When Procedures Fail

Learning the lesson the hard way

Pilots are a conscientious group. We do preflights, use checklists, and respect our physical and technical limitations. We pride ourselves in using a disciplined approach to developing and setting procedures, aware that the muscle memory that develops as habit is an important part of being a safe pilot. We constantly assess risk, and do everything possible to reduce error. But however disciplined and mature we are, there's still a "normal risk coefficient" that says we're human and can make mistakes.

It seems then that the key to safety is to give ourselves plenty of margin for error. Then if we do err, we'll still be on the conservative side of the power curve. Because air show professionals need to fly low for the spectators, our safety margins are even more critical. We pay special attention to preflights, FOD and preventative maintenance.

At air shows, I like to get my airplane ready early so I can chill and think about my flight. During my preflight, I naturally fasten the cowl after checking the engine, and I check the oil and make sure my fuel caps are secure. Then, I can relax and watch the winds and the sky until it's my turn in the box.

As much as we try to eliminate it, risk is always lurking around the corner and is part of the game. One year at the Dayton Air Show, the "normal risk coefficient" gave me a wake-up call. The Dayton Air Show is famous for being one of the biggest and best shows in the country, and to perform there is an honor. As I was diving into the box for my opening maneuver, I saw 100,000 people, their eyes turned to the sky, waiting to be awed by my display of aerial magnificence. As I pushed the stick forward for a knife-edge spin, my Extra 230 growled with intention as the airspeed indicator edged toward red line. At 220 knots, I pulled the stick back into a hard 9 G pull to the vertical and the Extra went straight up. As it ran out of airspeed, I checked my altitude and had plenty of air between me and the ground to continue.

Pivoting out of a hammerhead entry, I stuffed each of the controls into the right corner---aileron, elevator and rudder---and the airplane wrapped up. It knife-edge spun once, twice, three then four rotations. I looked for the ground, and then pulled back on the stick for my next maneuver. As I started leveling off, something didn't feel right. Instead of a slippery monoplane, I felt like I was flying a biplane, all wings and wires, lots of drag and not enough power. More importantly, I didn't have enough airspeed for my next maneuver and my oil temp gauge indicated higher than normal.

I thought---What the heck, over? But the problem was right in front of me. The left side of the hinged metal engine cowl was open and bending backward, shuddering and completely disturbing the airflow. I thought it was going to break and slam into my canopy or possibly my elevator---or both. I broke off the routine, immediately reduced power and leveled off, hoping the cowl would stay on the airplane until I landed. I then radioed the Air Boss to tell him I had a little "problem" and needed to land. So much for aerial magnificence. I successfully embarrassed myself in front of 100,000 spectators!

What happened, and why did my sacred procedures fail? The easy answer was I got distracted. Shortly before I flew, a local TV station asked me for an interview. They suggested I unbutton my cowl, close only two of the five fasteners, and then turn to the camera and say, "Welcome to the Dayton Air Show!" Happy to oblige, I smiled, did as they asked, and promptly forgot the other three fasteners as I jumped in my airplane and taxied out to the runway.


The more complex answer was something I mulled, pondered and stewed over for a long time. What good are procedures if we don't follow them? What if we follow them, but they fail us? We get distracted; we forget things. In fact, distractions happen so often we probably need to practice for them. (When I'm instructing, I purposely distract my students and do things like chatter away on short final, much to their annoyance, for this very reason.) Distractions are something we need to be aware of and plan for. In Dayton, I ended up looking like a dork, but it could have been a lot worse.

After the Dayton incident, I developed my non-violable, carved-in-stone air-show-flight preflight, written checklist. My crew follows it, puts a check mark after each item then puts their signature on it. I, as the PIC, check it and sign it off as well. This reminds me that no matter how much I rely on my team, I'm ultimately responsible for the condition of my airplane. And, if my crew gets distracted during the preflight, they know exactly where they left off by the check marks.

Whether you have a crew or not, this kind of checklist could work for you. Make copies and keep a stack of them in your hangar. Check each preflight item off with a pen when completed. If you get distracted, you'll know where you left off. And with any preflight checklist, you can at least back up a few steps from where you left off when something takes your attention away.

I don't like to make mistakes, and I don't like surprises, so whatever checklist I'm using, I have another trick up my sleeve that works in any airplane to eliminate errors. I always do a CIGAR check before takeoff, and a GUMP check before landing. These checks cover all of the important basics. I learned them early in my flying career, but I'm surprised how many newer pilots don't.

CIGAR: Controls, Instruments, Gas, Attitude (trim) and Run-up. In my Extra, I add an extra "C" for Canopy. You can add an "F" in there for Flaps depending on your airplane, and an "S" at the end for Safety if you're wearing a parachute.

GUMP: Gas, Undercarriage (Gear! Gear! Gear!), Mixture, Prop.

Not fastening my cowl and having it nearly break off isn't the only mistake I've ever made, but I don't beat myself up over it---unless I ever do it again! My art teacher used to say, "Mistakes can be your best friend." He meant it as a creative way to explore potential or "propel" you forward into a new direction, but I think it applies to aviation, as well. I have a lot of gratitude for the mistakes I've learned from---both mine and others. Mistakes give us wisdom, keep us alive and make us better, more careful pilots. When I screw up, it's just one more thing I don't have to repeat!

Isn't it great that flying keeps us humble? Just when you think you're getting pretty good, something comes along that lets you know you still have a lot to learn. That's at least part of why I love to fly. The challenge of perfection is always there, but it's so elusive we can never quite get our hands on it! Awesome.

Patty Wagstaff is a 3-time U.S. National Aerobatic champion, and one of the world's top airshow pilots. Visit pattywagstaff.com/school.html or reach Patty via email through pattyaerobatics@gmail.com.

Subscribe to Our Newsletter

Get the latest Plane & Pilot Magazine stories delivered directly to your inbox

Subscribe to our newsletter