accidents - Roy Bourgeois chief pilot 7/21/2021

Some thoughts on 2 recent serious accidents

Friends:
We enjoyed about 5 years of no bad accidents, but now coming out of the pandemic we have had 2 recent serious ones - fortunately without injury but with tens of thousands of dollars in damage. As Chief Pilot I've been thinking a lot about why this may have occurred and if there is something that I have been missing or doing wrong. That's the purpose of this article. I don't have all the answers but I want to share a few thoughts with you.

During the pandemic my primary goal was to keep the club flying. We had lost about 90% of our CFI staff and about 60% of our tow pilots - all sitting out the pre-vaccine pandemic. For the first half of the 2020 season I did most of the glider instruction and all of the tow pilot re-currency instruction. Again, the goal was to keep the club flying. And, there was a large pent up demand in the club for members to get into the air - especially for people who could fly solo.

We made safety concessions to do this. For the 2020 season we waived our traditional pre-season check ride of all non instructors (we didn't have the CFI staff to do them). We allowed for a "self assessment" form to be completed and did the same thing in the Spring of 2021 (but frankly paying less attention to the self assessment form that second year) for all private rated pilots. In retrospect that was a mistake: we treated very low time private rated glider pilots (who should have had a check ride) the same as 1000 hour pilots (who probably didn't need a checkride). The goal was to keep us flying and perhaps flight safety took a back seat to covid safety.

The Pilatus accident involved a low time, non glider current (2 flights in the last 90 days), private rated pilot, who was not required to have a check ride. On the accident flight he wanted to land short so he could get back to the line quickly to get another flight in. He wanted to keep flying and cut his margins to do it. He wasn't prepared for the thin margin he created.

The recent ground loop accident occurred with an experienced pilot, who had already flown that day and knew that there had been a previous ground loop in the high / thick grass. He approached the line and next learned that his radio was inoperative (a fact unrelated to the accident but significant in my view). Anxious to get a flight in, he took a launch and he ground looped badly - breaking the tail of the glider off. He wanted to keep flying and cut his margins to do it.

Many experienced people (including several CFIs) saw the earlier ground loop on take off that day and took no steps to stop operations and get the grass cut. Although it had rained a record amount in the preceding 3 weeks (and the grass showed it), they were too quick to blame the first ground loop on the pilot without examining the grass nor asking "Why did that dropped wing result in a ground loop?" Operations were not stopped (nor the grass cut) until after the second ground loop. They wanted to keep flying and accepted reduced margins to do it.

Most significant to me however, is that following that accident there developed a pointed discussion/argument between two very experienced members (both CFIGs) about whether we should continue operations (even while the wrecked glider was still in the grass) by operating off the paved runway - with one member saying that the decision to end operations (with the grass still uncut and a wrecked glider still sitting in it) was a "knee-jerk reaction lacking a considered risk analysis" (his words in a later email). It was later pointed out to him that the absence of a "considered risk analysis" should mean: We Don't Fly. He wanted to continue even with reduced margins (overgrown grass with a wrecked glider in it) or perhaps not recognizing that they were reduced.

Maybe you are seeing the same common thread or cause in all of this. Did the pandemic recovery for the club give us an attitude or a value that we must always endeavor to fly - even if we are cutting our margins short for silly reasons? Or does pressure to fly not even allow us to see that we are reducing our margins? I doubt that any of the people discussed above consciously considered that they were reducing thier margins. In fact, the last person discussed (who wanted to keep flying off the paved runway after the accident) later recognized that this would have been a mistake.

And let me be clear - your Chief Pilot may have been a contributor to this problem with his relentless focus on keeping the club flying. I often say (and it's very true) "I don't have this job because I'm safer than anyone else - I have it becuse I've made more mistakes than most of you". Maybe we all made the same mistake of blinding ourselves to the margins we were cutting during and after the pandemic. But now the pandemic is mostly over and we are back to regular flying. It's time to learn to get good at it again and with good safety margins.