off with tail dollies attached. Several gliders involved are L- 33 Blaniks.

 Standard Cirrus wing dropped in a crosswind take off and glider started to ground loop. Pilot released without further incident. C of G hook and under estimation of the strength of the crosswind were factors. This is a recurrent theme, in this case the pilot did the right thing! With other pilots are we highlighting the need to release immediately.

 Cross country pilot returns to field and after a quick pass lands and groundloops. Winds were gusting to 25 kts and wind was crosswind on landing so pilot could reach tie down area easily. On landing, the wing was observed to touch the ground with the tail high.

 Air proxy was reported to TC between a glider and a King Air twin engine aircraft.

 Air proxy reported between two gliders in the circuit. One not using active runway made radio call that was not intelligible. Effective communication would have been acknowledgement from the second glider in circuit.

 Air proxy between two seat glider on downwind and a 1-26 which passes 15 m overhead in the opposite direction. 1-26 blown downwind and trying to get upwind to start circuit.

 Thermal entry by glider causes conflict with glider already in thermal.

 Solo student makes a slow low approach and landing in 20 kts head wind. Did not adjust circuit base leg closer to compensate sufficiently for the wind and additional speed for the wind gradient.

Analysis

There were two major accidents and one incident associated with launch interruptions reported. Many clubs have a hazard/risk zone (height and location) in tow operations where the glider pilot has few options for a safe landing if there is a launch interruption. Some of these zones may be seasonal such as soft fields in the spring or corn crops in the late summer. Has your club identified them? Is there risk mitigation that can be done? Some clubs have modified or restricted their towing operations (short term) until they could afford a more powerful tow plane (long term) to reduce the risk of low level launch interruptions. Also the FTSC has produced a guide for motor glider pilots and CFIs on the web site to help them prepare pilots for such emergencies.

Landing and take off continues to be our most vulnerable stages of flight for the majority of accidents. “Options” in the take off checklist CISTRSC-O is the time to assess the wind strength and direction and how it will effect your take off and possible launch interruption. If conditions appear to be marginal make a change such as runway or time of launch to opt for better conditions. If the decision is made to go ahead, plan to release if the wing touches the surface and have landing areas determined for each phase of the launch until you can make a normal circuit.

Hangar rash/ line incidents will continue to plague us. Carelessness can only be countered by training and a well disciplined approach to moving gliders, conducting a DI, flight line operations, etc. CFI’s may need to be more formal in this training if investigation show that new members are having the majority of incidents. If experienced club pilots are the culprits then complacency is creeping in. In this case hangar rash and line incidents could be an indicator of a more insidious problem that could develop into more serious accidents. CFIs should immediately hold a pilot’s meeting to get to the root of the problems. Finger pointing is not the answer but working together to identify hazards and solutions to reduce risk is the way ahead.

Air proxies are becoming critical internationally and we manage a few incidents each year. Aviation experts claim that there are 10 incidents not reported for every one that is reported. Airspace is an issue and knowing, communicating effectively, and avoiding places where there will be higher collision conflicts is half the battle to minimizing risk. The second half of the battle is seeing and avoiding. New scan techniques have been written about in Freeflight magazine and have been included in our SOAR manual. Are we disciplined enough to change our own technique? Is our own technique working or are we just lucky? Latest scan techniques are based on human factors and limitations of human sight. They are designed to stack the odds of detection in your favor. Why not learn to use them.

Several take off or attempts with wheel dollies attached and incidents of spoilers, canopies, etc unlocked or open indicate a lack of a walk around before the flight or the rushing of checklists. Pilots are responsible for their own safety but we can structure our operations/organization to build in additional safeguards to protect them and our equipment. Flight line supervisors who do not see a walk around before the flight should not allow a launch to continue. Training ground personnel wing runners to be alert to these problems can also help avoid a potential disaster.

I also received a report from a club referring to their continuous training program, which includes:
 Mandatory calls must be made out loud (even solo), at 100 and 300 feet.
 Group briefing each day (Weather, field condition, traffic, any abnormalities and procedures)
 Conduct two pre season "intensive" check flights.
 Training program also includes an unannounced "check flight". Items are reviewed with the CFI.
 A review exam of 25 questions that is completed by all to stimulate thought and currency. This exam is reviewed in group.
Does your club have a recurrent training program or do you fly just a couple of circuits to get the “cob webs” out each spring? An annual check flight should include at least the items on a license check ride.

Conclusion

You have seen we have made some major improvements in our accident rate. Just being more aware and discussing safety openly can improve safety culture. Also the trend in reporting is that the number of incidents is greater than the number of accidents. This is ideal and an indication that the safety system in clubs is working better. By dealing with incidents through analysis and improving our risk mitigation we will improve safety. SAC has introduced the Safety Management System (SMS) at the national level. Many clubs are stalled at the analysis phase and are having difficulty producing the Club Safety Program Manuals due to the work involved. Working to complete this manual will continue to bring the club safety culture to be more proactive rather than reactive. The process will allow you to look inward at what needs to be done to address active hazards and latent conditions in your safety net. The bottom line is we all benefit.
Now how can I get more clubs to send in their annual safety analysis listing all the incidents??


Dan Cook
FTSC
National Safety Officer
_________________
Dan Cook

FTSC Chairman

[Paul Moggach]

To Jean Richards point about the L33. If the club standard operating procedure is to use the nose hook for aerotow, then this is an incident regardless of what the aircraft operating manual states. The aircraft behave quite differently on launch depending on which one is used.

Safety is not always about what is 'legal', but what you define as safe behaviour and how you deviate from this. Stall turns are 'legal' in L-13, but just ask the guys who progressed into a tail slide if it was a good idea as their tail feathers were collapsing.

Some countries such as Austrailia even banned the use of CofG hooks for aerotow.