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Ron Panton of Experimental Aircraft Association Chapter 187 is a member of LAMP (Learning Activities for Mature Persons), a lecture and seminar series at the Osher Lifelong Learning Center on the UT-Austin campus. He didn’t attend my “Pilot Error in Fact and Fiction” presentation there on January 24, 2013, but he read the summary and thought the Chapter might be interested in hearing it at one of their monthly meetings. Ron contacted Mark Petrosky, who in coordination with the Chapter president Anthony Plattsmier coordinated with me to speak last evening at the Wells Branch Community Library.

Mark sent out an eblast to Chapter members with MailChimp and did a great job with the layout, which included a bio, photos, the title page slide of the PowerPoint presentation, the wraparound covers for the paperback versions of my books, and this great lead-off image, which I assume is reproduced here with permission.

As originally designed, the presentation assumes an audience of normal people who don’t subject themselves to the flyer’s world, consisting of hours of boredom interspersed with moments of sheer, stark, raving terror. The invitation created a dilemma of sorts, in that parts of the presentation delve into topics that are unfamiliar to non-aviators but self-evident to pilots. I didn’t want to insult the collective experience and skill in the room, nor did I relish revising the slides and script.

The solution I chose was to alter the objective of the talk by moving more quickly through the fundamental subject matter and show them how I chose to explain to non-aviators what it’s like up there in the cockpit, and in particular, how pilot actions can affect the final outcome when something goes wrong.

In the aftermath, I can report that the audience appeared to be interested throughout the presentation, and two members of Chapter 187 mentioned other speaking opportunities that I might consider. The answer, of course, is sign me up.

Thanks to Ron, Mark, and Anthony for the invitation and the Chapter’s welcoming attitude. The experience was both a pleasure and an honor.

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During my recent presentation “Pilot Error in Fact and Fiction” as a part of the UT LAMP Lecture and Seminar Series, discussing the role of human performance in aircraft accidents included an example of a how a mistake by an aviation mechanic could be the primary cause.

Any bolt in an airplane needs to stay put, and there are three methods used to ensure they do not loosen up. Bolts tightened to a specific torque value use safety wire to apply clockwise tension as shown in this image of six propeller attachment bolts.

Image credit ultralightnews.ca

A castle nut is used in applications where a specific torque value is not critical and the primary objective is to prevent the nut from backing off. The nut is snugged down on the bolt and tightened until the nearest slot is lined up with a hole in the bolt. A cotter pin slipped into the slot, through the hole in the bolt, out the opposite slot in the nut and bent back onto itself secures the nut in place.

Image credit amazon.com

A nylon lock nut is remains in place because of the friction between the nylon insert and the threads on the bolt, which cut into the nylon as the nut is tightened. The are designed for one-time use.

Image credit toolstation.com

If a bolt comes loose because it was not properly safety wired, for example, and that is determined to be the first link in the chain of events, the primary cause of the accident can be attributed a mistake by a mechanic. Such was the case as reported on AVweb:

NTSB Cites Maintenance Errors In Fatal Crash

A tourist helicopter that crashed in Nevada in December 2011, killing the pilot and two couples on a sightseeing tour over Hoover Dam, was brought down by an improperly fastened nut, the NTSB determined on Tuesday. The investigators found that a maintenance crew working on the Eurocopter AS350-B2 before the flight had probably reused a self-locking nut that should not have been reused. The nut failed in flight, making the aircraft uncontrollable. The mechanic and a supervisor both had been called in to work on their day off, the board said, and fatigue was cited as a factor. NTSB Chairman Deborah Hersman said the accident shows that mechanics need to use checklists in their work, just as pilots do.

Finding the cause of the crash required “old-fashioned investigative gumshoe work,” Hersman said at the board meeting. The aircraft, operated by Sundance Helicopters, had no flight data recorder on board, there were no witnesses to the crash, weather was clear and calm, and there were not even any ATC tapes. Radar showed that the helicopter deviated from the usual tour route about one minute before the accident, first climbing and turning, then descending and turning again before impact. The helicopter was heavily damaged by the impact and a post-crash fire. A synopsis of the safety board’s findings is posted online; the full final report will be posted in several weeks.

