• Just This Once

    Created and narrated by Gene Benson

    broken image
  • About the course

    This course is presented free of charge courtesy of Avemco Insurance.

    Our title, “Just This Once,” comes from mishaps that occur when someone knowingly acts contrary to an established procedure or regulation and justifies it by thinking or saying, “it will be okay just this once.”

    We begin by reviewing the concepts of hazard and risk and a reminder that the pilot's job is to manage risk to an acceptable level. We see how and why established good operating procedures and regulations have been developed to help pilots manage risk.

    We then go into why pilots sometimes deviate from procedures and regulations as we address external factors and our humanness. We caution against the slippery slope we may start down when we begin to act contrary to good operating practices and regulations.

    Perhaps most importantly, we provide tips on how to mitigate the risk of having an accident or incident as a result of thinking or saying it
    will be okay “Just This Once.”


    The course consists of text, videos, accident examples, references, and a quiz. The reference section consists of both required and optional material. The required material is part of the course and may be included in the quiz. The optional material is strongly recommended to increase your safety as a pilot. Successful completion of the course, including the quiz, is valid for 1 credit at the Master Level Topic 2.


    Sucessful completion of the course also qualification for the Avemco Safety Rewards Program.


  • Hazard and Risk

    Watch this video to learn more about hazard and risk and pilot responsibilities for managing them. When the video ends, move on to the next section.

  • Precedures, Regulations, and Mentors

    In this section we are reminded of how we have been taught about standard precedures and regulations by our instructors and mentors. When the video ends, move on to the next section.

  • External Factors

    In this section we will explore how external factors can contribute to faulty decision making. When the video ends, move on to the next section.

  • Our Humanness

    This section explores our humanness for answers to why we sometimes are influenced to act contrary to what we know is right. The first video mentions briefly the effect of three cognitive biases. When the video ends, watch the next video, " The Bias Bundle Bomb" for more insight on how this works.

    Bias Bundle bomb

    When the video ends, use the links provided below to download samples of a Personal Minimums Checklist and a Flight Risk Assessment Tool (FRAT).

  • Accident Examples

    This section includes a discussion of three airplane crashes. Please read and think about each example and ask yourself if you might have travelled down that same path. If more information is desired on any of the examples, a link is provided at the end of each discussion to download the accident report from the NTSB website.


    Accidents discussed in this presentation are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Thoughour topic is “Just this Once” we cannot know the complete circumstances nor the pilot’s thoughts that resulted in an accident. The accidents presented here represent events in which it is possible that the pilot, at some time in the past or present, thought that it would be fine “Just this Once.”

    Accident Example #1


    The pilot was supposed to perform a ferry flight for the airplane owner. They were conducting a familiarization flight when the accident occurred. The owner told the pilot that he had added 25 gallons of fuel and the pilot did not perform his own preflight inspection. They departed on a flight around the pattern and experienced fuel exhaustion on the first time around. An off-airport landing followed with the airplane being substantially damaged.

    broken image

    There were no injuries. The NTSB probable cause states, "A total loss of engine power due to fuel starvation. Contributing to the accident was the pilot’s failure toaccomplish a preflight inspection."


    There were no injuries. Did the pilot think it would be okay to skip the preflight inspection just this once? Click here to download the accident report from the NTSB website.

    Accident Example #2


    Picture these two airplanes landing on opposite ends of the same runway at night. the NTSB accident report includes the following: "The private pilot of the Cessna was landing while the airline transport pilot of the Aero Commander was landing on the opposite runway during night visual meteorological conditions, after the airport control tower had closed. The Cessna pilot activated the runway approach lighting system and mistakenly believed that the green threshold lights indicated the direction for landing on the active runway. The pilot-controlled lighting system used a separate radio frequency from the common traffic advisory frequency (CTAF) at this airport. The Cessna pilot stated that he then “switched radio channels” and made “routine calls.” The Aero Commander pilot made radio announcements on the CTAF during each leg of the traffic pattern, announcing his location and intentions. Contrary to the Cessna pilot’s belief that the green lights he observed indicated the active runway (and the one on which he intended to land), they denoted the location of the (displaced) runway threshold of the adjacent runway. During landing rollout, the right-wing tip of the Cessna contacted the underside of the right wing of the Aero Commander, which had landed on the opposite runway, resulting in substantial damage to the Cessna’s right wing. The Cessna pilot reported that he did not hear any radio transmission from other aircraft operating at the time, and the pilot of the Aero Commander did not hear any radio transmissions from the Cessna pilot. Audio recordings of the CTAF frequency captured the radio transmissions made by the Aero Commander pilot (and other traffic) but did not capture any transmissions from the Cessna pilot. It is therefore likely that the Cessna pilot kept his single communications radio tuned to the pilot-controlled lighting frequency rather than change it to the CTAF as indicated in the airport/facility directory, which resulted in his communications not being heard by other pilots in the vicinity and his lack of awareness of the Aero Commander pilot’s position."

    broken image

    ADS-B track - Graphic Source: NTSB

    broken image

    Dekalb-Peachtree airport near Atlanta. FAA Airport Diagram with added annotations

    broken image

    Source of photos: NTSB

    The NTSB probable cause states, "The Cessna pilot’s failure to tune his radio to the common traffic advisory frequency, which resulted in a lack of awareness of the other aircraft operating at the airport. Contributing to the accident was the Cessna pilot’s lack of understanding of the airport lighting system."