Another example of human error from my presentation is fuel starvation. I used it to indicate how failure of a commercial airline operations dispatcher to consider the potential for rapidly changing weather to cause inflight delays might result in an aircraft not having adequate fuel reserves. In the example below from Avweb, however, the blame falls squarely on the pilot-in-command.

Danbury Chute-Pull Aircraft Out Of Fuel

The NTSB says a Cirrus SR20 that parachuted to safety last week in Danbury, Conn., was out of fuel. In its preliminary report on the incident, which was widely publicized in the mainstream media, the NTSB says the aircraft, with a flight instructor, another pilot and a third person on board, was on final for the Danbury Airport when the pilot flying radioed to air traffic control that the aircraft was “out of fuel.” Investigators later were able to drain just 26 ounces of fuel from the tanks and none had spilled when the plane settled to the ground about three miles from the airport.

The report says the flight originated in Danbury and the trio flew to Groton and landed. They were returning to Danbury when the prop stopped. The round trip was about 150 miles if both legs were flown direct. After making the radio call, the pilot pulled the parachute handle and the aircraft settled in some trees in a residential area, breaking off the empennage. There were no injuries. There was a remote data module on board and a memory card in the avionics and both have been sent to the NTSB’s lab for analysis.

Note: The parachute visible in the photo above is not a personal chute. It was installed as part of the equipment aboard this Cirrus aircraft, and it’s designed to lower the entire aircraft safely to the ground as shown on the right. Safely, however, does not necessarily mean gently, and some aircraft damage can be expected. As mentioned in the article, the airplane landed in some trees, and the tail section broke off. Had it landed on flat terrain with no trees, that probably would not have occurred.

In any case, “There were no injuries” is the operative objective of this feature.

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Waiting for Rita to ring the little brass bell

Ann sells the first book to an eager customer

Greeting customers

The “Silver Fox” signs

Tosh and Ann with Elaine Shelton, UT LAMP Curriculum Director for the Business/Lifestyles Track

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When I first heard about UT LAMP (Learning Activities for Mature People), two facts about the program seemed a little hard to believe.

First, that when invited to be a guest speaker, the earliest open lecture slot was 10 months in the future. Second, that membership is capped at 500, and at a yearly fee of $195, there’s a waiting list of prospective members who seek an invitation to join. As of Thursday, January 27, 2013, when I presented “Pilot Error in Fact and Fiction,” I no longer have any doubts about the popularity of the program or the reasons for it.

If I had to guess, I’d say that the combination of my pilot and military backgrounds makes me especially appreciative of competency in anything. Doing something well is never an accident, and the entire UT LAMP organization and its members are absolutely first class.

The expression “like clockwork” describes well the lecture sessions. I arrived a little before 9:00 a.m. and met Elaine Shelton, the curriculum director who invited me to be a speaker. We had been coordinating periodically over the past 10 months, and from the outset, Elaine did everything she said she would do to help me prepare, from presentation content, to timing, to logistics of setting up the book signing table, to obtaining the special parking permit, and arranging a visit as a guest to observe how the lectures were run.

Not to downplay the importance of my own preparation to revise the script and the slide show, but walking into the lecture room with confidence was due in large part to Elaine’s assistance. Another staff member facilitated connecting my computer to the A/V system and fitted me with the Lavalier microphone, and I was ready to go about 10 minutes before the scheduled start time.

Speaking of which, all flight briefings during my Air Force career began with a time hack. On one notable occasion, the flight lead of a combat mission in Vietnam provided a time hack with an exaggerated gesture to look at his wristwatch and announce in a ridiculous simulated accent, “Ah so. Seiko say time zero-eight-thirty hours.”

We all stared at him as if he’d gone crazy overnight until he showed us his brand-new Seiko watch that he bought the previous afternoon at the Base Exchange. None of us had ever seen a Seiko, but it didn’t take long to remedy that. From that moment on, most time hacks began with, “Ah so . . .”

I can report, however, that I didn’t need one at UT LAMP. You can set your watch by how they run it. And when you meet Rita, you know why.

Remember the hall monitors in school, or maybe your homeroom teacher with the ruler? This delightful lady is the gatekeeper, if you will, and she leaves no doubt in your mind who’s in charge when it comes to signing in guests, preparing the name tags, and the handling of the little brass bell that signals an advance warning. And when the clock strikes 9:30, the door closes and ding-a-ling we begin. Don’t be late.

After a few announcements, introduction of guests (and special thanks to my wife Ann, Dr. Guy Knolle, and Dr. Sue Ellen Young (Knolle) for their interest and support), Elaine steps to the podium, presents a very nice introduction, and the audience greets me with what felt like welcoming applause. That’s the way to launch into presenting for the first time an hour-long lecture that has changed significantly since one earlier event that didn’t meet my own standards. My nervousness vanished almost immediately.

I had timed my practice sessions giving the lecture to an empty home office/study and knew that it took just under the allotted hour. I also knew from previous experience that I have a tendency to stray from a script with extemporaneous additions, any of which might well cause me to overrun the limit. And that might get me in hot water with Rita, so I definitely didn’t want to let that happen. Don’t make her ring the little bell, Tosh!

I am relieved to report that I opened the Q&A period with two minutes to spare. For the next 17 minutes, UT LAMP volunteers responded to raised hands within the audience by distributing microphones and exerting direct control over who asked a question and when.

With no idea about what to expect from the questions, I have to say that they all addressed specific points covered during the lecture and indicated genuine interest in the topic.

And then the control of timing reigned once again. With only 15 minutes between the end of the Q&A and Rita’s next ringing of the little bell, I had to disconnect my computer and vacate the podium. That was not an easy task with UT LAMP members wanting to engage me in conversation, which I was delighted to do, but it required multi-tasking. And I’m proud to report that Rita shook my hand. Twice.

The book signing table looked really nice. I had posters of the front covers for each of the books and a price list with thumbnails of the covers. The final sales tally was 27 books, consisting of 11 novels and 16 (8 each) of the non-fiction titles.

One interesting note is that UT LAMP didn’t used to allow speakers to sell copies of their books. But that changed a few years ago, and it created a positive effect on their ability to attract speakers on a greater variety of topics.

Feedback from a variety of sources has validated for me the utility of combining a topic of interest with extensive preparation and repetition to create a professional lecture. I’d love to do it again, but the next available slot may be many years down the road.

I salute UT LAMP and everyone associated with it.

Well done!

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Two older posts in the Pilot Error Logbook address the topic of a PowerPoint presentation titled “Pilot Error in Fact and Fiction” that I created after being invited to be a guest speaker at the Lakeway Men’s Breakfast Club (LMBC) in March, 2012: “Have Presentation – Will Travel” on 03/19, and “Presentation Aftermath” on 04/22.

As mentioned in the second of those posts, I received a subsequent invitation to give the presentation as part of the UT LAMP (Learning Activities for Mature People) Lecture and Seminar Series, a part of the Osher Lifelong Learning Institute, on January 24, 2013, beginning at 9:30 a.m. at the Thompson Conference Center on the University of Texas at Austin Campus.

Based on the LMBC experience and in coordination with my UT LAMP curriculum contact, relative emphasis on the factual and fictional elements of the presentation has been changed. I’ve picked three high-profile aviation accidents to illustrate the effect of human performance on the ultimate outcomes. In each case, the event sequence is examined to show how a series of key elements fit together such that if any one had not occurred, the accident would never have happened. In addition, I revamped the slide show to further enhance the presentation and am currently in the process of fine-tuning both the show and the script.

I jokingly tell anyone unfortunate enough to engage with me in conversation about the presentation that the World Tour has begun, as evidenced by a recent invitation to be a guest speaker at Querencia at Barton Creek on March 6, 2013, at 2:00 p.m.

Please note that at this point, the tour schedule is relatively open. If you hurry, you can reserve the primo slots.