    We know that we must look up and carefully use the correct radio frequencies. Is not doing so okay "Just this Once?"


    Click here to download the accident report from the NTSB website.

    Accident Example #3


    The NTSB accident report includes the following, "The airline transport pilot departed on the instrument flight rules cross-country flight in night visual meteorological conditions with about 45 gallons of fuel, which, based on fuel burn rates, was sufficient for about 3 hours of flight. About 3 hours after departure and 50 miles from the destination airport, the pilot told air traffic control he was having engine problems and requested a vector to the nearest airport. A witness near the accident site heard the airplane descending and described the sound of an engine being re-started several times. The airplane came to rest in wooded terrain. Postaccident examination revealed the wing bladder tanks were intact, and no visible fuel was observed in either tank. When the wings were removed, a total of less than 2 quarts of fuel was drained from both the left and right fuel tanks. Examination of the airplane and engine revealed no pre-accident mechanical deficiencies that would have precluded normal operation. The pilot was aware that the left and right fuel tank bladders were bulging prior to the accident flight. The bulging fuel bladders may have resulted in erroneous fuel quantity readings during the flight. Given the absence of fuel in the airplane's fuel tanks and the length of flight that corresponded to the fuel available, the pilot likely departed without sufficient fuel to complete the flight to the intended destination and the loss of engine power was likely the result of fuel exhaustion."


    The NTSB accident reort continues, "The pilot was found deceased, slumped over in the left seat, still wearing his lap belt. Although the airplane was equipped with a single shoulder harness (across the left shoulder), it was not secured to the lap belt at the time of the accident. The pilot's failure to have properly secured the shoulder harness at the time of the accident likely contributed to the severity of his injuries. Examination of the pilot's seatbelt and shoulder harness assembly revealed that the seat belt shoulder harness attachment post elastic grommet was not installed, nor was it found in the wreckage. When manually assembled, the shoulder harness attachment buckle would not seat securely to the seatbelt attachment post."


    Photo source: NTSB

    The NTSB probable cause finding states, "The pilot's improper preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the severity of the pilot's injuries was his failure to have a properly secured shoulder harness at the time of the accident."


    This experienced pilot must have known the importance of preflight planning and of the substantial survivable benefit if wearing the shoulder harness. Did either or both of his decisions regarding preflight planning and the use of the shoulder harness have an element of, it will be okay "just this once?" And if so, was the "just this once" decision made prior to this flight or had the decision been made in the past and the pilot had travelled down that slippery slope?


    Click here to download the accident report from the NTSB website.

  •  Reference Section


    Having a custom Personal Minimums Checklist is very important for every pilot. This document from the FAA explains the why and how of developing your own Personal Minimums Checklist.

    Download and read Developing Personal Minimums


    The advantage of the Flight Risk Assessment Tool is that it requires only objective decisions rather than subjective ones. This document is for demonstration purposes only. It is not to be used for actual flights unless modified to suit individual pilot circumstances. This sample is appropriate for a non-instrument rated pilot flying a simple or complex single-engine airplane.

    Download and study the sample FRAT.


    Checklists Micro-Course (Wings Advanced Knowledge-2)

    This course will explain why checklists should be dynamic documents, always ready to be improved or expanded. It will discuss the creation or revision of checklists for normal operations, abnormal operations, and emergency procedures. It will also show how the process of creating or revising checklists will increase better understanding of the airplane's systems and operation.

    The course consists of four learning modules, a downloads module, and a quiz.

    Click here to begin the course 


    Combating Mental Inertia (Wings Basic Knowledge-3)

    It is widely recognized that humans tend to continue with a task once it is started. Pilots sometimes continue with a flight even when evidence indicates that the plan should be changed or abandoned. This course examines the forces in the unconscious mind that cause this behavior and provides some practical mitigation strategies to improve safety.

    Click here to continue to the course

  • Summary and Quiz


    During this course, we saw the practical importance offollowing established procedures and regulations. We examined how external factors and our humanness can adversely affect our decision making. We saw a
    fictional example of how a pilot might be led into thinking, “It will be okay just this once.” Finally, we saw the tools that we can use to help prevent us from starting down this slippery slope.


    Congratulations on completing the course. There is just one more step to earn your FAA Wings credit! Feel free to review any of the material in the course. When you are ready for the quiz, click the link below. The quiz consists of ten multiple choice questions and the passing grade is 80%. If you are not successful the first time, you may take the quiz again.

    VERY IMPORTANT! When you enter your email address in the quiz, please be sure to accurately enter the email address you use to access your Wings account on FAASafety.gov. Credit can not be issued any other way and an alternate email address or a typo will prevent the FAA system from accepting the credit. Also, be sure to enter the full email address. A common error is to leave off the ".com" or ".net" at the end. For example, most humans would know that "abcdefg@gmail" means "abcdefg@gmail.com" but the computer does not make that association and will reject the credit request.